202 Exam 3

A nurse is reviewing the use of electronic documentation with a newly licensed nurse. Which of the following statements should the nurse make?

"Electronic documentation provides evidence of care provided."

A staff nurse is evaluating a newly licensed nurse's understanding of telephone prescriptions. Which of the following statements by the newly licensed nurse indicates an understanding of the information?

"I can take a telephone prescription if a provider is directing a cide for an unresponsive client."

A charge nurse is teaching a group of nurses about protecting themselves from an abusive client. Which of the following statements by a nurse within the group demonstrates an understanding of the teaching?

"I should try to escape or put a barrier between myself and the client." The nurse should always try to escape a dangerous situation. If escape is not possible, creating a barrier where the client cannot reach them until help arrives is the next acceptable action.

A charge nurse is teaching a newly licensed nurse about the concept of team nursing. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

"Nurses will pair together to care for an assigned group of clients." Team nursing is the concept of nursing that pairs two or more nurses together to provide care for a group of clients. Team nursing provides support for novice nurses and others that are not as skilled in performing more complex tasks. A positive outcome of team nursing is the team works together. No one is expected to perform tasks that they are uncomfortable with or not competent to perform.

A nurse is reviewing the documentation of a newly licensed nurse. Which of the entries should the nurse identify as meeting the American Nurses Association (ANA) standards of documentation?

"The client vomited 240 mL of clear emesis but denies pain or nausea"

A nurse is assisting with preparation of a teaching program about healthy nutrition for a group of clients who are tactile learners. Which of the following should be included as a learning strategy in the program? 1. Watch a video discussing healthy meal preparation. 2. Prepare a healthy meal to serve at the end of class. 3. Read pamphlets about preparing a healthy meal. 4. Discuss healthy meal preparation as a class.

2. Prepare a healthy meal to serve at the end of class. Tactile learners learn best by touching and doing; therefore, having the participants prepare a healthy meal to serve at the end of class is a learning strategy appropriate for tactile learners.

A nurse is collecting nutritional data on an older adult client. Which of the following findings is suggestive of a healthy nutritional status? 1. Spongy gums that are receding 2. Fissures at eyelid corners 3. Easily plucked hair 4. Deep reddish-colored tongue

4. Deep reddish-colored tongue Deep reddish-colored tongue is suggestive of a healthy nutritional status. The tongue should be a healthy pink to a deep, reddish color with surface papillae present, without swelling or lesions.

A nurse is reviewing documentation principals with a group of newly hired assistive personnel (AP). Which of the following should the nurse include?

A nurse who delegates a task to an AP will review the charting for that task

A nurse is discussing problem-oriented medical records with a group of newly licensed nurses. Which of the following information should the nurse include?

A problem-oriented medical record uses progress notes, which promotes information sharing among members of the interdisciplinary team.

a nurse is caring for a client who is experiencing unexpected manifestations with several body systems. which of the following priority setting frameworks should the nurse use the prioritize client assessment

ABCDE

A nurse is assisting with teaching a newly licensed nurse about using barcode technology in client care. The nurse should include that barcode technology is used to reduce errors during which of the following phases of the medication process?

Administering

A nurse and urgent care clinic is auscultating the lungs of a client who reports a cough and shortness of breath. Which of the following steps of the nursing process is the nurse using?

Assessment

In what order should an RN perform the steps of the nursing process?

Assessment, analysis, planning, implementation, evaluation

A charge nurse is planning to discuss factors that can influence the clinical decision making process in client care with a newly licensed nurse. Which of the following factors should the charge nurse include?

Available resources, awareness of client status, support from other staff

A nurse is preparing to administer morphine 15 mg PO every 4 hr PRN pain for a client who has a new prescription. By which of the following routes should the nurse plan to administer the medication?

By mouth

A nurse is discussing computerized provider order entry systems with staff. Which of the following statements from a staff member indicates an understanding of a CPOE system?

CPOE systems can increase the speed of care delivery

A newly licensed nurse is orienting to a facilities documentation process. The facility requires staff to on,y document variations from an expected set of findings when performing a physical assessment. The nurse should identify this system as which of the following documentation methods?

Charting by exception

A nurse is reviewing methods created to assist nurses in using evidence-based practice. Which of the following is a NCSBN model that can assist the nurse is critical thinking and decision making?

Clinical judgment

A nurse is discussing clinical pathways with a newly licensed nurse. Which of the following information should the nurse include?

Clinical pathways use evidence-based practice guidelines for health care delivery.

A nurse is caring for a client who is being transferred to another unit, but the receiving nurse is unavailable to take report. Which of the following concepts is being violated that could place the client at risk?

Continuity of care The nurse should understand that continuity of care can cause a safety risk of a client when there are numerous hand-off reports completed during a transfer to another unit. The nurse should wait until the other nurse is available for report.

A nurse is reviewing the concept of critical thinking with a newly licensed nurse. Which of the following statements should the nurse make?

Critical thinking is the foundation for clinical decision making

A nurse is completing a medication reconciliation on a newly admitted client. Which of the following information should the nurse include? (Select all that apply.)

Current prescribed medications is correct. Nutritional supplements the client takes is correct. Over-the-counter medications the client uses is correct.

A nurse is caring for a client who has been wheezing. The nurse asked an assistive personnel do use a stethoscope and listen to the clients lung sounds to determine if their wheezing has improved. This is an example of which of the following concepts?

Delegation of the wrong task

A nurse asked the client to write the current level of pain using a scale of 0 to 10 after administering a pain medication 30 minutes ago. Which of the following steps of the nursing process is the nurse performing?

Evaluation

A nurse is reviewing the role of health information technology in client care with a newly licensed nurse. Which of the following information should the nurse include? (Select all that apply.)

Facilitates care coordination is correct. Improves practice efficiencies is correct. Is capable of being overridden by a nurse is correct. Improves clinical outcomes is correct.

A nurse is discussing legal regulations regarding medical records with a newly hired assistive personnel (AP). Which of the following information should the nurse include?

Facilities can establish their own rules for documentation methods

A nurse is assisting with teaching a class about HIPAA. Which of the following information should the nurse include? (Select all that apply.)

HIPAA protects the unauthorized release of a client's protected health information is correct. The loss of a provider's cell phone that contains a client's protected health information is considered a data breach is correct. A breach in HIPAA should be reported within 60 days after the breach is discovered is correct.

A nurse is talking with a client about the electronic health record at the facility. Which of the following client statements indicates an understanding of EHRs?

I will be able to track my health information

A charge nurse is discussing health records with a newly licensed nurse. Which of the following information should the nurse identify as a component of a health record?

Immunization data

A nurse is reviewing the impact low health literacy has for clients with a newly licensed nurse. Which of the following information should the nurse include?

Increase in mortality rate

A charge nurse is preparing to discuss critical thinking skills with a group of newly licensed nurses. Which of the following skills should the nurse plan to include in the discussion?

Inference, creativity, inductive reasoning

A nurse is preparing to use a video-enabled device to communicate with a client who is at home. Which of the following actions should the nurse plan to take?

Instruct the client to use a computer for the video conference.

A nurse is reviewing documentation guidelines with a newly licensed nurse. Which of the following abbreviations should the nurse note as being on the joint commissions do not use list?

MSO4, IU, qhs

A newly licensed nurse is reviewing the client assignments for a shift and determining tasks to complete. Which of the following is a time management strategy the nurse should use?

Make a list and prioritize a plan. Managing multiple clients can be difficult for a new nurse. Making a list of all tasks to accomplish and then prioritizing a plan can help the nurse stay organized and efficient.

A nurse is teaching a class about using smart infusion pumps to administer intravenous medications. Which of the following information should the nurse include?

Nurses enter client information into the smart infusion pump.

A nurse in the clinic is reviewing a clients prescriptions prior to discharge. The nurse should instruct the client that which of the following abbreviations indicates the medication can be taken as needed?

PRN

A nurse is preparing an in-service about HIPAA. Which of the following information should the nurse plan to include?

Personnel can be terminated for breaching a client's confidentiality

A nurse is developing a goal for a client to ambulate with assistance at least once by the end of the shift. The nurse should identify that this is an example of which of the following steps of the nursing process?

Planning

A nurse is reviewing discharge instructions with a client who has low health literacy. Which of the following actions should the nurse take?

Provide examples.

A charge nurse is reviewing soap documentation with a group of newly licensed nurses. Which of the following chart entries should the nurse include as an example of objective data?

Rebound tenderness noted in RLQ of the abdomen

A charge nurse is reviewing characteristics of electronic documentation with staff at a providers office. Which of the following characteristics should the charge nurse plan to include?

Reduces medical errors, makes clients medical history more easily available, increases accuracy of coding procedures

A charge nurse is reviewing client acuities and tasks to make the nursing staff's daily assignments. When using the Five Rights of Delegation, which of the following should the charge nurse use to ensure client safety?

Right task The charge nurse should delegate an assignment or task that is safe for a health care worker to carry out. Safety includes right training, competency, or within the health care worker's scope of practice.

A nurse is assisting with teaching a newly licensed nurse about the use of electronic health records (EHRs). Which of the following is an outcome associated with the use of EHRs that the nurse should include?

Saves time

A nurse manager is reviewing the documentation of for newly licensed nurses. Which of the following medication entries should the nurse identify as being written correctly?

Synthroid 100 mg PO every morning ac

A nurse is discussing the history of electronic health records (EHRs) during a staff in-service. The nurse should identify that which of the following agencies advocated for nationwide use of EHRs.

The Institute of Medicine (IoM)

A nurse is documenting information in a clients chart and makes the entry quotation mark client reports "abdominal pain on exertion". Which of the following documentation format describes this entry?

The S in soap

A nurse is reviewing the HIPAA regulatory rules. Which of the following rules is restricted to electronic protected health information (e-PHI)?

The Security Rule

A nurse is caring for a client after a stroke. The nurse should recognize that which of the following individuals is allowed access to the client's medical record without obtaining special consent from the client first?

The admitting provider, the charge nurse on the unit, the client

A nurse is giving change-of-shift report to an oncoming nurse using SBAR reporting. Which of the following entries by the nurse demonstrates the correct use of SBAR?

The client in room 1 has been experiencing breakthrough pain following an exploratory surgery yesterday. Vital signs are stable. Recommend calling the provider for a breakthrough dose if pain continues. The nurse is providing relevant and needed information for SBAR reporting: situation, background, assessment, and recommendation.

A nurse is taking an admission history from a client who is concerned about the facility using an electronic documentation system. Which of the following should the nurse include as a benefit of electronic documentation?

The system alerts providers of possible actions that could cause client harm

A nurse is assisting with teaching a client about remote patient monitoring (RPM) devices. Which of the following information should the nurse include? (Select all that apply.)

The transfer of data is accomplished using wireless devices. Clients can participant in their health by using RPM. A client's heart rhythm can be transferred using RPM.

A nurse is assisting with teaching a class about using simulation for clinical education. Which of the following information should the nurse include?

The use of simulation improves communication skills.

A nurse is assisting with teaching a class about using health information technology for client care. Which of the following examples should the nurse include?

Using a barcode to verify a client's medication

A nurse is speaking with a client who is non-compliant in performing a daily blood glucose testing regimen. Which of the following responses should the nurse make?

What is preventing your consistency with your daily blood glucose checks?" The nurse is using an open-ended question to encourage the client to talk more about what is hindering them from the process for daily blood glucose testing.

a nurse is assisting with client triage at the scene of a mass casualty event. which of the following clients should the nurse recommend for transport first.

a client who has an abdominal wound that is actively bleeding

a nurse is assessing a client using the ABCDE approach. the nurse has already assessed the client's airway and breathing status. which of the following assessments should the nurse perform next

blood pressure

a nurse is caring for a client who is confused and trying to remove their peripheral IV. using the least restrictive/least invasive priority setting framework, which of the following actions should the nurse take first

cover the IV site with an elastic bandage

a nurse is assessing a client using the ABCDE priority-setting approach. which of the following actions should the nurse take when completing the exposure component of this priority setting method

observe the client's lower extremities for indications of deep vein thrombosis measure the client's temperature check the client for bruising

a nurse is admitting a client who has hypertension. using the nursing process, which of the following actions should the nurse take first

perform a physical assessment

a nurse is caring for a client who reports feeling inferior and states that they are not good enough. the nurse should recognize that these feeling fall under which of the following categories of Maslow's Hierarch of needs

self-esteem

a nurse is performing an admission assessment on a client. using the safety and risk reduction priority setting framework, which of the following finding should the nurse identify as the priority

the client reports dizziness when standing

a nurse is providing education on priority setting frameworks to a group of newly licensed nurses. which of the following statements should the nurse make regarding the safety and risk reduction priority setting framework?

this framework assigns the highest priority to the situation that poses a threat to the client's physical well-bing

a nurse is caring for a client who reports new onset of abdominal pain. the nurse should assign the client's condition to which of the following categories when prioritizing care

urgent

A nurse is caring for a patient who is diagnosed with anemia. Which of the following skin variations is caused by reduced amount of oxyhemoglobin? 1. Cyanosis 2. Jaundice 3. Erythema ​4. Pallor

​4. Pallor Oxyhemoglobin is the combined state of oxygen that is to be delivered to peripheral tissues with the hemoglobin molecule that will carry it. In clients who have anemia, the RBCs are reduced, by function or in number, to the point that peripheral tissues are not receiving adequate oxygen because of a decreased amount of circulating oxyhemoglobin. The reduced oxygen supply to the tissues causes changes to the client's skin color. Pallor is caused by a reduced amount of oxyhemoglobin. Pallor is a decrease in the coloring of the peripheral tissues that is caused by an overall reduction in the blood flow or by a decrease in the number of RBCs that contain oxyhemoglobin, which reduces the visibility of oxyhemoglobin. Erythema is a red color of the skin caused by increased blood flow, which enhances the visibility of oxyhemoglobin. Jaundice is a yellow-orange color of the skin caused by increased amounts of bilirubin being deposited in the tissues. Reduced oxygen levels in the tissues because of an increase in circulating deoxygenated hemoglobin results in cyanosis, which is a bluish color to the skin.

A nurse is precepting a newly licensed nurse and suggests using the IDEAL method to structure the client's discharge planning. The client's caregiver is also in the room. Which of the following statements made by the newly licensed nurse demonstrates the correct the use of the IDEAL method?

"I will include the client and caregivers in the discharge discussion." "I" stands for "include" in this model. The nurse should include the client and caregivers to review the discharge instructions. Research shows including caregivers in the discharge instructions with the client leads to a safer transition.

A nurse is precepting a newly licensed nurse while he is charting. Use of which of the following abbreviations indicates a need for further teaching? 1. mcg 2. q.d. 3. mL 4. PO

2. q.d. To reduce the occurrence of medical errors, the Joint Commission developed a list of do-not-use abbreviations that should be avoided in health care settings. The abbreviation "q.d." was previously used to indicate every day, which can be mistaken as the abbreviation for "four times daily (qid)," resulting in medical errors. The Joint Commission has recommended the use of "daily" to indicate every day. This is not an acceptable abbreviation; therefore, additional teaching is needed.

A nurse is caring for a client who is in an acute care facility. The nurse should recognize that the clients care requires clinical reason when it is complicated by which of the following factors?

Complex clinical situations, ongoing client and family concerns

A nurse is teaching the SMART goal method to a client who has diabetes mellitus and is setting nutrition and weight loss goals. Which of the following client statements should indicate to the nurse an understanding the teaching?

"I will reduce my sugar intake by 10 grams each week for one month until I reach the desired level." This response indicates the client understands and is using the SMART goal method: creating goals that are specific (S), measurable (M), attainable (A), realistic (R), and timely (T).

A nurse is caring for a patient who diagnosed with urinary tract infection and is prescribed ciprofloxacin (Cipro) 250 mg PO two times daily. The amount is available is 100 mg/tablet. How many tablets should the nurse administer with each dose?

2.5 tablets

A nurse is providing discharge education to parents of preschooler who is prescribed Tylenol 300mg every 4hr as needed. The liquid suspension that has been prescribed provides 120 mg/5mL. How many teaspoons should the nurse teach the parents to administer per dose?

2.5 tsp

A nurse is caring for a male client who has been prescribed an indwelling urinary catheter. In which of the following positions should the client be placed for insertion of the catheter? 1. Dorsal recumbent 2. Orthopneic 3. Side-lying ​4. Supine

​4. Supine Indwelling urinary catheters are indicated in numerous situations, such as relief of bladder distension, strict measurement of urinary output, need for bladder irrigations, and surgery. A prescription from the provider is required for urethral catheterization. When preparing to implement this procedure, it is important to ensure client privacy by draping nonessential body parts and positioning the client for optimal visualization while still maintaining comfort. A male client should be positioned in the supine position for insertion of an indwelling urinary catheter. This position allows for optimal visualization, which reduces trauma and increases success of insertion. A female client should be positioned in the dorsal recumbent position for insertion of an indwelling urinary catheter. The orthopneic position improves respiratory effort and is used to increase chest expansion, especially in clients who are having difficulty exhaling. A female client who is unable to abduct the leg at her hip joint should be positioned side-lying with the upper leg flexed at the hip.

A nurse is collecting data on a client who has received a preoperative dose of morphine. Which of the following indicates the client is experiencing an adverse effect of the medication? 1. Urinary retention 2. Rapid respirations 3. Dilated pupils 4. Diarrhea

1. Urinary retention Morphine is an opioid used to treat moderate to severe pain, and can reduce anxiety, produce a sense of well-being, as well as cause drowsiness and mental clouding. Morphine has an agonist effect on opioid receptors in the CNS, causing many of the adverse effects associated with the medication. Urinary retention is an adverse effect of morphine. By increasing bladder sphincter and detrusor muscle tone and reducing awareness of bladder stimuli, morphine can cause urinary hesitancy, urinary retention, and urinary urgency. Respiratory depression is an adverse effect of morphine and can cause pupils to constrict, known as miosis, which can result in impaired vision. Also, decreased GI motility, constipation is an adverse effect of morphine.

When collecting data on a client who is immobile, a nurse locates a reddened area of skin on the left scapula. Which of the following actions should the nurse take? 1. Reposition the client every 4 hr. 2. Cover the area with a transparent wound barrier. 3. Massage areas surrounding the redness. 4. Wash the area with hot water every 8 hr.

2. Cover the area with a transparent wound barrier. Damage to tissues caused by continuous pressure is described as a pressure ulcer. The risk for pressure ulcers can be complicated by factors such as immobility, inadequate nutrition, bowel and bladder incontinence, decreased mental status, reduced sensation, increasing age, and excessive body heat. Appropriate care of pressure ulcers is based on the characteristics and stage of the wound. A wound that manifests as a reddened area is a stage 1 pressure ulcer. A transparent wound barrier applied to reddened skin or a stage 1 pressure ulcer to prevent contamination and reduce friction to the area is an appropriate action by the nurse.

A Nurse is caring for a patient with rheumatoid arthritis and is prescribed dexamethasone (Prednisone). Which of the following indicates the client is experiencing an adverse effect of the medication? 1. Hypomagnesemia 2. Hyperglycemia 3. Hyponatremia 4. Hyperkalemia

2. Hyperglycemia Dexamethasone, a glucocorticoid, is a powerful anti-inflammatory and immunosuppressant and is indicated for the treatment of multiple disorders, including rheumatoid arthritis. Adverse effects of dexamethasone increase with the dosage and duration of treatment and can include adrenal insufficiency, osteoporosis, infection, myopathy, fluid and electrolyte disturbances, cataracts, peptic ulcer disease, and iatrogenic Cushing's syndrome among others. Hyperglycemia, an elevated blood glucose level, is an adverse effect of dexamethasone. Both hyperglycemia and glycosuria can be manifested in clients who are taking dexamethasone because of its effect on the production and use of glucose.

A nurse is caring for a client who has been prescribed an indwelling urinary catheter. When preparing to insert the catheter, the nurse should first open the sterile package in which of the following directions? 1. To the left 2. To the right 3. Away from the body 4. Toward the body

3. Away from the body Sterile packages are resistant to pathogens and are used for specific techniques or procedures to prevent contamination. During such procedures, any sterile item that comes into contact with an unsterile object is considered contaminated. To prevent contamination of the sterile field, nurses follow certain steps when opening sterile packages and creating a sterile field. Opening the sterile package away from the body first allows a nurse to open the remaining flaps without reaching over the sterile field, which could result in contamination. This is the appropriate direction to open the sterile package.

a nurse has received change-of-shift report on four clients. which of the following clients should the nurse plan to see first

a client who has audible wheezing during respiration

a nurse at a provider's office is reviewing the records of several clients. which of the following clients should the nurse recommend as the priority for treatment

a client who report new chest pain

a nurse has received change-of-shift report for a group of clients. which of the following clients should the nurse plan to see first

a client who is receiving a blood transfusion and reports urticaria

A nurse is caring for a client who is prescribed IV fluids. While inserting the IV catheter, blood is pilled on the floor. which of the following solutions should the nurse use to clean the spill? 1. Isopropyl alcohol 2. Chlorhexidine gluconate (Hibiclens) 3. Chlorine (bleach) 4. Iodophor

3. Chlorine (bleach) Chlorine is a disinfectant that is effective against bacteria, tuberculosis, spores, fungi, and viruses, and is specifically recommended for cleaning blood spills. Antiseptics prevent or stop the growth of certain pathogens, and disinfectants destroy certain pathogens. Antiseptics are most often used on the skin, while disinfectants are more concentrated solutions that can be toxic to the skin and are typically used on inanimate objects. Chlorine should be used to clean the spill. Disinfectants are concentrated solutions that can be toxic to the skin and are typically used to destroy certain pathogens on inanimate objects. Isopropyl alcohol is an antiseptic often found in hand sanitizers and is effective against bacteria, tuberculosis, fungi, and viruses. Antiseptics prevent or stop the growth of certain pathogens, and disinfectants destroy certain pathogens. Antiseptics are most often used on the skin, while disinfectants are more concentrated solutions that can be toxic to the skin and are typically used on inanimate objects. Isopropyl alcohol should not be used to clean the spill. Chlorhexidine gluconate is an antiseptic skin cleanser with bactericidal properties and is effective against bacteria and viruses. Antiseptics prevent or stop the growth of certain pathogens, and disinfectants destroy certain pathogens. Antiseptics are most often used on the skin, while disinfectants are more concentrated solutions that can be toxic to the skin and are typically used on inanimate objects. Chlorhexidine gluconate should not be used to clean the spill. Iodophor is a disinfectant that is effective against bacteria, tuberculosis, spores, fungi and viruses, and is used to cleanse equipment. Antiseptics prevent or stop the growth of certain pathogens, and disinfectants destroy certain pathogens. Antiseptics are most often used on the skin, while disinfectants are more concentrated solutions that can be toxic to the skin and are typically used on inanimate objects. If diluted, iodophor is acceptable for use on skin. This solution should not be used to clean the spill.

a nurse is reviewing the medical records of four clients. which of the following clients should the nurse identify as the priority for care

a client who received digoxin and has a heart rate of 48/min

A nurse preceptor is working with a newly licensed nurse to transfer a client from the bed to a chair. Which of the following actions by the new nurse indicates a need for further teaching to prevent lift injuries? 1. Twisting at the waist and shoulders 2. Standing with feet in a wide stance 3. Positioning self close to the client 4. Using arms and legs to lift

1. Twisting at the waist and shoulders To prevent a lift injury when transferring the client from the bed to a chair, alignment of the back, neck, pelvis, and feet should be maintained to reduce the risk of injury to the lumbar vertebrae. This action by the newly licensed nurse is not appropriate and indicates a need for additional teaching. To prevent a lift injury when transferring the client from the bed to a chair, the nurse should stand with the feet in a wide stance because it improves stability. To prevent a lift injury when transferring the client from the bed to a chair, the nurse should stand close to the client to reduce stress on the back by decreasing the need to reach for the client. To prevent a lift injury when transferring the client from the bed to a chair, the nurse should use the arms and legs to lift because larger muscle groups allow for heavier lifting without causing injury.

A nurse is caring for a client who is receiving intermittent enteral tube feedings and have diarrhea after each feeding. Which of the following actions should the nurse take in an attempt to prevent diarrhea after subsequent feedings? 1. Chill formula prior to administration. 2. Verify feeding tube placement. 3. Reduce the rate of the feedings. 4. Place the client supine during feedings.

3. Reduce the rate of the feedings. Enteral tube feedings are used for clients who are able to absorb and digest nutrients but are unable to ingest food. Complications of enteral tube feedings include feeding tube regurgitation and aspiration of feedings, delayed gastric emptying, and malabsorption among others. Reducing the rate of feedings is an appropriate action by the nurse to prevent diarrhea after subsequent feedings. A client receiving intermittent enteral tube feedings can experience diarrhea because of the administration of hyperosmolar enteral feedings. To prevent this, administration should be slowed or switched to continuous enteral feedings. Findings associated with tube displacement include coughing, vomiting, and pulmonary aspiration. Chilled formula can cause abdominal cramping, nausea, and vomiting; therefore, formula should be administered at room temperature. The head of the bed should be elevated to at least 30° during the administration of enteral tube feedings to prevent aspiration.

A nurse is collecting date on a recently admitted patient. Which of the following techniques should the nurse use to measure tissue perfusion? 1. Determining the client's respiratory rate 2. Measuring the client's chest diameter 3. Obtaining the client's level of oxygen saturation 4. Checking the client's depth of respirations

3. Obtaining the client's level of oxygen saturation Perfusion is the delivery or pumping of arterial blood through tissues or an organ. Obtaining the client's level of oxygen saturation level is an appropriate technique of measuring perfusion. Oxygen saturation measures the percent of hemoglobin bound with oxygen that is being perfused through the arteries and into the tissues. Determining the client's respiratory rate is not an appropriate technique of measuring perfusion. The respiratory rate allows the nurse to determine if breathing is rapid, slow, or within the expected reference range for a client who has COPD. Measuring the client's chest diameter is not an appropriate technique of measuring perfusion. Comparison of the anteroposterior chest diameter to the lateral chest diameter can indicate a ratio that is consistent with COPD caused by air trapping, which results in the chest having a rounded, rather than an oval, shape. Checking the client's depth of respirations is not an appropriate technique of measuring perfusion. The depth of respirations allows the nurse to determine if respirations are deep or shallow by determining the degree of lung expansion.

A nurse is caring for a patient who scheduled for cardiac surgery and tells the nurse, " I don't think I'm going to have the surgery. Everybody has to die sometime." Which of the following responses by the nurse is appropriate? 1. "Clients having this surgery are always scared." 2. "Why have you changed your mind about the surgery?" 3. "You shouldn't worry, everything will be fine." 4. "Tell me more about your concerns."

4. "Tell me more about your concerns." The use of effective communication techniques fosters trust and therapeutic relationships with clients, co-workers, and members of the interdisciplinary team. Giving a general lead encourages the client to openly share feelings and concerns in a non-threatening environment, which will assist in establishing a meaningful nurse-client relationship. This response by the nurse is appropriate and fosters the nurse-client relationship. Sharing generalized beliefs is an automatic response and can result in the client feeling belittled or that her concerns are not being taken seriously. Beginning a question with "why" or requesting an explanation from the client can lead to resentment, mistrust, and insecurity. Offering false reassurance is an attempt to avoid the client's concerns and discourages additional discussions, resulting in a communication block.

A nurse is providing patient education about a new prescription of nitroglycerin (NitroQuick) to a client who is diagnosed with angina. Which of the following statements indicates a needs for further teaching? 1. "I'll make sure that the medication container is kept tightly sealed." 2. "I'm lucky I have a prescription plan that allows me to buy pills in bulk quantities." 3. "I'll keep my pills in the medicine cabinet when I'm home." 4. "I'll go to the emergency room if my chest pain doesn't go away."

2. "I'm lucky I have a prescription plan that allows me to buy pills in bulk quantities." Buying nitroglycerin in bulk quantities is not a safe practice. The chemical instability of the medication allows it to lose effectiveness over time. While some nitroglycerin tablets have a shelf life of 24 months, NitroQuick retains its effectiveness for only 8 to 10 months. Because of the shortened shelf life, the client should not buy the medication in bulk quantities, and the client should be instructed to date the bottle when it is first opened. The client should keep the nitroglycerin tablets in a dark, dry place, and in a dark-colored glass bottle with a tight lid. Tablets lose potency in containers made of plastic or cardboard or when mixed with other capsules or tablets. Exposure to air, heat, and moisture cause loss of potency. Going to the emergency department for chest pain is a critical point that can save the client's life. The client should call 911 or go to the nearest emergency department if anginal pain is not relieved within 5 min. Typically, the client can take up to 2 additional nitroglycerin tablets at 5-min intervals while awaiting emergency care.

A nurse preceptor is orienting a newly licensed nurse. Which of the following actions indicates a breach of confidentiality and requires intervention by nurse preceptor? 1. Faxing laboratory results to a client's provider 2. Discussing changes in a client's plan of care with his friend who is a nurse on another unit 3. Describing a client's level of independence to the case manager arranging home health services 4. Remaining in the room with the client while he reviews his own medical records

2. Discussing changes in a client's plan of care with his friend who is a nurse on another unit HIPAA is federal legislation that requires protection of a client's health information and describes the rights and privileges of clients in regard to privacy and confidentiality. A nurse discussing changes in a client's plan of care with another nurse on another unit is a breach of confidentiality. Client information can only be shared with other health care professionals involved in that client's care. The nurse on the other unit should be directed to the client to request information about changes in the client's plan of care. This action is not appropriate and requires intervention by the nurse preceptor. Faxing laboratory results to a client's provider is not a breach in confidentiality. The provider is involved in the client's care and review of the lab work can impact currently prescribed interventions. When faxing client information, the nurse should verify the fax number, use a cover sheet with a confidentiality statement, and verify receipt of the document with the provider's office. Describing a client's level of independence to the case manager arranging home health services is not a breach in confidentiality. The case manager is directly involved in caring for the client and needs this information to determine which home care services are most appropriate. According to HIPAA, clients have the right to review and request copies of medical records, as well request amendments of those medical records. Policy and procedure regarding these rights of the client varies by facility and can include remaining with the client as he reviews his records.

A nurse is conducting a breast examination on a client who has a family history of breast cancer. Which of the following should the nurse report to the provider? 1. Silver-colored striae 2. Unilateral nipple inversion present since menarche 3. Dimpling of the tissue in the upper outer quadrant 4. Visible symmetrical venous patterns

3. Dimpling of the tissue in the upper outer quadrant Dimpling of the tissue in the upper outer quadrant should be considered an unexpected finding and reported to the provider. In fact, dimpling that is noted anywhere within the breast tissue should be reported. Dimpling makes the tissue appear retracted in a particular area and can result from underlying scar tissue or an invasive tumor causing ligaments to pull the skin inward toward the tumor. This variation of the breast tissue is consistent with breast cancer.

A nurse is assisting with the preparation of an education program regarding advance directives for newly hired staff. Which of the following information should be included about living wills? 1. Living wills require a written prescription from the provider to be legal. 2. Living wills allow the client to designate a health care proxy. 3. Living wills ensure hospitals provide emergency care regardless of health coverage. 4. Living wills detail treatment wishes of the client in the event of terminal illness.

4. Living wills detail treatment wishes of the client in the event of terminal illness. Advance directives include both living wills and durable powers of attorney for health care. The living will details treatment wishes of the client in the event of terminal illness or persistent vegetative state. This information is accurate and should be included in the teaching about living wills Living wills must be signed by the client to be legal, but a prescription from the provider is not necessary. A written prescription from the provider is required for a do-not-resuscitate (DNR) order to take effect. The durable power of attorney for health care allows the client to designate a health care proxy, not the living will. The Emergency Medical Treatment and Active Labor Act ensures that hospitals provide emergency care regardless of health coverage, not the living will.