saunders quiz 7

nursing staff members are sitting in the lounge taking their morning break. an AP tells the group that she thinks the unit secretary has AIDS and proceeds to tell the nursing staff that the secretary probably contracted it from her husband, who is supposedly a drug addict. the RN should inform the AP that making this accusation has violated which legal tort? 1. libel 2. slander 3. assault 4. negligence

2

the nurse has just assisted a client back to bed after a fall. the nurse and PHCP have assessed the client and determined that the client is not injured. after completing the occurrence report, the nurse should implement which action next? 1. reassess the client 2. conduct a staff meeting to describe the fall 3. contact the nursing supervisor to update information regarding the fall 4. document in the nurse's notes that an occurrence report was completed

1

the nurse is performing an assessment on an older adult client. which assessment data would indicate a potential complication associated with the skin? 1. crusting 2. wrinkling 3. deepening of expression lines 4. thinning and loss of elasticity in the skin

1

the nurse is caring for a client hospitalized for heart failure exacerbation and suspects the client may be entering a state of shock. the nurse knows that which intervention is the priority for this client? 1. administration of digoxin 2. administration of whole blood 3. administration of IV fluids 4. administration of packed RBCs

1. administration of digoxin

which action by the nurse will best facilitate adherence to the treatment regimen for a client with a chronic illness? 1. arranging for home health care 2. focusing on managing a single illness at a time 3. communicating with one provider only to avoid confusion for the client 4. allowing the client to teach a support person about their treatment regimen

1. arranging for home health care

a client is admitted to the ED with chest pain that is consistent with MI based on elevated troponin levels. heart sounds are normal. the nurse should alert the PHCP because the vital sign changes and client assessment are most consistent with which complication? refer to the chart. 1. cardiogenic shock 2. cardiac tamponade 3. pulmonary embolism 4. dissecting thoracic aortic aneurysm

1. cardiogenic shock

the nurse who works on the night shift enters the med room and finds a coworker with a tourniquet wrapped around the upper arm. the coworker is about to insert a needle attached to a syringe containing a clear liquid into the antecubital area. which is the most appropriate action by the nurse? 1. call security 2. call the police 3. call the nursing supervisor 4. lock the coworker in the med room until help is obtained

3

which clinical findings are consistent with sepsis diagnostic criteria? select all that apply 1. urine output 50 mL/hr 2. hypoactive bowel sounds 3. temperature of 102 F 4. heart rate of 96 bpm 5. MAP of 65 6. systolic BP 110 mm Hg

3, 4, 5 temperature of 102 F heart rate of 96 MAP of 65

the nurse is assessing the functioning of a chest tube drainage system in a client with a chest injury who has just returned to the recovery room following a thoracotomy with wedge resection. which are the expected assessment findings? select all that apply 1. excessive bubbling in the water seal chamber 2. vigorous bubbling in the suction control chamber 3. drainage system maintained below the client's chest 4. 50 mL of drainage in the drainage collection chamber 5. occlusive dressing in place over the chest tube insertion site 6. fluctuation of water in the tube in the water seal chamber during inhalation and exhalation

3, 4, 5, 6 drainage system maintained below the client's chest 50 mL of drainage in the drainage collection chamber occlusive dressing in place over the chest tube insertion site fluctuation of water in the tube in the water seal chamber during inhalation and exhalation

the nurse working in a community outreach program for foster children plans care knowing that which health conditions are common in this population? select all that apply 1. asthma 2. claustrophobia 3. sleep problems 4. bipolar disorder 5. aggressive behavior 6. ADHD

3, 4, 5, 6 sleep problems bipolar disorder aggressive behavior ADHD

the nurse calls the PHCP regarding a new medication prescription, because the dosage prescribed is higher than the recommended dosage. the nurse is unable to locate the PHCP and the medication is due to be administered. which action should the nurse take? 1. contact the nursing supervisor 2. administer the dose prescribed 3. hold the medication until the PHCP can be contacted 4. administer the recommended dose until the PHCP can be contacted

1

a client develops an anaphylactic reaction after receiving morphine. the nurse should plan to institute which actions? select all that apply 1. administer oxygen 2. quickly assess the client's respiratory status 3. document the event, interventions, and client response 4. keep the client supine regardless of the BP readings 5. leave the client briefly to contact a PHCP 6. start an IV infusion of D5W and administer a 500 mL bolus

1, 2, 3 administer oxygen quickly assess the client's respiratory status document the event, interventions, and client response

which identifies accurate nursing documentation notations? select all that apply 1. the client slept through the night 2. abdominal wound dressing is dry and intact without drainage 3. the client seemed angry when awakened for vital sign measurement 4. the client appears to become anxious when it is time for respiratory treatments 5. the client's left lower medial leg wound is 3 cm in length without redness, drainage, or edema

1, 2, 5

the charge nurse is planning the assignment for the day. which factors should the nurse remain mindful of when planning the assignment? select all that apply 1. the acuity level of the clients 2. specific requests from the staff 3. the clustering of the rooms on the unit 4. the number of anticipated client discharges 5. client needs and workers' needs and abilities

1, 5

the nurse is caring for a client experiencing acute lower GI bleeding. in developing the plan of care, which priority problem should the nurse assign to this client? 1. deficient fluid volume related to acute blood loss 2. risk for aspiration related to acute bleeding in the GI tract 3. risk for infection related to acute disease process and medications 4. imbalanced nutrition, less than body requirements, related too lack of nutrients and increased metabolism

1. deficient fluid volume related to acute blood loss

the nurse is completing the admission assessment of a client who is intellectually disabled. which part of the client encounter may take more time to complete? 1. history 2. physical assessment 3. nursing plan of care 4. readmission risk assessment

1. history

the nurse is caring for a client with chronic kidney disease on continuous replacement renal therapy without the use of a hemodialysis machine. the nurse determines that which parameter is most important in ensuring success of this treatment? 1. mean arterial pressure 2. systolic blood pressure 3. diastolic blood pressure 4. central venous pressure

1. mean arterial pressure

a client had a 1000 ml bag of 5% dextrose in 0.9% sodium chloride hung at 1500. the nurse making rounds at 1545 finds that the client is complaining of a pounding headache and is dyspneic, experiencing chills, and apprehensive, with an increased pulse rate. the IV bag has 400 ml remaining. the nurse should take which action first? 1. slow the IV infusion 2. sit the client up in bed 3. remove the IV catheter 4. call the PHCP

1. slow the IV infusion

which teaching method is most effective when providing instruction to members of special populations? 1. teach-back 2. video instruction 3. written materials 4. verbal explanation

1. teach back

which is most appropriate when communicating with a transgender person? 1. using their preferred pronouns 2. using their first name to address them 3. using pronouns associated with birth sex 4. anticipating the client's needs and making suggestions

1. using preferred pronouns

the home health nurse is visiting a client for the first time. while assessing the client's medication history, it is noted that there are 19 prescriptions and several over the counter medications that the client has been taking. which intervention should the nurse take first? 1. check for medication interactions 2. determine whether there are medication duplications 3. determine whether a family member supervises medication administration 4. call the prescribing PHCP and report polypharmacy

2

the nurse arrives at work and is told to float to the ICU for the day because it is understaffed and needs additional nurses to carer for the clients. the nurse has never worked in the ICU. the nurse should take which best action? 1. refuse to float to the ICU based on lack of unit orientation 2. clarify the ICU client assignment with the team leader to ensure that it is a safe assignment 3. ask the nursing supervisor to review the hospital policy on floating 4. submit a written protest to nursing administration and call a hospital lawyer

2

the nurse is providing medication instructions to an older client who is taking digoxin daily. the nurse explains to the client that decreased lean body mass and decreased glomerular filtration rate, which are age related body changes, could place the client at risk for which complication with medication therapy? 1. decreased absorption of digoxin 2. increased risk for digoxin toxicity 3. decreased therapeutic effect of digoxin 4. increased risk for side effects related to digoxin

2

the nurse manger is discussing the facility protocol in the event of a tornado with the staff. which instructions should the nurse manager include in the discussion? select all that apply 1. open doors to client rooms 2. move beds away from windows 3. close window shades and curtains 4. place blankets over the clients who are confined to bed 5. relocate ambulatory clients from the hallways back into their rooms

2, 3, 4

the home care nurse is visiting an older client whose house died 5 months ago. which behaviors by the client indicates effective coping? select all that apply 1. neglecting personal grooming 2. looking at old snapshots of family 3. participating in a senior citizens program 4. visiting the spouse's grave once a month 5. decorating a wall with the spouse's pictures and awards received

2, 3, 4, 5

the nurse is providing an educational session to new employees and the topic is abuse of the older adult client. the nurse helps the employees identify which client as most typically a victim of abuse? 1. a man who has moderate hypertension 2. a man who has newly diagnosed cataracts 3. a woman who has advanced Parkinson's disease 4. a woman who has early diagnosed Lyme disease

3

the nurse has made an error in documentation of the dose administered of an opioid pain medication in the client's record. the nurse draws 1 mg from the vial and another RN witnesses wasting of the remaining 1 mg. when scanning the medication, the nurse entered into the MAR that 2 mg of hydromorphone was administered instead of the actual dose administered, which was 1 mg. the nurse should take which actions to correct the error in the MAR? select all that apply 1. complete and file an occurrence report 2. right click on the entry and modify it to reflect the correct info 3. document the correct info and end with the nurse's signature and title 4. obtain a cosignature from the RN who witnessed the waste of the remaining 1 mg. 5. document in a nurse's note in the client's record detailing the corrected info

2, 3, 4, 5

a client is brought to the ED with partial thickness burns to his face, neck, arms, and chest after trying to put out a car fire. the nurse should implement which nursing actions for this client? select all that apply 1. restrict fluids 2. assess for airway patency 3. administer oxygen as prescribed 4. place a cooling blanket on the client 5. elevate extremities if no fractures are present 6. prepare to give oral pain medication as prescribed

2, 3, 5 assess for airway patency administer oxygen as prescribed elevate extremities if no fractures are present

the long term care nurse is performing assessments on several of the residents. which are normal age related physiological changes the nurse should expect to note? select all that apply 1. increased heart rate 2. decline in visual acuity 3. decreased respiratory rate 4. decline in long term memory 5. increased susceptibility to UTIs 6. increased incidence of awakening after sleep onset

2, 5, 6

the nurse is monitoring a client with a head injury for signs of increased intracranial pressure. the nurse would note which trend in vital signs if the intracranial pressure is rising? 1. increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure 2. increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure 3. decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure 4. decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure

2. increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure

a client at risk for shock secondary to pneumonia develops restlessness and is agitated and confused. urinary output has decreased and the BP is 92/68 mm Hg. the nurse minimally suspects which stage of shock based on this data? 1. stage 1 2. stage 2 3. stage 3 4. stage 4

2. stage 2

the nurse is providing instructions to the AP regarding care of an older adult client with hearing loss. what should the nurse tell the AP about older adult clients with hearing loss? 1. they are often distracted 2. they have middle ear changes 3. they respond to low-pitched tones 4. they develop moist cerumen production

3

a client is brought to the ED by EMS after being hit by a car. the name o fat client is unknown, and the client has sustained a severe head injury and multiple fractures and is unconscious. an emergency craniotomy is required. regarding informed consent for the surgical procedure, which is the best action? 1. obtain a court order for the surgical procedure 2. ask the EMS team to sign the informed consent form 3. transport the client to the OR for surgery 4. call the police to identify the client and locate the family

3

a nurse employed in a hospital is waiting to receive a report from the lab via the fax machine. the fax machine activates and the nurse expects the report, but instead receives a sexually oriented photograph. which is the most appropriate initial nursing action? 1. call the police 2. cut up the photograph and throw it away 3. call the nursing supervisor and report the occurrence 4. call the lab and ask for the name of the individual who sent the photograph

3

the RN is planning the client assignments for the day. which is the most appropriate assignment for an AP? 1. a client requiring a colostomy irrigation 2. a client receiving continuous tube feedings 3. a client who requires urine specimen collections 4. a client with difficulty swallowing food and fluids

3

the nurse hears a client calling out for help, hurries down the hallway to the client's room, and finds the client lying on the floor. the nurse performs an assessment, assists the client back to bed, notifies the PHCP, and completes an occurrence report. which statement should the nurse document on the occurrence report? 1. the client fell out of bed 2. the client climbed over the siderails 3. the client was found lying on the floor 4. the client became restless and tried to get out of bed

3

the nurse is performing an assessment on an older client who is having difficulty sleeping at night. which statement by the client indicates the need for further teaching regarding measures to improve sleep? 1. I swim 3 times a week 2. I have stopped smoking cigars 3. I drink hot chocolate before bedtime 4. I read 40 minutes before bedtime

3

a client is admitted to the hospital with a diagnosis of DKA. the initial blood glucose level is 950 mg/dL. a continuous IV infusion of short acting insulin is initiated, along with IV rehydration with normal saline. the serum glucose level is now decreased to 240 mg/dL. the nurse should next prepare to administer which medication? 1. an ampule of 50% dextrose 2. NPH insulin subcutaneously 3. IV fluids containing dextrose 4. phenytoin for prevention of seizures

3. IV fluids containing dextrose

the nurse is caring for a female client in the ED who presents with a complaint of fatigue and shortness of breath. which physical assessment findings, if noted by the nurse, warrant a need for follow up? 1. reddening sclera of the eyes 2. dry flaking noted on scalp 3. a reddish-purple mark on the neck 4. a scaly rash noted on the elbows and knees

3. a reddish purple mark on the neck

the nurse working in a correctional facility is caring for a new prisoner. the client asks about health risks associated with living in a prison. how would the nurse respond? 1. health care is very limited in the prison setting 2. living in a prison isn't different than living at home 3. living in a prison can predispose a person to different health conditions 4. living in a prison is similar to living in a condominium complex or dormitory

3. living in a prison can predispose a person to different health conditions

a hospitalized client tells the nurse that an instructional directive is being prepared and that the lawyer will be bringing the documents to the hospital today for witness signatures. the client asks the nurse for assistance in obtaining a witness to the will. which is the most appropriate response to the client? 1. I will sign as a witness to your signature 2. you will need to find a witness on your own 3. whoever is available at the time will sign as a witness for you 4. I will call the nursing supervisor to seek assistance regarding your request

4

a nursing graduate is attending an agency orientation regarding the nursing model of practice implemented in the health care facility. the nurse is told that the nursing model is a team nursing approach. the nurse determines that which scenario is characteristic of the team based model of nursing practice? 1. each staff member is assigned a specific task for a group of clients 2. a staff member is assigned to determine the client's needs at home and begin discharge planning 3. a single RN is responsible for providing care to a group of 6 clients with the aid of an AP 4. an RN leads 2 LPNs and 3 APs in providing care to a group of 12 clients

4

a nursing instructor delivers a lecture to nursing students regarding the issue of clients' rights and asks a student to identify a situation that represents an example of invasion of client privacy. which situation, if identified by the student, indicates an understanding of a violation of this client right? 1. performing a procedure without consent 2. threatening to give a client a medication 3. telling the client that she or he cannot leave the hospital 4. observing care provided to the client without the client's permission

4

an older woman is brought to the ED for treatment of a fractured arm. on physical assessment the nurse notes old and new ecchymotic areas on the client's chest and legs and asks the client how the bruises were sustained. the client, although reluctant, tells the nurse in confidence that her son frequently hits her if dinner is not prepared on time when he arrives home from work. which is the most appropriate nursing response? 1. oh really? I will discuss this situation with your son 2. let's talk about the ways you can manage your time to prevent this from happening 3. do you have any friends who can help you out until you resolve these important issues with your son? 4. as a nurse, I am legally bound to report abuse. I will stay with you while you give the report and help find a safe place for you to stay.

4

the nurse employed in a longterm care facility is planning assignments for the clients on a nursing unit. the nurse needs to assign 4 clients and has an LPN and 3 APs on a nursing team. which client would the nurse appropriately assign to the LPN? 1. a client who requires a bed bath 2. an older client requiring frequent ambulation 3. a client who requires hourly vital sign measurements 4. a client requiring abdominal wound irrigations and dressing changes every 3 hours

4

the nurse employed in an ED is assigned to triage clients coming to the ED for treatment on the evening shift. the nurse should assign priority to which client? 1. a client complaining of muscle aches, a headache, and history of seizures 2. a client who twisted her ankle when rollerblading and is requesting medication for pain 3. a client with a minor laceration on the index finger sustained while cutting an eggplant 4. a client with chest pain who states that he just ate pizza that was made with a very spicy sauce

4

the nurse has received the assignment for the day shift. after making initial rounds and checking all of the assigned clients, which client should the nurse prepare to plan for first? 1. a client who is ambulatory demonstrating steady gait 2. a postoperative client who has just received an opioid pain medication 3. a client scheduled for physical therapy for the first crutch-walking session 4. a client with a WBC count of 14,000mm3 and a temperature of 38.4 C

4

the nurse is assigned to care for four clients. in planning client rounds, which client should the nurse assess first? 1. a postoperative client preparing for discharge with a new medication 2. a client requiring daily dressing changes of a recent surgical incision 3. a client scheduled for a chest x-ray after insertion of an NG tube 4. a client with asthma who requested a breathing treatment during the previous shift

4

the nurse is caring for an older adult client in a long term care facility. which action contributes to encouraging autonomy in the client? 1. planning meals 2. decorating the room 3. scheduling haircut appointments 4. allowing the client to choose social activities

4

the nurse is giving a bed bath to an assigned client when an AP enters the room and tells the nurse that another assigned client is in pain and needs pain medication. which is the most appropriate nursing action? 1. finish the bed bath and then administer the pain medication to the other client 2. ask the AP to find out when the last pain medication was given to the client 3. ask the AP to tell the client in pain that medication will be administered as soon as the bed bath is complete 4. cover the client, raise the side rails, tell the client that you will return shortly, and administer the pain medication to the other client

4

the nurse manager has implemented a change in the method of the nursing delivery system from functional to team nursing. an AP is resistant to the change and is not taking an active part in facilitating the process of change. which is the best approach in dealing with the AP? 1. ignore the resistance 2. exert coercion on the AP 3. provide a positive reward system for the AP 4. confront the AP to encourage verbalization of feelings regarding the change

4

the visiting nurse observes that the older male client is confined by his daughter in law to his room. when the nurse suggests that he walk to the den and join the family, he says "I'm in everyone's way; my daughter in law needs me to stay here." which is the most important action for the nurse to take? 1. say to the daughter in law "confining your father in law to his room is inhumane" 2. suggest to the client and daughter in law that they consider a nursing home for the client 3. say nothing, because it is best for the nurse to remain neutral and wait to be asked for help 4. suggest appropriate resources to the client and daughter in law, such as respite care and a senior citizens center

4

the nurse planning care for a military veteran must prioritize nursing interventions targeted at managing which condition, if present, that commonly occurs in this population? 1. hypertension 2. hyperlipidemia 3. substance abuse disorder 4. PTSD

4. PTSD

the nurse caring for a refugee considers which healthcare need as a priority for this client? 1. access to housing 2. access to clean water 3. access to transportation 4. access to mental health care services

4. access to mental health care services

the nurse is volunteering with an outreach program to provide basic health care for homeless people. which finding, if noted, must be addressed first? 1. BP 154/72 2. visual acuity of 20/200 in both eyes 3. random blood glucose level of 206 mg/dl 4. complaints of pain associated with numbness and tingling in both feet

4. complaints of pain associated with numbness and tingling in both feet

packed RBCs have been prescribed for a female client with anemia who has a hemoglobin level of 7.6 g.dL and a hematocrit level of 30%. the nurse takes the client's temperature before hanging the blood transfusion and records 100.6 F orally. which action should the nurse take? 1. begin the transfusion as prescribed 2. administer an antihistamine and begin the transfusion 3. administer 2 tablets of acetaminophen and begin the transfusion 4. delay hanging the blood and notify the PHCP

4. delay hanging the blood and notify the PHCP

a client in shock develops a central venous pressure of 2 mm Hg and a MAP of 60. which prescribed intervention should the nurse implement first? 1. increase the rate of oxygen flow 2. obtain ABG results 3. insert an indwelling urinary catheter 4. increase the rate of IV fluids

4. increase the rate of IV fluids

the nurse is assessing a client with multiple trauma who is at risk of developing ARDS. the nurse should assess for which ealiest sign of ARDS? 1. bilateral wheezing 2. inspiratory crackles 3. intercostal retractions 4. increased respiratory rate

4. increased respiratory rate