Adaptive Quizzing Basics of Nursing Practice - Intermediate

A nurse is helping a client who observes the traditional Jewish dietary laws to prepare a dietary menu. What considerations should the nurse make? Eating beef and veal is prohibited. Consumption of fish with scales is forbidden. Meat and milk at the same meal are forbidden. Consuming alcohol, coffee, and tea are prohibited.

Meat and milk at the same meal are forbidden. Rationale Jewish dietary laws prohibit any combination of milk and meat at the same meal. The Hindu, not Jewish, religion prohibits the ingestion of beef and veal; many Hindus believe that the cow is sacred. Fish that have scales and fins are considered clean, and therefore allowed in the diet. Seventh Day Adventists, Baptists, Mormons, and Muslims prohibit some or all of the beverages alcohol, coffee, and tea.

The healthcare provider has prescribed enoxaparin 1 mg/kg for a client who had a total knee replacement. The client weighs 187 pounds (85 kg). This medication is available in a concentration of 30 mg/0.3 mL. What dose will the nurse administer in milliliters? 0.8 mL 0.85 mL 0.9 mL 0.95 mL

0.85 mL Rationale The answer is calculated as follows: 1 kg = 2.2 lb (187 divided by 2.2 = 85 kg) 85 mg/0.3 mL = 25.5 mg/mL 25.5 mg divided by 30 = 0.85 mL.

Which health care professional is accountable for establishing systems to assess and communicate competency requirements related to delegation? Registered nurses Chief nursing officers Licensed practical nurses Unlicensed nursing personnel

Chief nursing officers Rationale Chief nursing officers are expected to establish the systems to assess and communicate the competencies required for delegation. Registered nurses are accountable for client care. The licensed practical nurse and unlicensed nursing personnel act as delegatees for various tasks.

The nurse is conducting triage under mass casualty conditions. Which tag should the nurse use for a client who is experiencing hypovolemic shock due to a penetrating wound? Red Black Green Yellow

Red Rationale The nurse would use a red tag for a client who has injuries that are an immediate threat to life, such as hypovolemic shock, during mass casualty conditions. A black tag is used for a client who is expected and allowed to die. A green tag is used for a client with minor injuries that do not require immediate treatment. A yellow tag is used for a client who has major injuries requiring treatment.

A client experiences a muscle sprain of the ankle. When assessing the injury, the nurse discovers a developing hematoma and edema. The client reports tenderness when the ankle is palpated. The nurse anticipates that the plan of care will include the application of what? Binder Ice pack Elastic bandage Warm compress

Ice pack Rationale Applying ice directly to a soft tissue injury causes vasoconstriction, which results in decreasing hemorrhage, edema, and pain. Use of a binder or elastic bandage to the area of a soft tissue injury is contraindicated and may cause compartment syndrome (constriction resulting in decreased circulation and nerve function). A warm compress would result in vasodilation and cause increased hemorrhage (hematoma formation), edema, and pain.

The leader is teaching a nursing student about systems theory. Which statement by the student nurse indicates the need for further teaching? Select all that apply . "Systems theory accounts for unpredictability." "Systems theory focuses on the effect of random events." "Systems theory involves open as well as closed systems." "Systems theory is viewed as inputs, throughputs, and outputs." "A system consists of structure, technology, people, and environment."

"Systems theory accounts for unpredictability." "Systems theory focuses on the effect of random events." Rationale Systems theory tends not to account for unpredictability and random events. In contrast, chaos theory focuses on unpredictability and random events. Systems theory involves open as well as closed systems. It is viewed as inputs, throughputs, and outputs. A system theory involves a system that consists of structure, technology, people, and environment.

What does "information salience," a characteristic of communication, refer to according to Anthony and Vidal? Decay of information Clarity of information Change in client's health status Change in client's health information

Clarity of information Rationale According to Anthony and Vidal, "information salience" is a characteristic of communication that refers to the clarity of information shared between the delegator and the delegate. Decay of information, change in client's health status, and change in client's health information are described by the term "information decay."

A healthcare provider prescribes 0.2 mg of cyanocobalamin (vitamin B 12) intramuscularly for a client with pernicious anemia. A vial of the drug labeled 100 mcg = 1 mL is available. How much solution should the nurse administer? Record your answer using a whole number. _____ mL

2mL Rationale The prescribed dose is 0.2 mg. The available concentration is 100 mcg/mL. Use dimensional analysis and/or ratio and proportion to determine the appropriate dose in mL.

While assessing the body temperature of a client, the nurse finds subnormal temperature. Which intervention is beneficial for the client? Administering acetaminophen Covering the client with blankets Assessing for a headache, thirst, and chills Assessing for a possible site of localized infection

Covering the client with blankets Rationale When a client's temperature is subnormal, the nurse should cover the client with more blankets. Acetaminophen is not appropriate for a subnormal temperature; it is appropriate for an elevated temperature. If the client's temperature is elevated, the nurse should further assess for a headache, thirst, and chills. When the client's temperature is above normal, the nurse should assess for a possible site of infection.

During the activation of an emergency preparedness plan, which individual should communicate with the media? Medical director Emergency department nurse Director of human resources Hospital chief executive officer

Director of human resources Rationale The person who would most likely serve as a liaison between the healthcare facility and the media would be the director of human resources. The medical director would most likely decide the number, acuity, and resource needs of clients. The emergency department nurse would most likely evaluate each client to determine priorities for treatment. The hospital chief executive officer would most likely assume overall leadership for implementing the emergency plan.

The nurse makes an error while documenting client's findings. What should be the corrective action of the nurse? Drawing a single line Making new document Applying correction fluid Leaving a space and rewriting

Drawing a single line Rationale When nurses make an error while documenting the client's findings, they should draw a single line through the error. The nurse need not create a new document; just drawing a single line through the error can correct the mistake. The nurse should not apply any correction fluid while recording, because this can lead to illegible entries. While documenting the client's findings, the nurse should not leave blank spaces.

When assessing a client's blood pressure, the nurse notes that the blood pressure reading in the right arm is 10 mm Hg higher than the blood pressure reading in the left arm. The nurse understands what about this finding? It is a normal occurrence. It may indicate atherosclerosis. It can be attributed to aortic disease. It indicates lymphedema.

It is a normal occurrence. Rationale When auscultating blood pressures, readings between the arms can vary as much as 10 mm Hg and are often higher in the right arm. Readings that differ by 15 mm Hg or more suggest atherosclerosis or disease of the aorta. Lymphedema is swelling in one or more extremities that is the result from impaired flow of the lymphatic system.

Which services are covered by the hospice Medicare benefit? Select all that apply. Medication Equipment Care of clients with chronic illness Long periods of respite for caregivers Palliative care related to the terminal illness

Medication Equipment Palliative care related to the terminal illness Rationale The hospice Medicare benefit covers all expenses for medication, equipment, and palliative care related to a terminal illness. The hospice Medicare benefit also covers acute care when needed for the control of symptoms and occasional short periods of respite for caregivers.

A 65-year-old client is depressed and has dementia. Which health-care facility would be most beneficial for the client? Respite-care facility Hospice-care facility Palliative-care facility Long-term care facility

Long-term care facility Rationale A long-term care facility would be most beneficial for a client who suffers dementia and depression. Most residents of long-term care facilities have more than one health disorder when they are admitted. A respite-care facility is provided for family members or caregivers as a "break" from the responsibility of care to clients who are unable to care for themselves. Hospice-care facilities provide care to clients and families as the end of life approaches and are available to any age group. Palliative-care facilities provide comfort care to clients at an earlier stage of serious illness or disease.

When reviewing a drug to be administered, the nurse identifies that the package insert indicates that the Z-track injection technique should be used. Under what circumstance does the nurse expect that this technique will be necessary? Volume of medication to be administered is large. Medication is irritating to subcutaneous tissue and skin. Injection site must be massaged after it is administered. Procedure requires an air bubble to be drawn into the syringe.

Medication is irritating to subcutaneous tissue and skin. Rationale The Z-track method seals the puncture at the intramuscular level, preventing seepage of injected medication up the needle track and thereby avoiding injury to subcutaneous tissue and skin. The Z-track technique is unrelated to the volume of medication to be administered. When the volume of medication is large, it should be administered into a large muscle or divided into two syringes. Massage is avoided with the Z-track technique to help prevent the injected medication from flowing back up the needle track. Administration of a small air bubble at the completion of injection of medication into a muscle (air-lock technique) is no longer recommended because it does not increase the likelihood that medication will remain in the muscle without flowing back up the needle track.

While having a group discussion in a decision-making process, the leader has asked the team members to silently write down their ideas. The merits of each idea were discussed, and the best one was chosen based on highest ranking. Which strategy is involved in this scenario? Focus group Brainstorming Delphi technique Nominal group technique

Nominal group technique Rationale The nominal group technique has group members silently provide written input into the decision-making process. Choosing the ideas based on highest ranking is done after discussing the merits of the ideas. This technique allows equal participation among members and minimizes the problem of dominance. The focus group strategy is used to identify problems or to evaluate the effects of an intervention during a face-to-face discussion but not through writing the ideas. The brainstorming strategy is applied during a decision-making process to generate innovative ideas in spite of having criticism from team members. The Delphi technique is used to achieve consensus among team members by reconsidering and judging the opinions.

Why does a proprietary home health agency apply for a certificate of need to start up the business? To provide legal permission to operate the agency To evaluate certain predetermined standards for the agency To eliminate the need for separate surveys for some agencies To state considerations of the costs of starting and running the agency

To state considerations of the costs of starting and running the agency Rationale Some states grant certification of need according to rules and formulas that state regulators devise to consider the costs of starting and running the business and to determine the need for services provided by the agency. A certification of need does not provide legal permission to operate. Certification is a process in which the government evaluates and recognizes an individual, institution, or educational program as meeting certain predetermined standards. The federal government governs this certification. "Deemed status" is provided to some national accrediting agencies by federal regulators, and this may be helpful in eliminating the need for separate surveys for some agencies.

The registered nurse (RN) delegated a task to a licensed practical nurse (LPN). The LPN completed the task effectively. Which statement made by the RN is appropriate feedback? "Nice job." "Well done." "Your performance was good." "You performed that procedure safely and professionally."

"You performed that procedure safely and professionally." Rationale The statement, "You performed that procedure safely and professionally," clearly identifies what the LPN did well, so it can shape the future behavior positively. The RN should not include vague statements, such as, "Nice job," or, "Well done." The statement, "Your performance was good," could have a positive impact, but a specific behavior is not mentioned in the statement.

A client had surgery on the shoulder, and the nurse is to obtain a brachial pulse. Use the illustration to indicate where the nurse should palpate to best obtain the brachial pulse rate. A B C D

B Rationale One of the several pulse points in the body is the brachial artery; it is the main artery of the upper arm and it bifurcates into the radial and ulnar arteries. Option a is not a major artery of the arm; it is not a pulse point. Option c is the radial artery, which is where the radial pulse is palpated. Option d is the ulnar artery, which is where the ulnar pulse is palpated.

A client has a platelet count of 49,000/mL. The nurse should instruct the client to avoid which activity? Ambulation Blowing the nose Visiting with children The semi-Fowler's position

Blowing the nose Rationale Patients with thrombocytopenia are at a greater risk of excessive bleeding in response to minimal trauma. The nurse should instruct the patient to avoid blowing their nose as this activity can increase the risk of bleeding. The following activities are not contraindicated with thrombocytopenia: ambulation, visiting with children, and semi-Fowler's position.

How can the lines of communication be improved in a healthcare organization during the process of delegation? By considering all aspects of client care By selecting experienced nursing assistants as delegatees By appreciating and valuing each other's cultural perspectives By selecting a delegatee having similar strengths as that of the delegator

By appreciating and valuing each other's cultural perspectives Rationale The lines of communication in a healthcare organization can be improved by appreciating and valuing each other's cultural perspectives, which balances strengths between the delegator and delegatee and improves client care outcomes. Considering all aspects of client care ensures that all of the client care needs are addressed. Selecting experienced nursing assistants as delegatees increases the chances of the delegatee adapting to changing situations. Selecting a delegatee having similar strengths as that of the delegator may decrease the lines of communication because the delegatee might do the task of the delegator.

The registered nurse is delegating tasks for nursing assistants caring for a client who requires more attention. Which element should be considered when selecting the suitable nursing assistant for delegation of a task? Time Safety Stability Critical thinking

Critical thinking Rationale Critical thinking is of utmost importance for selecting a suitable nursing assistant for delegation of a task in a situation where a client requires more attention, as the delegatee should be able to perform the task effectively. Time, safety, and stability are also the elements for effective delegation, but these are suitable depending on the situation for assigning a task and delegation.

When permitted by the client, the nurse should always take the time to keep the family informed about what is happening to the client. What is the purpose of this approach? Informed families will be able to decrease the client's anxiety. Informed families will be more relaxed when interacting with the client. Informed families will be less likely to cause problems with the nursing staff. Informed families will be better equipped to undertake necessary family role changes.

Informed families will be better equipped to undertake necessary family role changes. Rationale Early notification provides an opportunity to prepare for change. The ability to decrease the client's anxiety, families being more relaxed and less likely to cause problems with nursing staff may be a secondary gain but are not the primary purpose.

A client has a "prayer cloth" pinned to the hospital gown. The cloth is soiled from being touched frequently. What should the nurse do when changing the client's gown? Make a new prayer cloth. Discard the soiled prayer cloth. Pin the prayer cloth to the clean gown. Wash the prayer cloth with a detergent.

Pin the prayer cloth to the clean gown. Rationale The prayer cloth has religious significance for the client and should be preserved as is. Making a new prayer cloth disregards what the prayer cloth means to the client. The prayer cloth is the property of the client and should not be discarded. Washing the prayer cloth with a detergent disregards what the prayer cloth means to the client; this never should be done without the client's permission.

An 82-year-old retired schoolteacher is admitted to a nursing home. During the physical assessment, the nurse identifies which ocular problem common at this client's developmental level? Tropia Myopia Hyperopia Presbyopia

Presbyopia Rationale Presbyopia is the decreased accommodative ability of the lens that occurs with aging. Tropia (eye turn) generally occurs at birth. Myopia (nearsightedness) can occur during any developmental level or be congenital. Hyperopia (farsightedness) can occur during any developmental level or be congenital.

A freestanding home health agency receives support from some sources that participate in Medicare-Medicaid and some that do not. Which type of agency is this? Official Voluntary Proprietary Combination

Proprietary Rationale A proprietary home health agency is freestanding and receives support from sources that may or may not participate in Medicare-Medicaid. An official home health agency receives support from local government, grants, fees from limited sources, and charitable contributions. A voluntary home health care agency receives support from tax-deductible contributions, grants, and fees. A combination home health-care agency receives support from local government revenues, grants, fees from limited sources, and charitable contributions.

A client with a fractured tibia and fibula is being discharged from the emergency department with a right leg cast and crutches. In addition to the technical aspects of crutch walking, what teaching should the nurse include? Decrease calcium intake Remove loose rugs from the environment Avoid taking showers until the cast is removed Increase weight bearing on the injured leg gradually

Remove loose rugs from the environment Rationale Loose rugs can interfere with crutch walking and cause a fall; they should be removed to prevent further injury. Calcium is encouraged to enhance bone healing. It is not within the legal role of the nurse to encourage the client to increase the dose of any medication without a health care provider's prescription. The client may shower if the cast is protected from becoming wet. Decisions regarding weight bearing are a medical, not a nursing, responsibility.

What does a nurse understand about the secondary level of prevention? Secondary prevention is aimed at helping clients achieve the highest function possible. Secondary prevention is focused on minimizing effects of long-term disease or disability. Secondary prevention is focused on individuals who are in the early stage of their illnesses. Secondary prevention is aimed at attaining health promotion through wellness development activities.

Secondary prevention is focused on individuals who are in the early stage of their illnesses. Rationale The secondary level of prevention is focused on individuals who are experiencing health problems or illnesses. Tertiary prevention is aimed at helping clients achieve the highest level of function possible. The tertiary level of prevention is focused on minimizing the effects of a long-term disease or disability. The primary level of prevention is aimed at attaining health promotion through wellness development activities.

A nurse observes an ordained priest moving a newborn in the air in the sign of the cross. What does the nurse infer from this observation? The infant is Muslim. The infant is Mennonite. The infant is Presbyterian. The infant is Eastern Orthodox.

The infant is Eastern Orthodox. Rationale Eastern Orthodox babies are required to be baptized within 40 days after birth. If sprinkling or immersion into water is not possible, an ordained priest can perform the baptism by moving the infant in the air in the sign of the cross. Muslim and Mennonite infants are not baptized. Presbyterian infants are baptized with pouring or sprinkling water.

The registered nurse (RN) who was caring for a postsurgical client went out for a break. The RN assigns the work to a healthcare professional who is also an RN. Which is the correct statement regarding this situation? The situation describes delegation. The situation describes assignment. The second nurse holds accountability rather than responsibility for the client. The second nurse holds responsibility rather than accountability for the client.

The situation describes assignment. Rationale When the work is assigned to another registered nurse (RN), it indicates assignment. The RN holds responsibility and also accountability of the assigned task. When the work is assigned to other practitioners, it indicates only responsibility is transferred.

A client is receiving albuterol to relieve severe bronchospasms caused by asthma. For which clinical indicators should the nurse monitor the client? Select all that apply Tremors Lethargy Palpitations Visual disturbances Decreased pulse rate

Tremors Palpitations Rationale Albuterol's sympathomimetic effect causes central nervous stimulation, precipitating tremors, restlessness, and anxiety. Albuterol's sympathomimetic effect causes cardiac stimulation that may result in tachycardia and palpitations. Albuterol may cause restlessness, irritability, and tremors, not lethargy. Albuterol may cause dizziness, not visual disturbances. Albuterol will cause tachycardia, not bradycardia.

Ceftriaxone (Rocephin) 2.5 g intravenous piggyback (IVPB) every 8 hours is prescribed for a client with a severe infection. The pharmacy sends a vial labeled 5 g per 10 mL. What volume of ceftriaxone should the nurse add to the IVPB solution? Record your answer using a whole number. ______ mL

5 ML Rationale Use the "Desire over Have" formula of ratio and proportion to solve the problem. Desire 2.5g x mL ------------- = ----- Have 5 g 10 mL 5x = 25 x = 25 ÷ 5 x = 5 mL

A client is scheduled to receive intravenous (IV) fluids to be delivered at 80 mL/hr. To adjust the drip rate when administering the IV via gravity, what must the nurse determine? Total volume of fluid in the IV bag Size of the needle or catheter in the vein Drops per milliliter delivered by the infusion set Diameter of the tubing being used to instill the fluid

Drops per milliliter delivered by the infusion set Rationale Different infusion sets deliver different preset numbers of drops per milliliter. Knowing this is a necessity for calculating the drip rate. Total volume of fluid in the IV bag and size of the needle or catheter in the vein do not determine the drip rate. Diameter of the tubing being used to instill the fluid determines the size of the drop, not the drip rate.

What should be the goal of physical therapy services that will be reimbursed by Medicare? Promotion Restorative Maintenance Improvement

Restorative Rationale In order to qualify for Medicare reimbursement, physical therapy has to be restorative.

The registered nurse, while teaching a group of nursing students about the characteristics of a good team player, states, "A good team player should work with determination and refuse to stop until the goal has been accomplished." Which characteristic is the registered nurse describing? Tenacity Selflessness Dependability Collaboration

Tenacity Rationale Tenacity means giving your all with determination and refusing to stop until the goal has been accomplished. Selflessness is a characteristic that involves putting the other members of the team ahead of oneself. Dependability involves the nurse following through and doing what he or she agreed to do. Collaboration involves each person bringing something to the project that adds value to the team and supports the creation of synergy.

The nurse finds that a client has an increased temperature. What other sign can be noticed on further assessment? Increased appetite Decreased pulse rate Decreased perspiration Increased respiratory rate

Increased respiratory rate Rationale An increase in body temperature is associated with increased respiratory rate. Decreased appetite is associated with increased temperature. An increased pulse rate is associated with hyperthermia. Increased perspiration is associated with increased body temperature.

A client is hospitalized with chest pain. The client's spouse voices concern about how pale the client is. What is the best response by the nurse? "You must be frightened by this." "Paleness is expected with heart problems." "Other people get pale and recover without any complications." "I can understand why you are worried, but your spouse will be alright."

"You must be frightened by this." Rationale The response "You must be frightened by this" addresses the spouse's concerns and encourages further verbalization of feelings. The response "Paleness is expected with heart problems" does not focus on the spouse's underlying concerns and keeps the discussion on a physiologic level. The responses "Other people get pale and recover without any complications" and "I can understand why you are worried, but your spouse will be alright" provide false reassurance and cut off further verbalization of feelings.

The nurse is caring for clients with different respiratory disorders. Which type of charting system used by the nurse would be appropriate to rate the clients by the severity of illness? Acuity charting Focus charting format Nursing Kardex system A 24-hour client care record

Acuity charting Rationale Acuity charting uses a score that would be helpful for the nurse to rate the clients by the severity of illness. Focus charting format is a modified list of nursing diagnoses used as an index for nursing documentation instead of problem lists. The nursing Kardex system is used by some facilities to consolidate the client's orders and care needs in a concise way. A 24-hour record keeping system helps the nurse to eliminate unnecessary record-keeping forms.

The nurse leader directs the nursing staff during the care of a client who is experiencing cardiac arrest. Which type of leadership should the nurse leader exhibit in the situation? Autocratic leadership Situational leadership Permissive leadership Democratic leadership

Autocratic leadership Rationale Autocratic leadership is important in emergency situations where immediate decisions are required and there is not enough time for group decisions. Cardiac arrest is an emergency situation that would require this type of leadership. Situational, permissive, and democratic leaderships involve group discussions that may delay critical client care.

Which strategy reflects the interdisciplinary rehabilitation team approach? Developing a discipline-specific goal Providing specific care based on the discipline Involving members of several disciplines in cross-training Collaborating with other team members to identify a common goal

Collaborating with other team members to identify a common goal Rationale The main characteristic of the interdisciplinary team approach is that the team involves collaboration among members of several disciplines to provide proper care to the client. Developing a discipline-specific goal and providing specific care based on the discipline are characteristics of a multidisciplinary rehabilitation team. Cross-training with other disciplines is a characteristic of a transdisciplinary rehabilitation team.

Which type of leadership theory explains the effectiveness of leadership and depends on the match between a leader's style and the demands of a situation? Path-Goal theory Two-Factor theory Contingency Model Normative-Decision Making Model

Contingency Model Rationale Fiedler developed the Contingency Model, which explains that the effectiveness of the group depends on an appropriate match between a leader's style and the demands of a situation. Path-Goal theory was developed by House and Mitchell and explains the personal characteristics of followers and environmental demands. The Two-factor theory was developed by Herzberg for motivation in leadership. Normative-Decision Making Model is a problem solving approach developed by Vroom and Yetton.

What should a nurse manager as a leader do to provide a non-threatening and positive environment to the group members? Select all that apply. Ask indirect and close-ended questions Encourage group members to actively participate Create an environment conducive to solving problems Protect the members and their suggestions from attack Encourage the attempts of members to monopolize the discussion

Encourage group members to actively participate Create an environment conducive to solving problems Protect the members and their suggestions from attack Rationale Encouraging group members to actively participate may help elicit different ideas from different members. An environment conducive to solving problems helps in keeping the group focused on tasks and strategies. Protecting members and their suggestions from attack should be done for a healthy discussion and to create a non-threatening environment. Asking direct and close-ended questions may not help involve members who are not actively involved in the discussion. Encouraging the attempts of members to monopolize the discussion may not encourage more passive individuals to contribute to the discussion.

Which of Gardner's tasks involves anticipating client outcomes for single clients or families and helping them formulate their vision of future well-being? Explaining Motivating Affirming values Envisioning goals

Envisioning goals Rationale Envisioning goals is one of Gardner's tasks of leading. It involves anticipating client outcomes for single clients/families and helping clients formulate their vision of future well-being. Explaining involves teaching and providing information to promote client/family functioning and well-being. Motivating involves relating to and inspiring clients and their families to achieve their vision. Affirming values involves helping the client/family explain personal values in relation to health problems and their effect on lifestyle.

The nurse is caring for a client who is recovering from a stroke. The primary health care provider has referred the client for rehabilitative care. Which interventions by the nurse help to make a successful referral process? Select all that apply. Make the referral after the client is discharged. Select a suitable rehabilitation center for the client. Explain the need for referral to the client and family. Provide the referral with adequate client information. Determine what the referral recommends for client care.

Explain the need for referral to the client and family. Provide the referral with adequate client information. Determine what the referral recommends for client care. Rationale Clients are discharged from health care facilities as soon as their conditions allow. Therefore they often need referrals for continuing care from another provider. It is important for the nurse to explain the need for the referral to the client and family. The nurse must coordinate with the referral and provide all necessary client information to prevent duplication of effort or exclusion of important information. The nurse must determine the referral recommendations for client care and include it in the treatment plan. Discharge planning starts as soon as the client is admitted to the health care facility. Therefore the nurse must plan for the referral as soon as possible, not after the client is discharged. The nurse should involve the client and family in the referral process. The client and family should be allowed to select a suitable rehabilitation center.

A client who sustained a leg fracture is discharged from the hospital after initial treatment and is provided with follow-up visits after discharge. Which specialized health-care professional would provide this type of care? Social worker Physical therapist Clinical nurse specialist Home-health-care nurse

Home-health-care nurse Rationale Home-health-care nurses can provide follow-up visits to a client's home to render nursing services. Social workers provide counseling to clients with terminal illnesses and other life crises and assist in finding financial resources to cover medical costs. Physical therapists assist physically disabled clients with their examination and treatment. Clinical nurse specialists work with staff nurses to develop appropriate nursing interventions to be provided to the client and provide instructions to clients and family members who will assume client care.

A nurse manager is assessing the qualities of a team that is led by the nurse leader. Which qualities indicate an effective team? Select all that apply. Autocratic leadership Informal in the work environment Objective involves many personal agendas Formal voting is followed by decision-making Ability to handle conflicts by open discussions

Informal in the work environment Ability to handle conflicts by open discussions Rationale Being informal and comfortable in the work environment indicates that the team is effective. The ability to handle conflict by open discussions will effectively help in resolving conflicts. Autocratic leadership represents an ineffective team. Objectives involving personal agendas may represent an ineffective team. To have an effective team, a decision making process should involve formal voting very minimally.

A nurse is supportive of a child receiving long-term rehabilitation in the home rather than in a health care facility. Why is living with the family so important to a child's emotional development? It provides rewards and punishment. The child's development is supported. It reflects the mores of a larger society. It is primarily where the child's identity and roles are learned.

It is primarily where the child's identity and roles are learned. Rationale Socialization, values, and role definition are primarily learned within the family and help develop a sense of self. Once established in the family, the child can move more easily into society. Although important, providing rewards and punishments, supporting the child's development, and reflecting the mores of society are just one aspect of the family's influence and are not as important as identity and roles in relation to emotional development.

A client with respiratory difficulties asks why the percussion procedure is being performed. What will the nurse tell the client is the purpose of percussion? It relieves pulmonary bronchial spasms. It increases the depth of respirations. It loosens pulmonary secretions. It expels carbon dioxide from the lungs.

It loosens pulmonary secretions. Rationale Percussion (chest physiotherapy) loosens pulmonary secretions by mechanical means. This is accomplished by vibrations over the lung fields on the client's posterior, anterior, and lateral chest. Percussion does not relieve bronchial spasms. Once pulmonary secretions are loosened by percussion and the client has a clearer airway, the depth of respirations may increase and facilitate removal of carbon dioxide from the lungs.

Which action by a home care nurse would be considered an act of euthanasia? Implementing a "do not resuscitate" order in the home health setting. Abiding by the decision of a living will signed by the client's family. Encouraging a client to consult an attorney to document and assign a power of attorney. Knowing that a dying client is overmedicating and not acting on this information.

Knowing that a dying client is overmedicating and not acting on this information. Rationale In this situation being aware that a client is overmedicating and taking no action can be considered an act of euthanasia on the part of the home care nurse. Implementing a "do not resuscitate" order, abiding by the decision of a living will signed by the client's family, and encouraging the client to consult an attorney are all appropriate actions for a home care nurse.

While caring for a client with urinary tract infection, the nurse manager delegated the work of administering oral medications. Which delegatee would be appropriate for this task? Select all that apply. Certified nursing assistant (CNA) Patient care associate (PCA) Licensed practical nurse (LPN) Licensed vocational nurse (LVN) Unlicensed assistive personnel (UAP)

Licensed practical nurse (LPN) Licensed vocational nurse (LVN) Rationale Medications can be administered by the licensed practical nurse (LPN) or licensed vocational nurse (LVN) if the task is not complicated. Patient care associates (PCA) perform basic hygiene for the client. Unlicensed assistive personnel (UAP) can record vital signs under the supervision of the delegator. A certified nursing assistant (CNA) performs basic hygiene and can record vital signs under the supervision of the delegator.

The primary health-care provider suggests that a low-income 40-year-old client with cardiovascular disease, hypertension, and cerebrovascular accident access long-term care services. Which system would financially support the client to access the services? Medicaid Medicare Third party Private pay

Medicaid Rationale Medicaid provides benefits to low-income clients. Therefore, the client can apply for Medicaid. Medicare gives reimbursement benefits to clients with terminal illnesses or clients 65 years of age or older. A third party provides post-hospitalization care services. In private pay, the individual has to pay for home health services.

A healthcare team is caring for a 68-year-old client with diabetes insipidus. Which task is most suitable to be delegated to a licensed practical nurse (LPN) to provide effective client care? Select all that apply. Emptying the urinary drainage bag Monitoring urine output Feeding the client Administration of intravenous fluids Administering oral rehydration medication

Monitoring urine output Administering oral rehydration medication Rationale The LPN scope of practice includes monitoring urine output. Administration of any type of oral medication can also be performed by the LPN. Activities related to a client's hygiene, such as emptying the drainage, are usually performed by an unlicensed assistive personnel (UAP). Feeding the client is usually performed by a UAP. Administration of intravenous fluids is the responsibility of the registered nurse.

The nurse is relating to and inspiring the client who has a psychiatric disorder to achieve the client outcomes. Which of Gardner's leadership tasks is reflected in the nurse's actions? Motivating Envisioning goals Serving as symbol Achieving workable unity

Motivating Rationale When the nurse relates to and inspires the client with a psychiatric disorder to achieve the client outcomes, the nurse is motivating according to Gardner's leadership tasks. Gardner's leadership task of envisioning goals involves envisioning client's outcomes for single clients/families. Gardner's leadership task of serving as symbol involves representing the nursing profession and values and beliefs of the organization to clients and families and other community groups. Gardner's leadership task of achieving workable unity involves assisting clients and families in achieving optimal functioning to benefit the transition to enhanced health functions.

The nurse manager is planning to assign an unlicensed healthcare worker to care for clients. What care can be delegated on a medical-surgical unit to an unlicensed healthcare worker? Select all that apply. Performing a bed bath for a client on bed rest Evaluating the effectiveness of acetaminophen and codeine (Tylenol #3) Obtaining an apical pulse rate before oral digoxin (Lanoxin) is administered Assisting a client who has patient-controlled analgesia (PCA) to the bathroom Assessing the wound integrity of a client recovering from an abdominal laparotomy

Performing a bed bath for a client on bed rest Assisting a client who has patient-controlled analgesia (PCA) to the bathroom Rationale Performing a bed bath for a client on bed rest is within the scope of practice of an unlicensed healthcare worker. Assisting a client who has PCA to the bathroom does not require professional nursing judgment and is within the job description of the unlicensed healthcare worker. Evaluating human responses to medications requires the expertise of a licensed professional nurse. Obtaining an apical pulse rate requires a professional nursing judgment to determine whether or not the medication should be administered. Evaluating human responses to health care interventions requires the expertise of a licensed professional nurse.

Which qualities of a leader indicate a transformational approach to leadership? Select all that apply. Being punitive in nature Possessing charismatic behavior Possessing contingent reward behavior Possessing intellectually stimulating behavior Having inspirational and motivational behavior

Possessing charismatic behavior Possessing intellectually stimulating behavior Having inspirational and motivational behavior Rationale The leader who has a transformational approach to leadership possesses charismatic behavior, intellectually stimulating behavior, and inspirational and motivational behavior. The transformational leader follows an inspirational and motivational approach. The leader who uses the transactional leadership approach has a punitive nature and gives rewards to followers contingently.

A client who has a long leg cast for a fractured bone is to be discharged from the emergency department. When discussing pain management, when does the nurse advise the client to take the prescribed as-needed oxycodone? Just as a last resort Before going to sleep As the pain becomes intense When the discomfort begins

When the discomfort begins Rationale Pain is most effectively relieved when an analgesic is administered at the onset of pain, before it becomes intense; this prevents a pain cycle from occurring. Analgesics are less effective if administered when pain is at its peak. Before going to sleep, it may or may not be necessary; the medication should be taken when the client begins to feel uncomfortable within the parameters specified by the healthcare provider's prescription. Analgesics are less effective if administered when pain is at its peak.

A client reported being administered the wrong dose of medication by the wrong route, which may lead to serious complications. The nurse leader is gathering information to determine what happened. According to Stetler's model, which phase of client care management is the nurse leader following? Validation Translation Preparation Comparative evaluation

Preparation Rationale Medication errors may occur due to the administration of the wrong dose through the wrong route, which may lead to serious complications in the client. According to Stetler's model, the nurse leader is in the preparatory phase, which involves searching, sorting, and selecting sources of evidence. The validation phase focuses on utilization with an appraisal of study findings rather than the critique of a study's design. The transactional, or application, phase involves practical aspects of implementing the plan for translating the research into practice at the individual, group, department, or organizational level. Comparative evaluation is also known as the decision-making phase and involves making a decision about the applicability of the study by synthesizing cumulative findings.

What is the priority of care to promote client safety directly after esophagogastroduodenoscopy? Select all that apply. Preventing aspiration Reminding the client not to drive Monitoring for signs of perforation Advising the client to use throat lozenges Teaching the client about hoarseness of voice

Preventing aspiration Monitoring for signs of perforation Rationale The priority for care to promote client safety after esophagogastroduodenoscopy (EGD) is to prevent aspiration. Signs of perforation such as bleeding, pain, and fever are also monitored as priority care. Reminding the client not to drive is low priority. The client is advised to use throat lozenges to relieve throat discomfort, which is a low priority care. Hoarseness of voice persists for several days after EGD. Therefore the client is taught about hoarseness of voice, which is considered low priority.

A nursing student is taking down notes about the domain of nursing. Which points have been correctly noted by the nursing student? Select all that apply. The domain is the perspective of nursing only and not all professions. The domain of nursing provides both a practical and theoretical aspect of the discipline. The domain provides the subject, central concepts, values and beliefs, phenomena of interest, and central problems of a paradigm. The domain is the knowledge of nursing practice as well as the knowledge of nursing history, nursing theory, education, and research. The domain of nursing gives nurses a comprehensive perspective that allows them to identify and treat a client's healthcare needs at all levels and in all healthcare settings.

The domain of nursing provides both a practical and theoretical aspect of the discipline. The domain is the knowledge of nursing practice as well as the knowledge of nursing history, nursing theory, education, and research. The domain of nursing gives nurses a comprehensive perspective that allows them to identify and treat a client's healthcare needs at all levels and in all healthcare settings. Rationale The domain of nursing provides both a practical and theoretical aspect of the discipline. The domain is the knowledge of nursing practice as well as the knowledge of nursing history, nursing theory, education, and research. The domain of nursing gives nurses a comprehensive perspective that allows them to identify and treat a client's healthcare needs at all levels and in all healthcare settings. The domain is the perspective of a profession. The domain provides the subject, central concepts, values and beliefs, phenomena of interest, and central problems of a discipline.

A nursing student is listing examples of healthcare services. Which scenario is an example of restorative care? Performing radiological procedures on a client who has sustained a heart attack Monitoring the blood pressure of an older adult with insomnia and hypertension Advising a pregnant woman to eat a nutrition-rich diet to avoid any deficiencies in the baby Visiting a private residence to perform maggot-aided debridement therapy of a client's wound

Visiting a private residence to perform maggot-aided debridement therapy of a client's wound Rationale Visiting a client's residence to perform maggot-aided wound debridement is an example of restorative care. Performing radiological procedures on a client who has sustained a heart attack is an example of secondary acute care. Monitoring the blood pressure of an older adult with insomnia and hypertension is an example of preventive care. Advising a pregnant woman to eat a nutrition-rich diet to avoid any deficiencies in the baby is an example of primary care.

The registered nurse (RN) is planning to provide feedback to the licensed practical nurse (LPN). Which questions asked by the RN help in eliciting the LPN's work quality? Select all that apply. "Are you feeling well today?" "How did the patient respond?" "Has the task been completed?" "Are you willing to perform the task?" "What changes were observed in the client?"

"How did the patient respond?" "What changes were observed in the client?" Rationale Providing feedback is the best strategy for shaping the future behavior of the individual. To elicit feedback, a series of open-ended questions should be asked by the registered nurse (RN). This will help collect pertinent information from the individuals delegated a portion of client care, such as client's response and the task to be completed. Asking personal questions about the delegatee does not help in eliciting the work quality of the delegatee. Asking whether the task has been completed is not an open-ended question. Willingness to perform the task directly implies the work interest of the delegate, but not the quality of the delegatee's work.

The nurse is caring for a Jehovah's Witness client who is scheduled for a surgery. Which statement made by the client indicates adherence to cultural beliefs? "I would like to be anointed before my operation." "Do not use a razor blade if you need to shave me." "If possible, please do not remove my jewelry for my surgery." "I don't want to have any blood transfusions during my surgery."

"I don't want to have any blood transfusions during my surgery." Rationale Jehovah's Witnesses believe the transfusion of blood violates God's laws. In this case, Jehovah's Witnesses prefer death to breaking the God's law in this way. The use of electric razor or scissors instead of a razor blade for shaving is a preference for Jewish clients. An Eastern Orthodox, not Jehovah's Witness, client may request anointment by a priest before surgery. For Muslims, some jewelry has important religious significance, so a Muslim, not Jehovah's Witness, client may request that jewelry be left on if possible.

The registered nurse is teaching a novice nurse about the rights of delegation. Which statement by the novice nurse indicates a need for further teaching? "I will refer to the guidelines before delegating the task." "I will check for the competence of the delegatee for the assigned task." "I will instruct the delegatee to monitor and evaluate the client appropriately." "I will check whether the environment is conducive to completing the task safely."

"I will instruct the delegatee to monitor and evaluate the client appropriately." Rationale Monitoring and evaluating the client's condition is the role of the registered nurse, not a delegatee. Referring to the guidelines before delegating the task is included under the delegation right, "right task." Checking for the competence of the delegatee for the assigned task is included under the delegation right, "right person." Checking whether the environment is conducive to completing the task safely is included under the delegation right, "right circumstance."

A client who is suffering from cancer visits a practitioner who believes in the holistic health belief system. Which statement is the practitioner most likely to make in regard to treatment of the client? "All you need to do is believe in God's wishes." "I will teach you meditation techniques for pain relief." "I will focus only on the use of medications and surgery." "I will try to heal you through the power of burning of candles."

"I will try to heal you through the power of burning of candles." Rationale A ritual like burning candles would most likely be a part of a holistic health belief system. Leaving treatment up to only a supernatural force is characteristic of a folk health belief. Using medication and a physical intervention like surgery is part of a biomedical health belief system. Teaching meditation techniques for pain relief is characteristic of an alternative or complementary health belief system.

A parent of a 13-year-old adolescent with recently diagnosed Hodgkin disease tells a nurse, "I don't want my child to know about the diagnosis." How should the nurse respond? "It's best for your child to know the diagnosis." "Did you know that the cure rate for Hodgkin disease is high?" "Would you like someone with Hodgkin disease to talk with you?" "Let's talk about how you're feeling about your child's diagnosis."

"Let's talk about how you're feeling about your child's diagnosis." Rationale Initiating a conversation about the parent's feelings does not prejudge the parent; it encourages communication. Stating that it is best for the child to know the diagnosis disregards the parent's feelings and cuts off further communication. Telling the parent about the cure rate may stop communication and does not recognize the parent's concerns. Offering to have someone with Hodgkin disease speak to the parent is premature and does not recognize the parent's concerns.

Which among the Five Rights of Delegation is the cornerstone of delegation? "Right person" "Right supervision" "Right circumstance" "Right communication and direction"

"Right communication and direction" Rationale Among the Five Rights of Delegation, "right communication and direction" is the most important right of delegation. It is the most useful in maintaining the quality and safety outcomes, as it involves communication and direction. "Right person" is useful for understanding which person has the appropriate skills to perform the task. "Right supervision" involves monitoring the tasks that are performed with the goal of improving outcomes. "Right circumstance" seeks to ensure that the appropriate equipment and resources are available for the delegatee.

The nurse is interviewing a client admitted for uncontrolled diabetes mellitus type II after binging on alcohol for the past two weeks. The client states, "I am worried about how I am going to pay the bills for my family while I am hospitalized." Which statement by the nurse would best elicit further information from the client? "You are worried about paying your bills?" "Don't worry; your bills will get paid eventually." "When was the last time you were admitted for hyperglycemia?" "You really shouldn't be drinking alcohol because of your diagnosis of diabetes."

"You are worried about paying your bills?" Rationale Reflection can help the client to elaborate. The other examples are false assurance, use of professional jargon, and offering advice, which can all restrict the client's response.

A registered nurse delegated a task to the unlicensed nursing personnel (UNP) and is supervising the UNP. Which statements made by the nurse after the UNP completes the task can yield a positive outcome from the UNP? Select all that apply. "Nice job." "What is wrong with you?" "You performed that task safely and professionally." "Did the client respond positively to the nursing care?" "The task was well done, but there is room for improvement."

"You performed that task safely and professionally." "The task was well done, but there is room for improvement." Rationale Feedback, when given clearly and honestly, will yield a positive outcome from the UNP. When the nurse says, "You performed that task safely and professionally," or "The task was well done, but there is room for improvement," it shows that the UNP's work is recognized. Statements such as, "Nice job," are vague and ineffective. Statements such as, "What is wrong with you?" will be perceived as a verbal attack and will not have any positive effect. Questions should be open-ended, in order to encourage the UNP to share experiences with the RN. "Did the client respond positively to the nursing care?" is a closed-ended question that cannot be described further.

Which nursing action is in accordance with the Health Insurance Portability and Accountability Act (HIPAA)? A nurse advocates for a client's wish to donate her eyes after she dies. A nurse seeks permission for the use of life support in an incapacitated client. A nurse avoids discussing a client's reports anywhere outside the health-care facility. A nurse discusses a client's condition with a primary health-care provider in another facility.

A nurse avoids discussing a client's reports anywhere outside the health-care facility. Rationale The Health Insurance Portability and Accountability Act (HIPAA) protects the confidentiality of health information. The nurse is following the law by avoiding discussion of a client's reports outside the health-care facility. The Patient Self-Determination Act (PSDA) emphasizes the right to accept or refuse treatment and requires institutions to maintain written policies and procedures regarding advance directives; this is the law the nurse is following by advocating for a client's wish to donate organs after death. This law also calls for the health-care provider to seek permission to apply life support in an incapacitated client. A nurse who discusses a client's condition with a primary health-care provider in another facility may be in breach of HIPAA if the client has not explicitly signed a release form for the nurse to do so.

A nursing student understands that a nursing theory is a conceptualization of some aspect of nursing that describes, explains, predicts, or prescribes nursing care. Which points about theories made by the nursing student are accurate? Select all that apply. A discipline constitutes a major portion of the knowledge of a theory. A nursing theory helps to identify the focus, means, and goals of practice. Theories give a perspective to assess the situation of a client and to organize data and methods for analyzing and interpreting information. Theory and scientific inquiry do not go hand in hand because they fail to provide guidelines for decision making, problem solving, and nursing interventions. Application of nursing theory in practice depends on the knowledge of nursing and other theoretical models, how they relate to one another, and their use in designing nursing interventions.

A nursing theory helps to identify the focus, means, and goals of practice. Theories give a perspective to assess the situation of a client and to organize data and methods for analyzing and interpreting information. Application of nursing theory in practice depends on the knowledge of nursing and other theoretical models, how they relate to one another, and their use in designing nursing interventions. Rationale A nursing theory helps to identify the focus, means, and goals of practice. Theories give a perspective for assessing clients' situations and organizing data and methods for analyzing and interpreting information. Application of nursing theory in practice depends on the knowledge of nursing and other theoretical models, how they relate to one another, and their use in designing nursing interventions. A theory constitutes much of the knowledge of a discipline. Theory and scientific inquiry are vital links to one another, providing guidelines for decision making, problem solving, and nursing interventions.

A nursing student is taking down notes about paradigm. Which point noted down by the nursing student needs correction? A paradigm is the perspective of a profession. The paradigm of nursing includes four links: the person, health, environment and situation, and nursing. A paradigm links the knowledge of science, philosophy, and theories accepted and applied by a discipline. The elements of the nursing paradigm direct the activity of the nursing profession including knowledge development, philosophy, theory, educational experience, research, and practice.

A paradigm is the perspective of a profession. Rationale The domain is the perspective of a profession, not a paradigm. The paradigm of nursing includes four links: the person, health, environment and situation, and nursing. A paradigm links the knowledge of science, philosophy, and theories accepted and applied by a discipline. The elements of the nursing paradigm direct the activity of the nursing profession, including knowledge development, philosophy, theory, educational experience, research, and practice.

What would help facilitate communication and coordination during a mass casualty event in a hospital using the hospital incident command system? Select all that apply. Activate communication equipment Establish a command center in a designated location Provide key personnel with distinctive clothing identifying their role Ensure key personnel are properly immunized and have a personal emergency plan Distribute job action sheets identifying reporting relationships, tasks, and responsibilities

Activate communication equipment Establish a command center in a designated location Provide key personnel with distinctive clothing identifying their role Distribute job action sheets identifying reporting relationships, tasks, and responsibilities Rationale To facilitate communication and coordination during a mass casualty event in a hospital using the hospital incidence command system, communication equipment needs to be activated. In addition, a command center needs to be created in a designated location. Key personnel need to be easily identified, which can be done by providing distinctive clothing which identifies their role. Jobs action sheets that identify reporting relationships, tasks, and responsibilities will also help facilitate communication and coordination at this time. Key personnel do not need to be immunized or have a personal emergency plan when handling a disaster within an organization.

Which should the licensed practical nurse (LPN) consider when assisting the registered nurse (RN) in assessing health disparities within the community? Select all that apply. Age Gender Ethnicity Disability Education

Age Gender Ethnicity Disability Rationale Health disparities can affect population groups based on gender, age, ethnicity, socioeconomic status, geography, sexual orientation, disability, or special needs health care needs. Education is not a specific consideration for assessing health disparities within the community, though other factors may influence education as well as health.

The nurse manager enlists 10 direct care nurses for a project addressing the needs of the human immunodeficiency virus (HIV). The project successfully completes within the timeline. What would be the most essential factor for the success of the nursing manager? Offering ideas to the direct care nurses Providing training to the direct care nurses Allowing the direct care nurses to share ideas Promoting discipline among the direct care nurses

Allowing the direct care nurses to share ideas Rationale The most important element of success for the nursing manager is to allow the direct care nurses to share their ideas about the project and participate in decision making. This approach will increase their organizational commitment and increase the feeling of self-worth. The nurses will then be more likely to invest extra effort for successful completion of the project. The other factors necessary for successful completion of the project include providing ideas, training the nurses, and promoting discipline.

Which of the following signs and symptoms are likely to be found in an adult experiencing sexual abuse? Select all that apply. Anorexia Flat affect Panic attacks Physical aggression Excessive daydreaming

Anorexia Flat affect Panic attacks Rationale Anorexia, a flat affect, and panic attacks are behavioral/nonverbal signs and symptoms a nurse may observe in an adult victim of sexual abuse. Physical aggression and excessive daydreaming are behavioral/nonverbal signs and symptoms more likely to be exhibited by a child victim of sexual abuse.

A nurse gathers data about the success of keeping the side rails of clients' beds up at nighttime to reduce the risk of falls. Which competency does the nurse display according to the Institute of Medicine (IOM) competencies of the 21st century? Using informatics Applying quality improvement Using evidence-based practice Working in interdisciplinary teams

Applying quality improvement Rationale According to the Institute of Medicine (IOM) competencies of the twenty-first century, nurses are required to incorporate quality improvement into their work. A nurse performs this task by identifying potential hazards, designing interventions to improve quality, and evaluating the success of the strategies. In the given situation, the nurse is evaluating the success of a strategy to minimize clients' risks of falls. Using informatics involves the use of information technology for the purposes of communication, management of knowledge, and reduction of errors. Using evidence-based practice involves participating in research activities and integrating results of research with client care. A nurse is required to work with interdisciplinary teams to provide better care to clients. This action is done by cooperating and collaborating with the client, caregivers, and other health care workers.

During peer review, a staff member tells the manager, "The newly appointed nurse leader does not ask for input from the staff while making decisions regarding the shifts of the nursing unit." Which type of leadership style does the manager think the newly appointed nurse leader is exhibiting? Autocratic leadership Situational leadership Permissive leadership Democratic leadership

Autocratic leadership Rationale In autocratic leadership, the leader retains all authority and responsibility and does not ask for team input. Based on the information provided, the nurse leader is exhibiting this leadership. Situational leadership takes into account the style of the leader, the group being managed, and the situation at hand. Permissive (laissez-faire) leadership involves relinquishing control and allowing the group to make all decisions. In a democratic leadership, the leader emphasizes team building and collaboration through the joint effort of all team members.

Which system thinking theory principle is involved when the nurse considers the decision of a client to terminate clinical treatment? Thinking of the big picture Balancing short-term and long-term objectives Using measurable versus non-measurable data systems Recognizing the dynamic, complex, and interdependent nature of systems

Balancing short-term and long-term objectives Rationale Balancing short-term and long-term objectives may involve the nurse considering the decision of the client about termination of clinical treatment in order to have a better quality outcome. Thinking of the big picture involves the nurse explaining the needs of all units of the hospital or all residents in a long-term facility. Using measurable versus non-measurable data systems involves moving beyond the tendency to see only what we measure and analyzing morale, working relationships, and teamwork. Recognizing the dynamic, complex, and interdependent nature of systems involves understanding how clients are connected to families and friends and how, together, they are connected to communities and cultures.

Which criteria would a 75-year-old client need to meet to qualify for Medicare services? Being qualified for social security benefits A validated need for long-term residential care A documented absence or desertion of family caregivers A history of failed responses to standard medical treatments

Being qualified for social security benefits Rationale In order to qualify for Medicare, an individual must be entitled to receive social security benefits. Medicare services are applicable to clients older than 65. An inadequate response to treatment is not a qualification criteria for Medicare services. The absence or desertion of family caregivers is not an adequate criterion to receive Medicare services. The Medicare insurance program does not cover residential care services.

Before assigning a task, the registered nurse makes sure that the delegation process is appropriate to the situation. To which delegation right does this situation refer? Person Supervision Circumstance Communication

Circumstance Rationale Ensuring that the delegation process is appropriate to the situation refers to right circumstance. Knowing whether the delegatee has the knowledge and experience to perform the specific task safely refers to the right person. Knowing whether the delegator is able to monitor and evaluate the client appropriately refers to the right supervision. Ensuring whether the delegator and delegatee understand a common work-related language refers to the right communication.

Which members of the healthcare team are under dependent status when a task is delegated by the registered nurse (RN)? Select all that apply. Unit secretary Client attendant Registered nurse (RN) Primary healthcare provider Licensed vocational nurse (LVN)

Client attendant Licensed vocational nurse (LVN) Rationale Unlicensed nursing personnel (UNP), the licensed practical nurse (LPN), or the licensed vocational nurse (LVN) whose function is under the direction of a registered nurse are given dependent status. The client attendant and the LVN are on dependent status when a task is delegated by the RN. The unit secretary is a member of the healthcare team but is devoid of formal preparation or legal recognition. The RN is the leader of the team and has responsibility for other members of the group. The primary healthcare provider is a member of the healthcare team but may delegate tasks to those with dependent status.

The registered nurse is teaching the student nurse about the concepts of delegation. Which response given by the student nurse indicates the need for further teaching? Delegation always involves two individuals. Delegation is the transfer of accountability while retaining responsibility. Delegation is an important strategy for client safety and quality of client care. Delegation has five rights that should be followed in the process of delegation.

Delegation is the transfer of accountability while retaining responsibility. Rationale Delegation is the transfer of the responsibility for the task, while the final accountability is always retained with the delegator. Delegation involves the delegator and the delegatee. Delegation is an important strategy for ensuring client safety and quality of client care. Delegation has five rights that are to be followed throughout the delegation process: right task, right person, right circumstance, right direction/communication, and right supervision.

Identify the populations who are eligible for the Medicare insurance program. Select all that apply. Disabled individuals Low-income children Clients receiving dialysis People older than 65 years Uninsured pregnant women

Disabled individuals Clients receiving dialysis People older than 65 years Rationale Medicare covers disabled people, dialysis clients, and clients older than 65 years of age. Medicaid insurance programs cover low-income children and uninsured pregnant women.

A nurse is caring for an older adult with a hearing loss secondary to aging. What can the nurse expect to identify when assessing this client? ( Select all that apply.) Dry cerumen Tears in the tympanic membrane Difficulty hearing high-pitched voices Decrease of hair in the auditory canal Overgrowth of the epithelial auditory lining

Dry cerumen Difficulty hearing high-pitched voices Rationale Cerumen (ear wax) becomes drier and harder as a person ages. Generally, female voices have a higher pitch than male voices; older adults with presbycusis (hearing loss caused by the aging process) have more difficulty hearing higher-pitched sounds. There is no greater incidence of tympanic tears caused by the aging process. The hair in the auditory canal increases, not decreases. The epithelium of the lining of the ear becomes thinner and drier.

A nurse is going through a pilot research study that aims to identify the effectiveness of using an experimental therapeutic communication technique when dealing with aggressive clients. What type of research study is this? Evaluation research Exploratory research Descriptive research Correlational research

Exploratory research Rationale Exploratory research studies are initial studies that are conducted to develop or refine dimensions of phenomena or to develop a hypothesis about the relationships among phenomena. The given example is an exploratory research study. Evaluation research focuses on determining the effectiveness of a program, practice, or policy. Descriptive research focuses on measuring the characteristics of people, situations, or groups and the frequency with which certain events or characteristics occur. Correlational research aims to explore variables of interest without any active intervention by the researcher.

A nurse is using evidence-based practice to formulate a treatment plan for a client. The nurse uses the PICOT format to ask a clinical question. What should be the next step in the decision-making process? Critically appraising all the evidence available Gathering the most relevant and best evidence Sharing the outcomes of the evidence-based practice changes with others Integrating all available evidence with clinical expertise and client preferences

Gathering the most relevant and best evidence Rationale After asking the clinical question, the nurse should gather the most relevant and best evidence. The nurse may perform a critical appraisal after gathering all the necessary evidence. Sharing the outcomes of the evidence-based practice changes with others is the last step of the decision-making process. After gathering relevant evidence and appraising the same, the nurse should integrate it with clinical expertise and client preferences.

What factors may result in health disparities? Select all that apply. Gender of the client Comorbidities in the client Health care provider attitude Height and weight of the client Socioeconomic status of the client

Gender of the client Health care provider attitude Socioeconomic status of the client Rationale Adult women use health services more than men do, so gender leads to health disparities. Health-care provider attitude may also lead to health disparities, because it can affect the quality of care provided to different demographic groups. Because socioeconomic status affects what kind of care a client can afford, this factor also creates health disparities. Comorbidities and height and weight of the client influence the client's health but not health disparities.

A client who is in the terminal stage of an autoimmune disorder has a question about a drug. Which member of the primary hospice care team is best equipped to answer the question? Hospice aide Primary nurse Hospice volunteer Hospice pharmacist

Hospice pharmacist Rationale A hospice pharmacist is responsible for providing drug consultation to the client. A hospice aide provides personal care to the client and assists the client with bathing. A hospice volunteer provides companionship to the client and caregiver. A primary nurse serves as a liaison among the client, the health-care provider, and the interdisciplinary team; evaluates the client's response to treatment; and educates the client and the family on the disease process and care.

While documenting client records, the nurse finds that an incorrect dose of drug was administered to a client. Which document should be filed in response to this action? Incident report Focus charting form Acuity charting form 24-hour client care record

Incident report Rationale An incident report is used to document the details of an unusual event that occurs at the facility, such as administering an incorrect dose of a drug to a client. The focus charting format uses a modified list of nursing diagnosis that involves positive concept of a client's needs. The acuity charting system uses a score to rate the client's based on the severity of the illness. A 24-hour-record keeping system is a consolidated format of documentation of a 24-hour period.

A client is admitted with a diagnosis of premature labor. The nurse discovers that the client has been using heroin throughout her pregnancy. What is the most appropriate action for the nurse to take? Notify the nurse manager of the unit. Inform no one because all client information is confidential. Inform the client's healthcare provider. Alert the hospital security department because heroin is an illegal substance.

Inform the client's healthcare provider. Rationale The fetus of a heroin-addicted mother is at risk for serious complications such as hypoxia and meconium aspiration. It is important to notify the healthcare provider of the client's heroin use, because this information will influence the care of the client and newborn. This information is used only in relation to the client's care. With the client's consent, it may be shared with other social service or health agencies that become involved with the client's long-term care. The nurse manager of the unit may be notified as it relates to the care of the client and her newborn. Client information is confidential and only necessary staff should be privileged to such information. Hospital security would only be notified if actual illicit substances were discovered on hospital premises.

A direct care nurse performs exceedingly well on a cancer project. As a result, the managerial team decides to promote the nurse to a managerial position. Which actions by the nurse would justify the decision of the panel? Select all that apply . Inspiring new ideas Establishing short-term goals Demonstrating positive feelings Maximizing results from existing resources Showing willingness to both lead and follow peers

Inspiring new ideas Establishing short-term goals Demonstrating positive feelings Maximizing results from existing resources Rationale The leader provides new ideas with a long-term effect on the progress of the organization. He or she should also provide a positive atmosphere by giving an equal importance to the followers. Providing short-term goals and maximizing results from existing resources are the job responsibilities of a manager. The willingness to lead and follow peers is the quality of a good follower.

The primary health-care provider advises a client to have an abortion to save her life. In accordance with their religion, the client and her family members agree this is the best choice. To which religion might this client belong? Islam Judaism Eastern Orthodox Jehovah's Witness

Judaism Rationale Although usually prohibited, when the mother's life is in danger, Judaism allows abortion. Abortion is forbidden no matter what in the Islam, Eastern Orthodox, and Jehovah's Witness communities.

A client with type 2 diabetes mellitus and hypertension is discharged from the hospital and is advised to go into long-term care. The client cannot afford a long-term care facility. What source would help the client to receive long-term care services? Medicaid Private pay Preferred provider organizations (PPOs) Health maintenance organizations (HMOs)

Medicaid Rationale Medicaid provides benefits of home health services to poor people and low-income people.

After the death of a client, the primary health-care provider asks the family members if they wish to donate the organs of the client, and in accordance with their religion, they agree to it without hesitation. To which religious group does this family belong? Islam Judaism Methodist Christian Science

Methodist Rationale Methodists encourage organ donation, so this family is likely Methodist. Jews and Muslims require all body parts to be present in the body for burial. Organ donation is unlikely for Christian Scientists, but it is an individual decision.

While caring for victims of a hurricane, a nurse is teaching hygiene practices and symptoms of various infections. Which phase of disaster management is the nurse executing? Mitigation Response Evaluation Preparedness

Mitigation Rationale Mitigation is the attempt to limit a disaster's impact on human health and community functions. Educating the client about the rapid spread of infectious diseases and various hygiene methods that can be adopted in such conditions will help limit the impact of the disaster. Response is the actual implementation of the disaster plan. Evaluation involves identifying successes and failures of the response effort in order to prepare for the future. Preparedness is the protective plan designed before the occurrence of a disaster to assess the risk and evaluate the potential damage.

The registered nurse (RN) is caring for a client who underwent surgery for a pituitary tumor. Which task can be delegated to unlicensed nursing personnel (UNP)? Teaching the client Monitoring vital signs Assessing laboratory reports Evaluating the status of the client

Monitoring vital signs Rationale The unlicensed nursing personnel (UNP) can be delegated to care for a client in an acute care setting if the client is stable. So, the vital signs can be monitored by the unlicensed assistive personnel (UAP) if the client has stable vital signs. Client teaching is in the scope of the registered nurse (RN). Reinforcement of the teaching can be delegated to the UAP. Assessing laboratory reports is the role of the RN; this task may not be delegated to unlicensed personnel. Evaluating client status is the role of the RN; this task is outside the scope of practice of the UAP.

A 2-year-old child admitted with a diagnosis of pneumonia was administered antibiotics, fluids, and oxygen. The child's temperature increased until it reached 103° F. When notified, the health care provider determined that there was no need to change treatment, even though the child had a history of febrile seizures. Although concerned, the nurse took no further action. Later, the child had a seizure that resulted in neurological impairment. Legally, who is responsible for the child's injury? Health care provider, because this decision took precedence over the nurse's concern Health care provider, because of total responsibility for the child's health and treatment regimen Nurse, because failure to further question the health care provider about the child's status placed the child at risk Neither, because high fevers are common in children and the health care provider had little cause for concern

Nurse, because failure to further question the health care provider about the child's status placed the child at risk Rationale It is the nurse's responsibility to foresee potential harm and prevent risks by acting as a client advocate. This is not acceptable as a rationale for inaction. The nurse and health care provider share interdependent roles in the assessment and care of clients. High temperatures are common in children but are nonetheless a valid cause for concern.

The nurse discovers several palpable elevated masses on a client's arms. Which term most accurately describes the assessment findings? Erosions Macules Papules Vesicles

Papules Rationale Papules are superficial and elevated up to 0.5 cm. Nodules and tumors are masses similar to papules but are elevated more than 0.5 cm and may infiltrate deeper into tissues. Erosions are characterized as loss of the epidermis layer; macules are nonpalpable, flat changes in skin color less than 1 cm in diameter; and vesicles are usually transparent, filled with serous fluid, and are a blisterlike elevation.

A client does not consent to disclose his or her medical records and information regarding his or her health status. However, a nursing student unintentionally makes the information public. According to the Health Insurance Portability and Accountability Act, which section has been violated? Privacy Confidentiality Durable power of attorney Uniform anatomical gift act

Privacy Rationale Privacy is the right of clients to keep personal information from being disclosed. In the given situation, the nursing student violates the client's privacy by disclosing medical information to outsiders. Confidentiality protects private client information once it has been disclosed in healthcare settings. A durable power of attorney is a legal document that allows a person or persons of the client's choosing to make healthcare decisions on his or her behalf. The uniform anatomical gift act deals with the right of donating organs after becoming an adult.

A registered nurse (RN) delegates a task to a licensed practical nurse (LPN). What should the RN do when the LPN executes the task improperly? Provide constructive feedback. Engage in a verbal attack on the delegate. Express satisfaction with the LPN's execution of the task. Ignore the task for now but stop considering the LPN for further delegation.

Provide constructive feedback. Rationale The delegator should provide constructive and positive, yet honest, feedback about the work of the delegatee. A verbal attack will destroy the relationship between the delegatee and delegator. The RN would lose credibility by conveying satisfaction with the delegatee's work, which is not satisfactory. Ignoring the task and not giving feedback will not promote a healthy relationship.

The nurse asks the health-care provider to provide new prescription by including potassium supplement to a client with low potassium levels. Which nursing process is involved in this situation? Situation Read back Assessment Recommendation

Recommendation Rationale Recommendation in SBARR (Situation, Background, Assessment, Recommendation and Read back) refers to requesting an order for the client to treat the condition. In this situation, the nurse is recommending that the health-care provider provide new prescription. Situation determines what is going on with a particular situation. Read back refers to reading the order back to understand the prescription correctly. Assessment involves finding the reason for the clinical situation raised (in this case, low potassium levels).

A client spends several minutes making negative comments to the nurse about numerous aspects of the hospital stay. What is the nurse's best initial response? Describe the purpose of different hospital therapies to decrease the client's anxiety. Explain that becoming so upset does not allow the client to get much-needed rest. Refocus the conversation on the client's fears, frustrations, and anger about the condition. Permit the client to release feelings and then leave the room to allow the client to regain composure.

Refocus the conversation on the client's fears, frustrations, and anger about the condition. Rationale Refocusing the conversation on the client's fears, frustrations, and anger about the condition provides an opportunity for the client to verbalize the feelings underlying the behavior. Describing the purpose of different hospital therapies will have no effect on decreasing the client's anxiety or on allowing ventilation of feelings. Explaining that becoming so upset dangerously blocks the need for rest will not decrease anxiety so that the client can rest. Although allowing release of feelings is therapeutic, leaving denies the client the opportunity for verbalization and discussion.

A healthcare team is delegated the task of assisting a client with bathing. Which member of the healthcare team is responsible and accountable for this aspect of client care? Nursing aide Registered nurse (RN) Patient care associate (PCA) Licensed vocational nurse (LVN)

Registered nurse (RN) Rationale Bathing is often delegated to a patient care associate (PCA) on the healthcare team. The registered nurse (RN) is accountable for the client care, but is not delegated the task of basic hygiene care such as bathing. Though the nursing aide is responsible for client care, he or she is not accountable for the client care. Similarly, a PCA may be responsible but not accountable for client care. As bathing is not generally delegated to a licensed vocational nurse (LVN), the LVN is neither responsible nor accountable for client care.

A client using fentanyl transdermal patches for pain management in late-stage cancer dies. What should the hospice nurse who is caring for this client do about the patch? Tell the family to remove and dispose of the patch. Leave the patch in place for the mortician to remove. Have the family return the patch to the pharmacy for disposal. Remove and dispose of the patch in an appropriate receptacle

Remove and dispose of the patch in an appropriate receptacle. Rationale The nurse should remove and dispose of the patch in a manner that protects self and others from exposure to the fentanyl. Having the family remove and dispose of the patch or having the mortician remove the patch is not safe. It is not the responsibility of nonprofessionals because they do not know how to protect themselves and others from exposure to the fentanyl. It is unnecessary to return a used fentanyl patch to the pharmacy.

A registered nurse delegates a task to a licensed practical nurse (LPN). The nurse manager asks the registered nurse, "Are the equipment and resources available for the LPN to complete the task?" Which right of delegation is the nurse manager preserving? Right task Right direction Right supervision Right circumstance

Right circumstance Rationale Questions such as, "Is the environment conducive to completing the task safely?" and, "Are the equipment and resources available to complete the task?" ensure the right circumstance for delegation. Right task is ensured with a question such as, "Is the task appropriate to the delegate, according to institutional policies and procedures?" Delegation is taking the right direction if the answer to a question such as, "Do the delegator and delegatee understand a common work-related language?" is positive. Right supervision is evaluated with a question such as, "Is the delegator able to monitor and evaluate the client appropriately?"

Which statements are true regarding the right supervision aspect of delegation? Select all that apply. Right supervision includes limits and expectations. Right supervision is essential to maintain accountability. Right supervision is essential to complete the task in time. Right supervision involves seeking assistance and providing feedback. Right supervision includes the appropriate client setting and available resources.

Right supervision is essential to maintain accountability. Right supervision is essential to complete the task in time. Right supervision involves seeking assistance and providing feedback. Rationale Right supervision is essential to maintaining accountability of events taken place while delegating a task. It has a major advantage of allowing the nursing staff to complete a task in a timely manner. It is essential for the delegatee to ask questions and seek assistance comfortably. Right communication involves limits and expectations. Right circumstances include figuring out the appropriate client setting and available resources.

The nurse leader teaches student nurses about ways of making care visible. During a follow up visit, the leader observes the nurse holding the client's hand after finding him or her anxious before radiation therapy. Which communication skill applied by the student nurse shows effective learning? Expressing appreciation Using blameless apology Showing nonverbal care Making clear a positive intent

Showing nonverbal care Rationale The use of a facial expression, intonation, posture, eye contact, and other body language to mirror the client's feelings signify nonverbal care. Expressing appreciation may involve giving a personal gift of positive regard. A blameless apology is used to express the genuine regret for a negative experience. Positive intent is made clear by explaining the work being done to suit the client's best interest.

A teenager begins to cry while talking with the nurse about the problem of not being able to make friends. What is the most therapeutic nursing intervention? Sitting quietly with the client. Telling the client that crying is not helpful. Suggesting that the client play a board game. Recommending how the client can change this situation.

Sitting quietly with the client. Rationale Sitting quietly with the client conveys the message that the nurse cares and accepts the client's feelings; this helps to establish trust. Telling the client that crying is not helpful negates feelings and the client's right to cry when upset. Distraction (suggesting that the client play a board game) closes the door on further communication of feelings. After a trusting relationship has been established, the nurse can help the client explore the problem in more depth.

A client with terminal cancer is admitted to a palliative care unit. Which specialized health-care professional is involved in providing counseling to this client? Social worker Speech therapist Physical therapist Occupational therapist

Social worker Rationale Social workers provide counseling to clients with terminal illnesses and other life crises; they also assist in finding financial resources to cover medical costs. Speech therapists assist clients with communication and speech. Physical therapists assist physically disabled clients with their examination and treatment. Occupational therapists teach clients to adapt to physical or cognitive challenges by learning new vocational skills or new ways to approach activities of daily living.

Which element creates an integrative process that fosters effective delegation decisions by the registered nurse? Ability Liability Stability Ethnicity

Stability Rationale Stability is the element that creates an integrative process that fosters effective delegation decisions. Ability is the factor that needs to be assessed to determine the level the leaders determine. Liability is the person's responsibility and accountability for individual actions. Ethnicity does not play a role in the process of delegation.

Which statements are true regarding home health-care organizations? Select all that apply. The Visiting Nurses Association is an example of a home health agency. Home health service organizations are typically nonprofits. Individual payments may help fund home health services. Physical therapy is a secondary skill of the home health service worker. Occupational therapy is a primary skill of the home health service worker.

The Visiting Nurses Association is an example of a home health agency. Individual payments may help fund home health services. Rationale The Visiting Nurses Association is an example of a home health agency. Home health-care services are funded by individual payments, private insurance, Medicare, and Medicaid. Therefore they are for-profit organizations, not nonprofits. Physical therapy is a primary, not secondary skill, and occupational therapy is a secondary, not primary, skill for home health workers.

In which situation does a living will become enforceable? The client becomes legally incompetent. The client is diagnosed with a terminal illness. A judge determines that the client has lost decisional capacity. The client decides that he or she will enforce the living will at that time.

The client becomes legally incompetent. Rationale For an advance directive like a living will to become enforceable, the client must be legally incompetent or lack the capacity to make decisions regarding health-care treatment. Terminal illness is not sufficient for enforcement of the living will if the client is legally competent. For a living will to be enforceable, the client must be found to have lost decisional capacity regarding health care. While a judge determines legal competency, the physician and family determine decisional capacity. The living will comes into effect only when the client is found to have lost decisional capacity, which means the client is unable to make a conscious decision to make the living will enforceable.

What should the nurse include in dietary teaching for a client with a colostomy? Liquids should be limited to 1 L per day. Non-digestible fiber and fruits should be eliminated. A formed stool is an indicator of constipation. The diet should be adjusted to include foods that result in manageable stools.

The diet should be adjusted to include foods that result in manageable stools. Rationale Each person will need to experiment with diet after a colostomy to determine what foods are best tolerated and also produce stools that are manageable, depending on the type of colostomy. Liquids are typically not limited unless there is a specific reason such as cardiac or renal disease. Food high in fiber such as fruit should be included in the diet as tolerated. Depending on the type of colostomy and the diet, a formed stool is acceptable and does not indicate a constipating diet.

Which statement is true regarding the measurement of rectal temperature? The thermometer probe is inserted about 3.5 inches into the rectum. The thermometer probe is lubricated before inserting into the rectum. The rectal route of measuring temperature is preferred in clients with traction. The client is placed in the side-lying position while measuring rectal temperature.

The thermometer probe is lubricated before inserting into the rectum. Rationale The thermometer probe should be lubricated before being inserted into the rectum. The probe is inserted about 1.5 inches into the rectum. The client is placed in the Sims' position while measuring the rectal temperature. In clients with traction, the rectal route for measuring temperature should be avoided.

The nurse leader is executing quality improvement (QI) processes in a team. Why are QI processes important? They involve chart audits. They inspect nursing activities. They discover and correct errors. They review the nursing activities.

They review the nursing activities. Rationale QI processes improve quality by reviewing nursing activities. Quality assurance (QA) processes involve chart audits. QI will only review nursing activities and does not inspect. Inspection of nursing activities is done during the QA process. The QA process discovers and corrects errors, whereas the QI process prevents errors.

A nursing student is recalling the Stage-Crisis Theory of Robert Havinghurst. Which step listed by the nursing student needs correction according to Havinghurst theory? The number of tasks differs in each age level for individuals. There are six stages and six-to-ten developmental tasks for each stage. Successful resolution of the developmental task is essential to successful progression throughout life. This theory includes four periods that are related to age and demonstrates specific categories of knowing and understanding.

This theory includes four periods that are related to age and demonstrates specific categories of knowing and understanding. Rationale Havinghurst's theory does not include four periods that are related to age and does not demonstrate specific categories of knowing and understanding; this statement is associated with Piaget's theory of cognitive development. Havinghurst's theory states that the number of tasks differs in each age level for individuals. Havinghurst's theory consists of six stages and six-to-ten developmental tasks for each stage. Havinghurst's theory believes that the successful resolution of developmental tasks is essential to successful progression throughout life.

Which objective is associated with creating urgency in Kotter's eight-step model? To create short-term targets To honor the people who helped complete a task To create a culture with continuous improvement To generate open dialogue about external and internal realities

To generate open dialogue about external and internal realities Rationale The attribute of creating urgency is associated with generating open dialogue about external and internal realities. Short-term targets are created for creating short-term wins. Honoring the people who help complete the task anchors the changes in the culture. A culture created with continuous improvement builds on the change.

What would the registered nurse describe as the role of the American Red Cross in emergency nursing after a community disaster? To manage mass fatalities To establish fully functional field surgical facilities To set up shelters for clients who have lost their homes To deal with emotions of healthcare providers after a disturbing event

To set up shelters for clients who have lost their homes Rationale American Red Cross is activated by state and federal government authorities for mass casualty situations or disasters. American Red Cross sets up shelter for clients who lost their homes in the disaster or are relocated from their homes. Disaster Mortuary Operational Response Teams (DMORTs) are a healthcare service that helps to manage mass facilities. International Medical Surgical Response Teams (IMSuRTs) are healthcare services that establish fully functional field surgical facilities in a disaster. Critical Incident Stress Debriefing (CISD) teams are called to deal with emotions of healthcare providers after a disturbing event.

What is the key idea of role theory in nurse leadership? Select all that apply. To allow a non-linear change To understand behavior in certain circumstances To consider the lower level of basic needs as important To clarify the relationship between the pathway employees To collect concepts that predict the actors' performance in a given role

To understand behavior in certain circumstances To collect concepts that predict the actors' performance in a given role Rationale Role theory involves understanding behavior in certain circumstances. It also includes collecting the concepts that predict the leader's performance in a given role. Diffusion theory focuses on allowing a non-linear change. The lower levels of the basic needs are considered important according to McGregor's theory. Path-Goal theory focuses on the environment for clarifying the relationship between the pathway employees.

A delegator working in a rural setting has to handle a task of managing care for clients in that area. Which crucial step should the delegator take to develop a productive strategy in delegating tasks to a delegatee? Assigning the task to the delegatee Providing feedback to the delegatee Supervising the task at regular intervals Understanding the capabilities of the delegatee

Understanding the capabilities of the delegatee Rationale A delegator, before handling a task, should understand the specific capabilities and skill set of the delegatee. Selecting a delegatee who has the specific skill set for the particular task is a more productive strategy than just selecting a competent individual. The delegator has to assess the delegatee and then assign the task on the basis of the competitive skills. Providing feedback during and after the task may enhance the working capabilities of the delegatee. Supervising a task is an ultimate essential element for the delegator, because the delegator is responsible for the accountability of completing the task.

A client with a massive head injury was admitted to emergency department. The trauma team leader notifies the family that the client is expected to die and asks the family about donating the client's organs. The family members agree to proceed with the donation. To which religious group does the family belong? Islam Christian Science Orthodox Judaism Unitarian Universalist Association

Unitarian Universalist Association Rationale Unitarian Universalists advocate for organ donation, so this family might belong to this religious group. Muslims, Jews, and Christian Science members do not believe in organ donation.

A client with terminal bone cancer is to receive 2 mg of hydromorphone intravenously (IV) every 4 hours as needed for severe breakthrough pain. The vial contains 10 mg/mL. When the client reports severe pain, how much solution of hydromorphone should the nurse administer? Record your answer using one decimal place. Include a leading zero if applicable. ___ mL

0.2 2mg/10mg = 0.2 Rationale The prescribed dose is 2 mg. The available concentration is 10 mg/mL. Use the dimensional analysis and/or ratio and proportion methods to determine how many milliliters the nurse should administer.

In which delegation right is it essential for the assistive personnel to be comfortable asking questions and seeking assistance? Right person Right supervision Right circumstance Right communication

Right supervision Rationale The right supervision is essential to allow assistive personnel to ask questions and seek assistance. The right person is essential for delegating the right task. The right circumstance is necessary to determine what to delegate. The right communication is essential to coordinate care.

A client scheduled to receive radiation therapy for cancer says to the nurse, "My family said I will get a radiation burn." What is the nurse's best response? "Your skin will look like a blistering sunburn." "A localized skin reaction usually occurs." "A daily application of an emollient will prevent a burn." "Your family must have had experience with radiation therapy."

"A localized skin reaction usually occurs." Rationale Radiodermatitis occurs three to six weeks after the start of treatment. The word "burn" should be avoided because it may increase anxiety. Emollients are contraindicated; they may alter the calculated x-ray route and injure healthy tissue. The response about the client's family does not address the client's concern.

A terminally ill client appears happy and tells a nurse a joke about the situation despite becoming sicker and weaker. What is the nurse's most therapeutic response? "Why are you always telling jokes?" "Your laughter is a cover for your fear." "Does it help to joke about your illness?" "The one who laughs on the outside cries on the inside."

"Does it help to joke about your illness?" Rationale The response "Does it help to joke about your illness?" is a nonjudgmental way to point out the client's behavior. The response "Why are you always telling jokes?" is confrontational; the client may not be able to answer the question. The response "Your laughter is a cover for your fear?" is confrontational and is an assumption by the nurse. The response "The one who laughs on the outside cries on the inside" is judgmental and is an assumption and a stereotypical response.

The nurse notes that a client is not adhering to prescribed antibiotic therapy. Which reason should the nurse document? "I skipped some doses because I don't like to take pills." "I left my pills in the bedroom and I forgot to take them with breakfast." "I saw on television what the side effects are and decided to not take the pills." "I had to choose between getting my prescription filled and paying the heating bill."

"I left my pills in the bedroom and I forgot to take them with breakfast." Rationale Nonadherence is accidental failure to take a medication. Noncompliance is deliberately failing to take a medication as might be done when skipping doses because of not liking to take pills, choosing to not take a medication because of information seen on television, and not being able to afford medication.

A registered nurse is teaching a licensed practical nurse (LPN) about protecting client confidentiality. Which statement by the LPN indicates effective learning? "I'll shred notes after use." "I'll always keep client statistics." "I'll personally keep client information." "I'll discuss client information in the cafeteria."

"I'll shred notes after use." Rationale Client information is confidential and should be exchanged only with members of the health-care team. To maintain confidentiality, the nurse should not keep any information. Instead, notes should be shredded after they have been used. A client's statistics should not be kept unless this has been authorized. The nurse should not personally keep client information. Client information should be discussed only in conferences or reports, not in public areas such as the cafeteria.

Which question does the registered nurse recognize as related to the right of circumstance when delegating? "Is the delegation appropriate to the situation?" "Is the task within the delegatee's scope of practice?" "Is the prospective delegate a willing and able employee?" "Is the delegator able to monitor and evaluate the client appropriately?"

"Is the delegation appropriate to the situation?" Rationale The question, "Is the delegation appropriate to the situation?" is related to right circumstance. The question, "Is the task within the delegatee's scope of practice?" is related to right task. The question, "Is the prospective delegate a willing and able employee?" is related to right person. The question, "Is the delegator able to monitor and evaluate the client appropriately?" is related to right supervision.

A nurse discusses situational leadership roles with a nursing student. Which statement by the nursing student is correct? "Situational leadership is also called free-run style." "This style allows the manager to grow professionally." "This style of leadership works well in highly motivated professional groups." "The basis of this leadership style is the manager's flexibility in adapting to the needs of the group or individual."

"The basis of this leadership style is the manager's flexibility in adapting to the needs of the group or individual." Rationale In situational leadership theory, the manager has flexibility in adapting to the needs of the group or individual. Laissez-faire leadership is termed free-run style. This type of leadership style fosters professional growth of the manager and staff. It does not work well with highly motivated professional groups.

An 80-year-old female is admitted to the hospital because of complications associated with severe dehydration. The client's daughter asks the nurse how her mother could have become dehydrated because she is alert and able to care for herself. What is the nurse's best response? "The body's fluid needs decrease with age because of tissue changes." "Access to fluid may be insufficient to meet the daily needs of the older adult." "Memory declines with age, and the older adult may forget to ingest adequate amounts of fluid." "The thirst reflex diminishes with age, and therefore the recognition of the need for fluid is decreased."

"The thirst reflex diminishes with age, and therefore the recognition of the need for fluid is decreased." Rationale For reasons that are still unclear, the thirst reflex diminishes with age, and this may lead to a concomitant decline in fluid intake. There are no data to support the statement "The body's fluid needs decrease with age because of tissue changes." The statement "Access to fluid may be insufficient to meet the daily needs of the older adult" is not true for an alert person who is able to perform activities of daily living. Research does not support progressive memory loss in normal aging as a contributor to decreased fluid intake.

A recent immigrant from mainland China is critically ill and dying. What question should the nurse ask when collecting information to meet the emotional needs of this client? "Do you like living in this country?" "When did you come to this country?" "Is there a family member who can translate for you?" "Which family member do you prefer to receive information?"

"Which family member do you prefer to receive information?" Rationale Studies have demonstrated that people from China, Greece, and Ethiopia view honesty about diagnosis and prognosis as heartless, unnecessary, and even harmful to the client; usually family members from these cultures decide what is most appropriate to share with the client. Asking whether the client likes living in this country and when he or she came to this country are not relevant when caring for a dying client. Based on the client's culture, "Is there a family member who can translate for you?" should not be asked because the family will be making the decision about what medical information the client should be given.

An intravenous infusion of 800 mL/24 hr is prescribed for a 2½-year-old child. At how many milliliters per hour will the nurse set the volume control device? 38 mL 33 mL 28 mL 23 mL

33 mL 800/24 = 33.3 (round to 33) Rationale The volume control device should be set at 33 mL/hr; 800 mL divided by 24 hours equals 33 mL/hr. A rate of 38 mL/hr is too fast; rates of 23 and 28 mL/hr are too slow.

A nurse suspects that a client has poison ivy. Assessment findings reveal vesicles on the arms and legs. What definition best describes a vesicle? A lesion filled with purulent drainage. An erosion into the dermis. A solid mass of fibrous tissue. A lesion filled with serous fluid.

A lesion filled with serous fluid. Rationale A vesicle is a small blisterlike elevation on the skin containing serous fluid. Vesicles are usually transparent. Common causes of vesicles include herpes, herpes zoster, and dermatitis associated with poison oak or ivy. A lesion filled with purulent drainage is known as a pustule; an erosion into the dermis is known as an excoriation or ulcer; and a solid mass of fibrous tissue is known as a papule.

The nurse executive is seeking to improve client care by helping multidisciplinary leaders achieve optimal functioning. Which behavior related to Gardner's tasks of leading is the executive exhibiting? Managing Affirming values Developing trust Achieving workable unity

Achieving workable unity Rationale The leader in an executive position helps multidisciplinary leaders achieve optimal functioning by applying Gardner's task of achieving workable unity. Managing involves helping other executives and corporate leaders with planning, priority setting, and decision making. Affirming values involves helping other organizational leaders in the expression of community and organizational values. Developing trust involves assisting and representing nursing and executive views openly and honestly.

A hospitalized client is scheduled to have a sigmoidoscopy. What pre-procedure interventions will the nurse anticipate? Providing instructions about restraints used during the procedure. Administering a fleet enema 1 hour before the procedure. Encouraging increased intake of clear fluids. Administering morphine 30 minutes before the procedure.

Administering a fleet enema 1 hour before the procedure. Rationale To facilitate visualization of the rectum and the sigmoid colon, the lower colon must be emptied immediately before the procedure. A fleet or tap water enema should be used. The client will be kept NPO for at least 8 hours before the procedure. Morphine is not typically used as a pre-op medication before a sigmoidoscopy. Restraints are not typically used during the procedure.

The registered nurse (RN) is caring for a client with severe diarrhea. Which task of the client care plan can be safely delegated to the unlicensed assistive personnel (UAP) by the registered nurse? Administration of oral antidiarrheal Administration of intravenous antibiotics Administration of oral replacement fluids Administration of intravenous antiemetics

Administration of oral replacement fluids Rationale The scope of practice of the UAP is limited to perform basic care, feeding, and hygiene. Administering oral replacement fluids can be safely performed by the UAP, as it is a basic care that may also be included under feeding. Administering oral medications such as antidiarrheal drugs can be safely delegated to a licensed practical nurse (LPN) or a licensed vocational nurse (LVN) according to guidelines but not to the UAP. Administering intravenous medication such as antibiotics or antiemetics is the role of the registered nurse.

Which client is three times more likely to die of heart disease than his or her white counterpart? Hispanic client Asian American client Native American client African American client

African American client Rationale Race and ethnicity influence disease risk and outcomes. For instance, African Americans are three times more likely to die of heart disease than are their white counterparts. Heart disease mortality rates for Hispanics, Asian Americans, and Native Americans are different as well.

The family member of a client with depression believes the client would benefit from aromatic therapy to the client more so than from medications. To which health belief system does the client's family member likely belong? Folk health Holistic health Biomedical health Alternative or complementary

Alternative or complementary Rationale Alternative or complementary belief system A client who opts for non medical treatment methods such as aromatic therapy probably believes in alternative medicine. In a folk health belief system, rituals or repentance may be used to treat the client. In a holistic health belief system, the client's family would look for ways to restore balance in the physical, social, and metaphysical worlds surrounding the client. A family member who believes in biomedical treatment would accept the medications for the client.

What is the status of the primary healthcare provider as a member of the healthcare team that is in the span of control of a registered nurse (RN)? Devoid of legal authority Devoid of delegation authority Answerable to the nurse manager Answerable to the registered nurse

Answerable to the nurse manager Rationale The primary healthcare provider as a team member is designated to be answerable to a delegator such as the nurse manager. The unit secretary is devoid of legal authority or formal preparation. The primary healthcare provider may delegate tasks to the members of the healthcare team who have dependent status, such as unlicensed assistive personnel (UAP), licensed practical nurses (LPN), or licensed vocational nurses (LVN). Generally, those with dependent status are answerable to the RN.

A client is admitted voluntarily to a psychiatric unit. Later, the client develops severe pain in the right lower quadrant and is diagnosed as having acute appendicitis. How should the nurse prepare the client for the appendectomy? Have two nurses witness the client signing the operative consent form. Ensure that the health care provider and the psychiatrist sign for the surgery because it is an emergency procedure. Ask the client to sign the operative consent form after the client has been informed of the procedure and required care. Inform the client's next of kin that it will be necessary for one of them to sign the consent form because the client is on a psychiatric unit.

Ask the client to sign the operative consent form after the client has been informed of the procedure and required care. Rationale Because the client is not certified as incompetent, the right of informed consent is retained. The client can sign the consent, but the client's signature requires only one witness. Because there is no evidence of incompetence, the client should sign the consent.

When providing care for a client with a nasogastric (NG) tube, the nurse should take measures to prevent what serious complication? Skin breakdown Aspiration pneumonia Retention ileus Profuse diarrhea

Aspiration pneumonia Rationale Of the choices provided, the potential complication of highest risk for a client with an NG tube is aspiration pneumonia. Care should be taken to prevent dislodging of the tube or vomiting. Proper positioning of the client with an NG tube would include supine or side-lying, semi-Fowler or higher. Skin breakdown in a client with an NG tube may result from pressure of the tube against nasal structures. The tube should be periodically repositioned and taped to prevent this complication. A retention ileus is not related to an NG tube. A client who develops profuse diarrhea with an NG tube requires further investigation. It may be totally unrelated or a result of an enteral feeding incompatibility.

Which nursing intervention is most appropriate for a client in skeletal traction? Add and remove weights as the client desires. Assess the pin sites at least every shift and as needed. Ensure that the knots in the rope are tied to the pulley. Perform range of motion to joints proximal and distal to the fracture at least once a day.

Assess the pin sites at least every shift and as needed. Rationale Nursing care for a client in skeletal traction may include assessing pin sites every shift and as needed. The needed weight for a client in skeletal traction is prescribed by the physician, not as desired by the client. The nurse also should ensure that the knots are not tied to the pulley and move freely. The performance of range of motion is indicated for all joints except the ones proximal and distal to the fracture, since this area is immobilized by the skeletal traction to promote healing and prevent further injury and pain.

The nurse is having difficulty understanding a client's decision to have hospice care rather than an extensive surgical procedure. Which ethical principle does the client's behavior illustrate? Justice Veracity Autonomy Beneficence

Autonomy Rationale The client is exhibiting the freedom to make a personal decision, and this reflects the concept of autonomy. Justice refers to fairness. Veracity refers to truthfulness. Beneficence refers to implementing actions that benefit others.

A nurse assisting in a research study calculates the risk-benefit ratio and concludes that there were no harmful effects associated with a survey of diabetic clients. This researcher was applying which principle? Human dignity Human rights Beneficence Utilitarianism

Beneficence Rationale Beneficence is defined as the promotion of well-being and abstaining from the injuring of others as well as doing good, being kind, and charitable. In this situation, the possible benefits outweigh the possible harm for the clients participating in a research study. In this situation, human dignity and human rights are underlying principles of research ethics but are not directly related to the risk-benefit ratio. Utilitarianism relates to the ethical doctrine that virtue is based on utility, and that conduct should be directed toward promoting the greatest good for the greatest number of people.

A client is diagnosed with AIDS. When examining the client's oral cavity, the nurse assesses white patchy plaques on the mucosa. The nurse recognizes that this finding most likely represents what opportunistic infection? Cytomegalovirus Histoplasmosis Candida albicans Human papillomavirus

Candida albicans Rationale White patchy plaques on the oral mucosa would most likely be a result of C. albicans, a yeastlike fungal infection. This condition is also known as "thrush." Cytomegalovirus may cause a serious viral infection in persons with HIV, resulting in retinal, gastrointestinal, and pulmonary manifestations. Histoplasmosis is an infection caused by inhalation of spores of the fungus Histoplasma capsulatum and is characterized by fever, malaise, cough, and lymphadenopathy. Human papillomavirus typically manifests as warts on the hands and feet as well as mucous membrane lesions of the oral, anal, and genital cavities. It may be transmitted without the presence of warts through body fluids with some forms associated with cancerous and precancerous conditions.

When tasks are delegated by the registered nurse (RN) to the unlicensed nursing personnel (UNP), who can assume the responsibilities when the RN goes for a break? Charge nurse Chief nursing officer Healthcare provider Licensed practical nurse

Charge nurse Rationale The charge nurses have knowledge and expertise in critical thinking, clinical practice, leadership, and communication; therefore, the charge nurse can assume the duties when the RN goes for a break. Chief nursing officers are accountable for establishing systems to communicate competency requirements related to delegation. Healthcare providers may delegate and assign tasks for UNPs. Licensed practical nurses (LPN) are not eligible for delegation; the LPNs are delegatees.

The nurse is providing postprocedure care for a client who had a central venous access device (CVAD) inserted. Before the CVAD is used, what procedure is performed to verify placement? Chest x-ray Flushing the line with heparin Withdrawing blood to ensure patency Chest fluoroscopy

Chest x-ray Rationale The insertion of a central venous catheter (CVC) into the subclavian vein can result in a pneumothorax, which would be seen on a chest x-ray. Indications of a pneumothorax before the chest x-ray would include shortness of breath and anxiety. If the chest x-ray is negative for pneumothorax, the CVC line may be used. The central line should not be flushed until placement is verified. Blood withdrawal is utilized once placement is verified, but is not used to verify initial placement. Fluoroscopy may be used during placement in certain settings, but not for placement verification.

The nurse is caring for four different clients. Which client is most the most appropriate candidate to be admitted to a long-term care facility? Client 1 - 30 y/o w/ hypertension Client 2 - 70 y/o w/ anxiety & Dementia Client 3 - 32 y/o w/ type 2 diabetes Client 4 - 50 y/o Exacerbation of asthma

Client 2 - 70 y/o w/ anxiety & Dementia Rationale A long-term care organization provides long-term care services, often for older clients who cannot effectively manage self-care. Of these clients, Client 2, the 70-year-old client with anxiety and dementia is best suited for a long-term care facility. Clients 1 and 3 are young and with manageable disorders, so they may not require a long-term care facility. While older, Client 4 is not that old, and asthma most likely does not indicate a need for long-term care.

Which client should be provided with immediate care? Client with sprains Client with open fractures Client with cold symptoms Client with closed fractures

Client with open fractures Rationale Clients with open fractures should be provided with immediate care because it is an emergency situation. Clients with sprains and cold symptoms can be established for a lower priority of care. Clients with closed fractures should be given second priority for care.

The registered nurse (RN) is delegating tasks to licensed practical nurses (LPNs) regarding client care. Which factors should be considered when delegating a task to the LPN? Select all that apply. Client's condition Complexity of the task Number of LPNs available Predictability of outcomes Relationship status between the delegatee and delegator

Client's condition Complexity of the task Predictability of outcomes Rationale The decisions for delegation should be based on multiple factors such as the client's condition, complexity of the task, and predictability of outcomes. The number of LPNs may not be important information while assigning the tasks. Relationship status between the delegatee and the delegator are not important considerations for delegating a task to the LPN effectively.

The nurse introduces herself to the client and explains a procedure to be performed to clean and dress a surgical wound. Which critical thinking attitude is the nurse applying? Risk taking Confidence Thinking independently Responsibility and authority

Confidence Rationale The critical thinking attitude of confidence grows with experience and the nurse is able to shift the focus from remembering the procedure to caring for the client's needs. The nurse builds a bond of trust by displaying confidence while performing a procedure. Risk taking involves recommending alternative methods to client care or questioning a primary healthcare provider's order. A nurse who reads nursing literature and shares ideas about nursing interventions with other nurses uses independent thinking. Responsibility and authority are critical thinking attitudes. A responsible nurse follows procedure manuals while caring for the client and reports problems immediately.

While assessing an immobilized client, the nurse notes that the client has shortened muscles over a joint, preventing full extension. What is this condition known as? Osteoarthritis Osteoporosis Muscle atrophy Contracture

Contracture Rationale Immobilized clients are at high risk for the development of contractures. Contractures are characterized by permanent shortening of the muscle covering a joint. Osteoarthritis is a disease process of the weight-bearing joints due to wear and tear. Osteoporosis is a metabolic disease process in which the bones lose calcium. Muscle atrophy is a wasting and/or decrease in the strength and size of muscles due to a lack of physical activity or a neurological or musculoskeletal disorder.

The registered nurse (RN) is caring for a client who was admitted to the hospital due to severe diarrhea. The RN assigns the unlicensed assistive personnel (UAP) to check on the client hourly and perform hygiene care as needed. Which concept best explains this situation? Leadership Delegation Supervision Assignment

Delegation Rationale Delegation involves transfer of responsibility for the performance of tasks and skills for the ultimate outcome. Here the registered nurse (RN) is delegating a task to the unlicensed assistive personnel (UAP). Supervision involves directing, guiding, and influencing the outcome of an individual who performs the task. Assignment mostly happens in professional staff members such as RNs because it involves transferring responsibility and accountability.

ccording to Kubler-Ross, during which stage of grieving are individuals with serious health problems most likely to seek other medical opinions? Anger Denial Bargaining Depression

Denial Rationale Denial includes feelings that the health care provider has made a mistake, so the client seeks additional opinions. Anger follows denial; behavior will be hostile and critical. Bargaining occurs after anger; the client verbally or secretly may promise something in return for wellness or a prolonged life. Depression occurs after bargaining; the client feels sadness and despair and may be withdrawn.

What should the nurse do initially when obtaining consent for surgery? Describe the risks involved in the surgery. Explain that obtaining the signature is routine for any surgery. Witness the client's signature, which the nurse's signature will document. Determine whether the client's knowledge level is sufficient to give consent.

Determine whether the client's knowledge level is sufficient to give consent. Rationale Informed consent means the client must comprehend the surgery, the alternatives, and the consequences. Describing the risks involved in the surgery is not within nursing's domain. Although obtaining a signature is routine, explaining that obtaining the signature is routine for any surgery does not determine the client's ability to give informed consent. Although witnessing the client's signature will be done, the nurse first should assess the client's knowledge of the surgery. Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer. Example: If you are being asked to identify a diet that is specific to a certain condition, your knowledge about that condition would help you choose the correct response (e.g., cholecystectomy = low-fat, high-protein, low-calorie diet).

Which statement regarding discharge planning is true? A clinical nurse specialist begins discharge planning and usually makes a home visit. A charge nurse is often responsible for discharge planning for the long-term care resident A social worker may also be responsible for discharge planning, depending on the facility. Discharge planning is a multidisciplinary process that involves participation by all members of the health-care team.

Discharge planning is a multidisciplinary process that involves participation by all members of the health-care team. Rationale Discharge planning is a multidisciplinary process that requires the participation of all members of the health-care team. A transition specialist begins discharge planning and usually makes a home visit. A charge nurse may be responsible for discharge planning depending on the facility. A social worker is often in charge of discharge planning for the long-term care resident.

Which nursing interventions are examples of the nurse as a caregiver? Select all that apply. Encouraging the client to exercise daily Setting goals for the client to reduce weight Arranging for the client to meet a spiritual advisor Evaluating the client's understanding of prescribed diet Demonstrating the procedure to self-administer insulin injection

Encouraging the client to exercise daily Setting goals for the client to reduce weight Arranging for the client to meet a spiritual advisor Rationale The nurse acts as a caregiver by encouraging the client to exercise daily. The nurse's role as a caregiver involves helping the client to maintain and regain health. As a caregiver, the nurse also sets goals and helps the client and family to achieve them. The duties of a caregiver involve restoring a client's emotional, spiritual, and social well-being. Therefore the nurse arranges for the client to meet a spiritual advisor to meet the client's spiritual needs. The nurse as an educator evaluates the client's understanding of prescribed diet. As an educator, the nurse demonstrates the procedure for administering insulin injection. The nurse also reinforces and evaluates learning.

A hospital has threatened to refuse the discharge of a newborn until the parents pay part of the hospital bill. The nurse is aware that which legal term best describes this situation? False threats Assault and battery False imprisonment Breach of confidentiality

False imprisonment Rationale The hospital is threatening to keep the infant; therefore false imprisonment is threatened. False imprisonment is restraining or confining a person without a clinical reason. False threat may be a term to describe false imprisonment; however it is inaccurate in this situation. Assault and battery legally means to threaten violence and the physical act of violence. Breach of confidentiality is a disclosure to a third party, without client consent or court order of private information.

The city health department provides home health services under the governance of a local unit of government. Which sources of funding support this agency? Select all that apply. Grants Country revenues Fees from limited sources Noncharitable contributions Tax-deductible contributions

Grants Country revenues Fees from limited sources Rationale The city health department is an example of an official home health agency. Its sources of support are grants, county revenues, charitable contributions, and fees from limited sources. It will not be supported by noncharitable contributions, and tax-deductible contributions support voluntary home health agencies.

Which statement regarding health disparities is true? Health disparities cannot be entirely eliminated. Genetics are the main cause of health disparities. Body mass index and genetic makeup contribute to health disparities. Health disparities encompass differences in incidence, prevalence, mortality rate, and burden of diseases.

Health disparities encompass differences in incidence, prevalence, mortality rate, and burden of diseases. Rationale Health disparities encompass differences in incidence, prevalence, mortality rate, and burden of diseases. Social, economic, and environmental disadvantages create health disparities, but genetics is not directly a factor. Health equity is achieved and health disparities could be eliminated if every person has the opportunity to attain his or her health potential. Body mass index and genetic makeup affect client health and may be influenced by health disparities, but they do not cause health disparities themselves.

A nurse visits a client with diabetic nerve damage to the feet twice a day to monitor medications and foot care. Which type of health-care organization typically employs such a nurse? Acute-care facility Extended-care facility Long-term care facility Home health-care facility

Home heath-care facility Rationale Home health-care services involve delivering nursing care to the client at home. Acute care involves treating a client in immediate critical need. Extended and long-term care take place outside of the client's home.

Which phase in the disaster management continuum does the nurse understand as including the attempt to limit a disaster's impact on human health and community function? Recovery Response Mitigation Preparedness

Mitigation Rationale There are five phases in the disaster management continuum: preparedness, mitigation, response, recovery, and evaluation. In mitigation, there will be plans for attempting to limit a disaster's impact on human health and community function. Recovery includes focusing on stabilizing the community and returning it to the previous status. Response includes implementation of the disaster plan. Preparedness is the preparation of a protective plan that is designed before the event has occurred.

A nurse identifies that an older adult has not achieved the desired outcome from a prescribed medication. When assessing the situation, the client shares that the medication is too expensive and the prescription was never filled. What is an appropriate nursing response? Ask the pharmacist to provide a generic form of the medication. Encourage the client to acquire the medication over the internet. Inform the health care provider of the inability to afford the medication. Suggest that the client purchase insurance that covers prescription medications.

Inform the health care provider of the inability to afford the medication.

A health care facility uses cardiac telemetry for a client. Which Quality and Safety Education for Nurses (QSEN) competency does this intervention adhere to? Safety Informatics Patient-centered care Evidence-based practice

Informatics Rationale Informatics is the use of advanced technology. Cardiac telemetry is an example of the use of informatics in client care. It is a device that monitors the client's heart rate wherever the client is on the unit. The safety competency requires the nurse to minimize the risk of harm to clients through system effectiveness and individual performance. The nurse provides patient-centered care by acknowledging the client as a full partner in health care. The nurse uses evidence-based practice while providing health care. It involves the conscientious use of current best practice based on research findings.

A nurse experiencing burnout feels despair and tries to conform to the expectations of other people. Which strategy helps to combat this nurse's behavior? Balance Integrity Awareness Compartmentalizing

Integrity Rationale A nurse experiencing burnout may feel despair and may forget his or her needs by trying to conform to the expectations of others. Restoration of personal integrity is an important strategy that helps to combat burnout. Balance among work, family, leisure, and lifelong learning enhances personal judgments, satisfaction, and productivity. Awareness helps to identify and create boundaries to prevent stress. Compartmentalizing helps the nurse to complete as much of a job at hand as possible.

Which of these is a one-on-one communication between a nurse and another person? Small-group communication Intrapersonal communication Interpersonal communication Transpersonal communication

Interpersonal communication Rationale Interpersonal communication is a one-on-one interaction between a nurse and another person that often occurs face to face. Small-group communication is interaction that occurs when a small number of people meet. Intrapersonal communication is a form of communication that occurs within an individual. Transpersonal communication is an interaction that occurs within a person's spiritual domain.

The nurse is caring for a female client who is scheduled for a tubal ligation. The client refuses to sign the consent form because it is against her religious beliefs, and she asks the health-care professional to wait until her husband arrives. To which religious community does the client belong? Islam Mormons Christian Science Eastern Orthodox

Islam Rationale Strict Muslims do not allow women to sign consent forms or make decisions regarding family planning; a woman's husband must be present to do so. For Mormons, only natural means of birth control are recommended. Family planning is left to the whole family for Christian Science clients. Birth control is not permitted for Eastern Orthodox clients.

A nurse is teaching a group of parents about child abuse. What definition of assault should the nurse include in the teaching plan? It is a threat to do bodily harm to another person. It is a legal wrong committed by one person against the property of another. It is a legal wrong committed against the public that is punishable by state law. It is the application of force to another person without lawful justification.

It is a threat to do bodily harm to another person. Rationale Assault is a threat or an attempt to do violence to another. Assault implies harm to persons rather than property. A legal wrong committed against the public that is punishable by state law is too broad to describe assault. Application of force to another person without lawful justification is the definition of battery.

What makes a crisis access hospital (CAH) different from an intensive care unit (ICU)? It offers 24-hour emergency care. It offers health care to acutely ill people. It provides temporary care for 96 hours or less. It provides the most expensive health care delivery.

It provides temporary care for 96 hours or less. Rationale A CAH is a rural hospital that provides temporary care for 96 hours or less to stabilize clients before they are transferred to a larger hospital. An ICU or a critical care unit is a hospital unit in which clients receive close monitoring and intensive medical care. Both CAH and ICU offer 24-hour emergency care. The CAH and ICU care for acutely ill clients by monitoring them on multiple devices. An ICU is the most expensive health care delivery site, as the nurse cares for only one or two clients at a time.

A hospital wants to implement the primary nursing model on the premises. Which challenges are likely to be faced by the management? Select all that apply. Lack of client rapport Lack of nurse availability Lack of experienced nurses Decrease in cost for management Lack of communication with healthcare providers

Lack of nurse availability Lack of experienced nurses Rationale In the primary nursing model, a single nurse cares for a client while that client is in the hospital. This model requires a nurse to be available 24 hours a day, but it is not possible for any nurse to work for that whole time period. A nurse may not be specialized in all fields and may not have enough experience to care for all types of clients; this may become a challenge for management. If a single nurse cares for a client, that client may be more comfortable, which will increase client rapport. This model becomes more costly as a nurse may charge more for working so many hours for a client. In this model there will be increased communication with the healthcare provider; this may be an advantage for management.

The nurse is teaching breathing exercises to a client who underwent surgery. Which member of the healthcare team is most suitable for reinforcement of teaching in the client? Certified technician Case manager Cross-trained technician Licensed vocational nurse (LVN)

Licensed vocational nurse (LVN) Rationale The licensed practical nurses (LPN) are most suitable to be delegated the task of reinforcement teaching. A certified technician is an unlicensed member who can only record the vital signs or provide basic hygiene to the client. A case manager can provide primary education to the client. These personnel can delegate the task of reinforcement teaching to the assistive nursing personnel. Cross-trained technicians may perform respiratory therapy, draw blood samples, and monitor electrocardiography.

When a bedridden client complains that he or she is thirsty, the nurse leader says, "I want to make you comfortable. Here is a glass of water, please take it." Which communication skill is the nurse leader using to make caring visible? Listening actively Expressing appreciation Showing caring nonverbally Making explicit her or his positive intent

Making explicit her or his positive intent Rationale The nurse is making explicit her or his positive intent by explaining the purpose and by showing what he or she is doing in the client's best interest. Listening actively indicates acknowledging and reflecting back the person's feelings in a nonjudgmental way. Expressing appreciation refers to giving the personal gift of positive reward. Showing caring non-verbally can be done by using a facial expression, intonation, posture, eye contact, and body language to mirror the client's feelings.

A client with postural hypotension requires nursing care. Which task can be safely delegated by the registered nurse to unlicensed nursing personnel (UNP)? Select all that apply. Mobilizing the client Assessing the pulse rate Assessing the blood pressure Managing foot care of the client Maintaining oral hygiene of the client

Managing foot care of the client Maintaining oral hygiene of the client Rationale In postural hypotension, any sudden change in posture will lower the blood pressure. Therefore, the client should be carefully evaluated before delegation. Managing foot care and maintaining oral hygiene can be done by the UNP because there is no foreseeable risk associated with the condition. Mobilizing the client and assessing vital signs such as pulse rate and blood pressure should be carefully monitored and performed by the registered nurse.

A 70-year-old client is admitted to the hospital with end-stage renal disease. Which insurance program would cover the client's hospital payments? Medicare Medicaid Preferred provider organizations (PPOs) Health maintenance organizations (HMOs)

Medicare Rationale Medicare is a federal insurance program that covers hospital payments for clients older than 65 years of age or clients who have end-stage renal disease. Medicaid is a federal insurance program that pays for the health-care costs for low-income clients of all ages and home-care services to the poor and needy. Preferred provider organizations (PPOs) and health maintenance organizations (HMOs) are prepaid health plans operated independently or through employer groups.

Which actions of the nurse exhibit transactional leadership? Select all that apply. Motivating or inspiring the employees Meeting the targets within the deadline Working according to organizational rules Correcting the errors in a reactive manner Increasing the employee commitment of an organization

Meeting the targets within the deadline Working according to organizational rules Correcting the errors in a reactive manner Rationale The characteristics of transactional leadership include valuing the orders and structures of an organization. The nurse who exhibits transactional leadership will meet the targets within the deadline given by the organization. The nurse will also follow the rules of an organization and will correct the errors of an employee in a reactive manner. Motivating or inspiring the employees and increasing employee commitment are the characteristics of transformational leadership.

A client is being admitted to a medical unit with a diagnosis of pulmonary tuberculosis. Which type of room should the nurse assign the client? Private room Semi-private room Room with windows that can be opened Negative airflow room

Negative airflow room Rationale Tuberculosis is an airborne contagious disease that is best contained in a negative airflow room. Negative airflow rooms are always private. A private room, semiprivate room, and a room with windows that can be opened are not appropriate for the standard of care for a client diagnosed with tuberculosis. Additionally, opening windows would present a possible safety hazard in a client's room.

A nurse is caring for an elderly client who has constipation. Which independent nursing intervention helps to reestablish normal bowel pattern? Administer a mineral oil enema. Offer one cup of fluid every hour. Manually remove fecal impactions. Offer a cup of prune juice.

Offer a cup of prune juice. Rationale Prune juice does not require a health practitioner order and helps to promote bowel movement because it contains sorbitol, which increases water retention in feces. Administration of mineral enema requires an order from a health care provider. Encouraging the client's fluid intake by offering one cup of fluid every hour is helpful in preventing constipation but not as effective in resolving constipation as a prune juice. Removing impactions does not establish regular bowel patterns.

The nurse is attending a city commission meeting being held to discuss using a community park to build a museum. How should the nurse advocate as a community opinion leader to help maintain a health conscious society? Oppose building the museum Suggest a layout for building a museum Raise funds from community members Contribute to a budget plan for the project

Oppose building the museum Rationale As a community opinion leader, the nurse should help build a more peaceful and healthful society. Building a museum in the place of a community park may affect public health by reducing green space. The nurse as a community leader should not suggest a layout for building a museum in place of a community park, as it affects the health of society. The nurse should not be involved in collecting funds from the community members to build a museum, as it does not help maintain a healthful society. The nurse as a community opinion leader should oppose the building of a museum in place of the community park and should not contribute to a budget plan.

A nurse assesses the vital signs of a 50-year-old female client and documents the results. Which of the following are considered within normal range for this client? Select all that apply. Oral temperature 98.2° F Apical pulse 88 beats per minute and regular Respiratory rate of 30 per minute Blood pressure 116/78 mm Hg while in a sitting position Oxygen saturation of 92%

Oral temperature 98.2° F Apical pulse 88 beats per minute and regular blood pressure 116/78 mm Hg while in a sitting position Rationale The client's temperature, pulse, and blood pressure are within normal ranges for a 50-year-old female. The client's respirations are mildly elevated and the oxygen saturation level is below normal. A normal respiratory rate for a female client in this age-group would be 12 to 20 per minute, and oxygen saturation level should be 95%.

The registered nurse (RN) who delegates work to a newly hired licensed practical nurse (LPN) says, "Please tell me how you will go about performing this procedure, and I will share my expectations with you." Which behavior strategy of Hersey's model is being applied? Telling Selling Delegating Participating

Participating Rationale When the LPN has the willingness and ability to perform a task, but the relationship is new, the RN will share his or her expectations and conditions with the LPN. This is a clinical example of participating. Participating is encouraging the delegatee to perform the task and taking an active part in problem solving, which may occur during the execution of a given task. If the LPN has limited knowledge and ability to perform a task, the RN will provide more guidance, which is an example of telling what is the task to be done and how it is to be performed. If the LPN is delegated a new task, it requires explanation from the RN. This is termed as selling in Hersey's model, which is the process of explaining and persuading; this happens if a situation involves a new task and the relationship is ongoing. If the LPN has an established relationship and experience, he or she requires a little guidance and this is called delegation.

A staff member is planning to start a new job but is worried about the impact it might have on future growth opportunities. The nurse leader is helping the staff member understand all the implications. Which ethical principle is the nurse manager as a leader following? Justice Veracity Paternalism Non-maleficence

Paternalism Rationale Paternalism is assisting people to make decisions when they do not have sufficient data or expertise. Helping the staff member understand all effects of a possible career change and how the potential change could impact his or her future growth reflects the leader nurse following paternalism. Justice is the principle of treating all persons equally and fairly. By following veracity, the nurse manager tells the truth and demands that the truth be told completely. The principle of non-maleficence states that one should do no harm to others

A client requires emergency cardiac surgery. The leader nurse wants to make the client aware of the situation and wants the client to decide what should be done. Which ethical model does the leader nurse follow here? Autonomy model Paternalistic model Social justice model Patient-benefit model

Patient-benefit model Rationale The patient-benefit model uses substituted judgment, that is, what the client would want for himself or herself if capable of making these issues known. The autonomy model facilitates making decisions for competent clients. In the paternalistic model the managers decide what is best for their team. The social justice model considers broad social issues and is accountable to the overall institution.

The registered nurse is assisting a client who is hospitalized with high fever. Which task delegated to the unlicensed assistive personnel (UAP) would be appropriate? Select all that apply. Assessing the vital signs Performing all hygiene tasks Administering oral medications Helping the client in changing clothes Administering intravenous medications

Performing all hygiene tasks Helping the client in changing clothes Rationale The UAP does all the hygiene tasks and also helps in changing the clothes. Assessing the vital signs may not be performed by the UAP. Administering the intravenous medications is performed by the registered nurse. Oral administrating of medication is performed by the licensed practical nurse.

Which drug is available in an injectable form? Pitocin Misoprostol Dinoprostone Methylergonovine

Pitocin Rationale Pitocin is available in an injectable form. Misoprostol and methylergonovine are available as oral medications. Dinoprostone is available as a topical gel for self-administration in the vagina.

A nurse needs to record a client's data from admission until discharge. Which record will the nurse use? Acuity record Source record Hand-off records Problem-oriented medical record

Source record Rationale The nurse will use the source record for writing information from the client's admission until discharge. This record has a separate section for each discipline (such as the admission sheet, nursing records, and medication). Acuity records are not part of a client's medical record. They are useful for determining the hours of care and staff required for a given group of clients. A hand-off record is used when up-to-date information about a client's condition, required care, treatments, medications, services, and any recent or anticipated changes is to be communicated. The problem-oriented medical record (POMR) is a method of documentation that places emphasis on the client's problems. In this record, data is organized by problem or diagnosis.

Which behavior from the nurse leader exhibits charismatic leadership qualities? Uses a shared vision as a core of leadership Encourages innovation and creativity in solving a problem Encounters a situation with the transactional leadership style Possesses an inspirational quality that makes team members attracted to him or her

Possesses an inspirational quality that makes team members attracted to him or her Rationale Charismatic behavior is seen in the transformational leadership style; this inspiring quality attracts team members. By sharing a vision the leader is not attracting team members; therefore this may not be a charismatic leadership behavior. Encouraging innovation and creativity in problem-solving will exhibit a quality of intellectual stimulation and is a transformational leadership behavior. Charismatic behavior is not seen in the transactional leader.

Which health-care facilities provide intermediate levels of care a client is discharged from a hospital? Select all that apply. Subacute Transitional Assisted living Long-term care Intermediate care nursing

Subacute Transitional Intermediate care nursing Rationale Subacute, transitional, and intermediate care nursing facilities are intended to provide intermediate levels of care after a client is discharged to help him or her transition back to regular daily life. Assisted living facilities and other long-term solutions are not intended for transitional purposes.

A nursing student is recalling information about the primary level of prevention. Which statement accurately describes primary prevention ? Primary prevention is directed at rehabilitation rather than treatment. Primary prevention is applied to clients who are physically and emotionally healthy. Primary prevention includes screening techniques and the treatment of the early stages of a disease. Primary prevention focuses on individuals who are ill and have a possibility for developing complications.

Primary prevention is applied to clients who are physically and emotionally healthy. Rationale Primary prevention is true prevention. This prevention is applied to clients who are considered to be physically and emotionally healthy. The tertiary level of prevention is directed at providing rehabilitative care to clients. Secondary prevention includes screening techniques and treatment of early stages of disease. Secondary prevention is focused on individuals who are ill and are at risk for further complications.

What is the responsibility of a hospice volunteer on the hospice team? Recruiting and training the volunteers Assessing and supporting the bereaved survivor Providing companionship to the client and caregiver Supporting the client and caregiver in coping with fears

Providing companionship to the client and caregiver Rationale A hospice volunteer is responsible for providing companionship to a client and caregiver. A volunteer coordinator recruits and trains volunteers. A bereavement coordinator is responsible for assessing and supporting the bereaved survivor. A primary spiritual leader is responsible for supporting the client and the caregiver in coping with fears.

A nurse must establish and maintain an airway in a client who has experienced a near-drowning. For which potential danger should the nurse assess the client? Alkalosis Renal failure Hypervolemia Pulmonary edema

Pulmonary edema Rationale Additional fluid from surrounding tissues will be drawn into the lung because of the high osmotic pressure exerted by the salt content of the aspirated ocean water; this results in pulmonary edema. Hypoxia and acidosis may occur after a near-drowning. Renal failure is not a sequela of near-drowning. Hypovolemia occurs because fluid is drawn into the lungs by the hypertonic saltwater.

A client with chronic asthma is being cared for in the inpatient care unit. To assess the client on a regular basis would be delegated to which healthcare team member? Charge nurse Registered nurse Patient care associate Licensed practical nurse

Registered nurse Rationale The registered nurse is a licensed nursing professional and is responsible for assessing the asthmatic symptoms of the client for providing care. The charge nurse is responsible for the coordination and assignment of tasks for the client's care. The patient care associate is an unlicensed assistive personnel whose scope of practice is limited from assessing the client. The licensed practical nurse does not assess the client's condition, but rather is responsible for providing treatment prescribed by the healthcare provider and delegated by the RN.

The nurse manager orders the direct care nurse to assist in providing tertiary care to a client. Which type of treatment would the direct care nurse be involved in? Chronic care Rehabilitation Health maintenance Prevention of disease complications

Rehabilitation Rationale Tertiary care includes rehabilitation. Chronic care and health maintenance are considered primary care, and prevention of disease complications is classified as secondary care.

A nurse is caring for a client with hemiplegia who is frustrated due to inmobility. How can the nurse motivate the client toward independence? Establish long-range goals for the client. Identify errors that the client can correct. Reinforce success in tasks accomplished. Demonstrate ways to promote self-reliance.

Reinforce success in tasks accomplished. Rationale Success is a basic motivation for learning. People receive satisfaction when a goal is reached. Progress toward long-range goals often is not apparent readily and may be discouraging. Constructive criticism is an important aspect of client teaching, but if it is not tempered with praise, it is discouraging. Demonstrating ways to promote self-reliance is an important part of teaching, but it probably will not motivate the client.

Nursing actions for the older adult should include health education and promotion of self-care. Which is most important when working with the older adult client? Encouraging frequent naps Strengthening the concept of ageism Reinforcing the client's strengths and promoting reminiscing Teaching the client to increase calories and focusing on a high carbohydrate diet

Reinforcing the client's strengths and promoting reminiscing Rationale Reinforcing strengths promotes self-esteem; reminiscing is a therapeutic tool that provides a life review that assists adaptation and helps achieve the task of integrity associated with older adulthood. Frequent naps may interfere with adequate sleep at night. Reinforcing ageism may enhance devaluation of the older adult. A well-balanced diet that includes protein and fiber should be encouraged; increasing calories may cause obesity.

The nurse prepares to give a prescribed capsule of hydroxyzine to a client. The client begins to vomit so the nurse holds the oral medication. The nurse has not opened the medication package. Proper and safe disposal of the capsule of hydroxyzine requires the nurse to perform which action? Drop the capsule into the sharps container Crush the capsule and flush it into the sewer system Place the capsule into a red biohazard bag and tie it shut Return the capsule to the pharmacy

Return the capsule to the pharmacy Rationale Medication taken from a stock supply cannot be returned; it should be returned to the pharmacy for safe disposal. The purpose of a sharps container is for safe disposal of sharp objects; a tablet dropped into a sharps container can be retrieved. Wasted medications should not be disposed of through the sewer system because this can contaminate underground water sources. Placing the tablet into a biohazard bag does not render it unusable.

Which statements about sleep are correct? Select all that apply. Sleep involves three phases. Sleep is associated with healing. Sleep is a state of rest that occurs for a sustained period. Sleep restores a person's energy and feeling of well-being. Sleep is a cyclic physiologic process that alternates with shorter periods of wakefulness.

Sleep is associated with healing. Sleep is a state of rest that occurs for a sustained period. Sleep restores a person's energy and feeling of well-being. Rationale Sleep is associated with healing. It is a state of rest that occurs for a sustained period and restores a person's energy and feeling of well-being. Sleep involves two phases, not three, and it is a cyclic physiologic process that alternates with longer, rather than shorter, periods of wakefulness.

A nursing supervisor sends an unlicensed healthcare worker to help relieve the burden of care on a short-staffed medical-surgical unit. Which tasks can be delegated to the health care worker? Select all that apply. Taking routine vital signs Applying a sterile dressing Answering clients' call lights Administering saline infusions Changing linens on an occupied bed Assessing client responses to ambulation

Taking routine vital signs Answering clients' call lights Changing linens on an occupied bed Rationale Taking routine vital signs is a universal activity that all healthcare workers are taught to perform regardless of the setting; it is within the job description for unlicensed health care workers. Answering call lights is a universal activity that all unlicensed healthcare workers are taught to perform regardless of the setting; it is within the job description for unlicensed healthcare workers. Making an occupied bed is a universal activity that all unlicensed healthcare workers are taught to perform regardless of the setting; it is within the job description for unlicensed healthcare workers. Unlicensed health care workers do not have the expertise or credentials to apply sterile dressings. Unlicensed healthcare workers do not have the expertise or credentials to administer intravenous solutions. Registered nurses are not permitted to delegate assessment.

A 70-year-old client with minor burns on his hands and legs receives care from a voluntary home health agency. Which of these statements about this agency are true? Select all that apply. The agency receives fees from the client. This agency offers public health services. This agency includes county health departments. A community-based board of directors governs this agency. This agency will provide care to the client for 24 hours a day

The agency receives fees from the client. This agency offers public health services. A community-based board of directors governs this agency. Rationale A voluntary health agency uses fees from all of the clients to which it provides care. Public health, home health, and community health are the services offered by such an agency. Community-based boards of directors govern voluntary home health agencies. County health departments are included in official home health agencies, not voluntary ones. Service provided to clients ranges from 30 minutes to eight hours, not 24 hours.

A client with dementia is admitted with a fractured hip after a fall at home. The client's family member witnessed the fall. Four hours after admission, the client's blood pressure increases to a moderately severe hypertensive level. The client pulls on the bedclothes continuously. The client's family member asks for pain medication for the client. What does the nurse conclude? The client needs to go to the bathroom. The client may be in pain and unable to respond appropriately. The family member may be trying to keep the client overmedicated. The family member feels guilty about the fall and wants to keep the client pain free.

The client may be in pain and unable to respond appropriately. Rationale The client's dementia indicates that the client has problems with thought processes and may not be able to interpret or communicate the presence of pain. Increased blood pressure, caused by central nervous system stimulation, and pulling on the bedclothes suggest that the client is in pain. The client may have a need to go to the bathroom, but it is more likely that the client has pain that he or she is unable to communicate. There is no evidence that the family member wants the client overmedicated or has feelings of guilt.

An emaciated older adult with dementia develops a large pressure ulcer after refusing to change position for extended periods of time. The family blames the nurses for the client's condition. What is considered when determining the source of blame for the pressure ulcer? The client should have been turned regularly. Older clients frequently develop pressure ulcers. The nurse is not responsible to the client's family. Nurses should respect a client's right not to be moved.

The client should have been turned regularly Rationale Clients should change position at least every two hours to prevent pressure ulcers. The nurse should not deviate from this standard of practice because of the cognitively-impaired client's refusal to move. The nurse was negligent for not changing the client's position. Although pressure ulcers may occur, nursing care must include preventive measures. The family is included in the health team. When a capable client refuses necessary health care, the nurse should provide health teaching to promote understanding of the treatment plan. If the client makes an informed decision after an explanation, then the client's rights must be respected; however, this client is cognitively impaired.

How does the nurse identify an illness as chronic? Select all that apply. The illness is reversible and often severe. The illness persists for longer than 6 months. The client may develop a life-threatening relapse. The symptoms are intense and appear abruptly. The illness affects the functioning of one or more systems.

The illness persists for longer than 6 months. The client may develop a life-threatening relapse. The illness affects the functioning of one or more systems. Rationale A chronic illness usually lasts longer than 6 months. The client with chronic illness often fluctuates between maximal functioning and serious health relapses that may be life threatening. The illness affects the functioning of one or more systems. A chronic illness is irreversible, whereas an acute illness is reversible and often much more severe than a chronic illness. The client with acute illness develops intense symptoms that appear abruptly and often subside after a relatively short period.

What does the nurse plan to do before administering preoperative medication to a client? Verify the consent Have the client void Check the vital signs Remove the client's dentures

Verify the consent Rationale Consent must be acquired when the client is fully oriented and in a clear mental state. Although important, having the client void can be implemented before surgery even if the client has received medication. Although important, checking the vital signs can be implemented before surgery even if the client has received medication. Although important, removing the client's dentures can be implemented before surgery even if the client has received medication.

According to style theory of leadership, which is an action of a nurse leader? Using feedback from superiors to measure own performance Using feedback from the family to measure own performance Avoiding using feedback from peers to measure own performance Avoiding using feedback from followers to measure own performance

Using feedback from superiors to measure own performance Rationale According to style theory of leadership, a nurse leader can use feedback from superiors to measure his or her performance. According to this theory, a nurse leader should not use feedback from the family to measure his or her leadership ability, as the family's feedback may not be accurate. Style theory also explains that a nurse leader can use feedback from peers and followers to measure his or her leadership performance.

A primary nurse is leaving the unit for lunch and gives a verbal report to another nurse on the unit. The primary nurse states that a client has a prescription for morphine 2 mg intravenously (IV) every 3 hours PRN for abdominal pain because the client had major abdominal surgery that morning. While the primary nurse is still at lunch, the client complains of pain at a level of 8 on a pain scale of 1 to 10. What is the first thing the covering nurse should do? Determine when the pain medication was last given Verify the pain medication prescription in the clinical record Employ nonpharmacological measures initially to relieve the pain Explain that the primary nurse will be back from lunch in a few minutes

Verify the pain medication prescription in the clinical record Rationale Before administering any medication for the first time, the nurse must verify the accuracy of the prescription. The prescription as it appears in the medication administration record is verified against the prescription in the client's medical record. This ensures that the prescription was transcribed accurately. Checking when the pain medication was last given is done after the prescription is verified. Nonpharmacological measures are used for mild to moderate pain, not pain associated with recent major abdominal surgery. The client's pain must be immediately addressed. The covering nurse is capable of verifying the pain medication prescription and administering it safely at the correct time.