Exam 2 Practice Questions P1

During a hospice visit, the client's spouse suddenly begins to cry and says, "I am so tired. I just can't do this anymore. I am not getting to sleep and I just eat sandwiches when I can." What is the nurse's best intervention? Request a mental health evaluation for the spouse. Send the spouse to the emergency department. Arrange for short-term inpatient care for the client. Have the chaplain visit with the spouse and client.

Arrange for short-term inpatient care for the client. This spouse is exhausted and needs respite care. The hospice nurse can arrange for short-term inpatient care for the client so that the spouse can rest. The other options will not be effective for exhaustion.

A nurse working in a primary care facility prepares insurance forms in which the provider is given a fixed amount per enrollee of the health plan. What is the term for this type of reimbursement? Capitation Prospective payment system Bundled payment Rate setting

Capitation . Capitation plans give providers a fixed amount per enrollee in the health plan in an effort to build a payment plan that consists of the best standards of care at the lowest cost. The prospective payment system groups inpatient hospital services for Medicare patients into DRGs. With bundled payments, providers receive a fixed sum of money to provide a range of services. Rate setting means that the government could set targets or caps for spending on health care services.

A nurse is collecting more patient data to confirm a patient diagnosis of emphysema. This is an example of formulating what type of diagnosis? Actual Possible Risk Collaborative

Possible An intervention for a possible diagnosis is to collect more patient data to confirm or rule out the problem. An intervention for an actual diagnosis is to reduce or eliminate contributing factors to the diagnosis. Interventions for a risk diagnosis focus on reducing or eliminating risk factors, and interventions for collaborative problems focus on monitoring for changes in status and managing these changes with nurse- and physician-prescribed interventions.

A nurse bandages the knee of a client who has recently undergone a knee surgery. What is the major purpose of the roller bandage? Supports the area around the wound Maintains a moist environment Keeps the wound clean Reduces swelling and inflammation

Supports the area around the wound Bandages and binders are used to secure dressings, apply pressure, and support the wound. A roller bandage is a continuous strip of material wrapped on itself to form a cylinder or roll and is applied using a circular turn, spiral turn, or figure-of-eight turn. It is effective for use around joints, such as the knee, elbow, ankle, and wrist.

intrapersonal communication

communication with oneself

Small-group communication

occurs when nurses interact with two or more individuals.

A caregiver asks a nurse to explain respite care. How would the nurse respond? "Respite care is a service that allows time away for caregivers." "Respite care is a special service for the terminally ill and their family." "Respite care is direct care provided to people in a long-term care facility." "Respite care provides living units for people without regular shelter."

"Respite care is a service that allows time away for caregivers." Respite care is provided to enable a primary caregiver time away from the day-to-day responsibilities of homebound patients.

The nurse is caring for a client with a sacral wound. Upon assessment, the wound is noted to have slough and a bad odor, and it extends into the muscle. How will the nurse categorize this pressure injury? stage I stage II stage III stage IV

Stage 4 Stage IV pressure injuries are characterized as exposing muscle and bone and may have slough and a foul odor. Stage I pressure injuries are characterized by intact but reddened skin that is unblanchable. Stage II involves blistering or a skin tear. Stage III involves a shallow skin crater that extends to the subcutaneous tissue; it may have serous or purulent drainage.

A nursing student is preparing to administer morning care to a patient. What is the MOST important question that the nursing student should ask the patient about personal hygiene? "Would you prefer a bath or a shower?" "May I help you with a bed bath now or later this morning?" "I will be giving you your bath. Do you use soap or shower gel?" "I prefer a shower in the evening. When would you like your bath?"

"May I help you with a bed bath now or later this morning? The nurse should ask permission to assist the patient with a bath. This allows for consent to assist the patient with care that invades the patient's private zones.

The nurse is teaching a client about healing of a large wound by primary intention. What teaching will the nurse include? Select all that apply. "Very little scar tissue will form." "This is a simple reparative process." "The margins of your wound are widely separated." "Your wound will be purposely left open for a time." "Your wound edges are right next to each other."

"Very little scar tissue will form." "This is a simple reparative process." "Your wound edges are right next to each other." Very little scar tissue is expected to form during first-intention healing in a wound whose wound edges are close to each other. Second-intention healing involves a complex reparative process in which the margins of the wound are not in direct contact. Third-intention healing takes place when the wound edges are intentionally left widely separated and later brought together for closure.

A student nurse tells the instructor that a patient is fine and has "no complaints." What would be the instructor's best response? "You made an inference that she is fine because she has no complaints. How did you validate this?" "She probably just doesn't trust you enough to share what she is feeling. I'd work on developing a trusting relationship." "Sometimes everyone gets lucky. Why don't you try to help another patient?" "Maybe you should reassess the patient. She has to have a problem—why else would she be here?"

"You made an inference that she is fine because she has no complaints. How did you validate this?" The instructor is most likely to challenge the inference that the patient is "fine" simply because she is telling you that she has no problems. It is appropriate for the instructor to ask how the student nurse validated this inference. Jumping to the conclusion that the patient does not trust the student nurse is premature and is an invalidated inference. Answer c is wrong because it accepts the invalidated inference. Answer d is wrong because it is possible that the condition is resolving.

The nurse is communicating with a client who has been newly diagnosed with cancer. Which statement(s) by the nurse is nontherapeutic? Select all that apply. "You will be OK. Your health care provider is an excellent surgeon." "Keep your chin up. People survive this type of cancer all the time." "Why did you not seek help when you first noticed a problem?" "This is upsetting news for you. Let's talk about it." "What are your thoughts about what your health care provider has recommended?"

"You will be OK. Your health care provider is an excellent surgeon." "Keep your chin up. People survive this type of cancer all the time." "Why did you not seek help when you first noticed a problem?" "You'll be OK...." is giving false reassurance to the client. It does not recognize the client's feelings, and it discourages further discussion. "Keep your chin up...." is using a cliche and provides worthless advice. From the information at the stem of the question, the outcome for the client is not known. "Why did you not seek help..." is demanding an explanation. The word "why" puts the client on the defensive and blames the client for failure to act sooner. "This is upsetting news for you..." acknowledges the client's feelings and encourages discussion. "Have you made decisions..." also engages the client and encourages the client to discuss any decisions that have been made.

A nurse is writing nursing diagnoses for patients in a psychiatrist's office. Which nursing diagnoses are correctly written as two-part nursing diagnoses? 1. Ineffective Coping related to inability to maintain marriage 2. Defensive Coping related to loss of job and economic security 3. Altered Thought Processes related to panic state 4.Decisional Conflict related to placement of parent in a long-term care facility a. (1) and (2) b.(3) and (4) c.(1), (2), and (3) d. (1), (2), (3), and (4)

(1), (2), (3), and (4) Each of the four diagnoses is a correctly written two-part diagnostic statement that includes the problem or diagnostic label and the etiology or cause.

A nurse caring for patients in a primary care setting submits paperwork for reimbursement from managed care plans for services performed. Which purpose best describes managed care as a framework for health care? A design to control the cost of care while maintaining the quality of care Care coordination to maximize positive outcomes to contain costs The delivery of services from initial contact through ongoing care Based on a philosophy of ensuring death in comfort and dignity

A design to control the cost of care while maintaining the quality of care Managed care is a way of providing care designed to control costs while maintaining the quality of care.

When interacting with a patient, the nurse answers, "I am sure everything will be fine. You have nothing to worry about." This is an example of what type of inappropriate communication technique? A) Cliché B) Giving advice C) Being judgmental D) Changing the subje

A) Cliché Telling a patient that everything is going to be all right is a cliché. This statement gives false assurance and gives the patient the impression that the nurse is not interested in the patient's condition.

A nurse is preparing a clinical outcome for a patient who is an avid runner and who is recovering from a stroke that caused right-sided paresis. What is an example of this type of outcome? After receiving 3 weeks of physical therapy, patient will demonstrate improved movement on the right side of her body. By 8/15/20, patient will be able to use right arm to dress, comb hair, and feed herself. Following physical therapy, patient will begin to gradually participate in walking/running events. By 8/15/20, patient will verbalize feeling sufficiently prepared to participate in running events.

After receiving 3 weeks of physical therapy, patient will demonstrate improved movement on the right side of her body. Clinical outcomes describe the expected status of health issues at certain points in time, after treatment is complete. Functional outcomes (b) describe the person's ability to function in relation to the desired usual activities. Quality-of-life outcomes (c) focus on key factors that affect someone's ability to enjoy life and achieve personal goals. Affective outcomes (d) describe changes in patient values, beliefs, and attitudes.

Which scenario is using a prospective payment plan to reimburse for services? An older adult client is admitted to the hospital and treated for pneumonia. The hospital is reimbursed based on a predetermined fixed price. A client is hospitalized for an emergency appendectomy. Since the hospital is a preferred provider the fee for service was discounted. A client with chronic heart failure is offered health care teaching and preventative services for free. A child is hospitalized and treated for a fractured femur. The hospital receives a preset fee for each member regardless of whether the member required services.

An older adult client is admitted to the hospital and treated for pneumonia. The hospital is reimbursed based on a predetermined fixed price. A prospective payment system uses financial incentives to decrease total healthcare charges by reimbursing hospitals on a fixed rate basis. Reimbursement is based on the diagnostic-related group (DRG). Therefore, the scenario in which the hospital is reimbursed is an example of a prospective payment plan. The other scenarios demonstrate other types of payment plans.

The nurse is providing care to several clients on a medical-surgical unit. For which client's plan of care should the nurse include information regarding extended care? A middle-aged client who had a knee replacement A client who developed sepsis after a ruptured polyp A client who had a cholecystectomy An older adult client who fell at home and required a hip replacement

An older adult client who fell at home and required a hip replacement Extended care meets the health needs of clients who no longer require acute hospital care but require rehabilitation and skilled nursing care, such as an older adult following a hip replacement surgery, who may need additional assistance with mobility and more time for physical therapy before being ready to be discharged home. The other clients do not require, or would not benefit from, extended care.

The nurse has removed the sutures and is now planning to apply wound closure strips. What should the nurse do before applying the strips? Apply a skin protectant to the skin around the incision. Apply a skin protectant to the incision site. Apply a sterile gauze sponge over the incision site. Apply a transparent dressing over the incision site.

Apply a skin protectant to the skin around the incision. Before applying the wound closure strips, the nurse should apply a skin protectant to the skin surrounding the incision site. The skin barrier will help the closure strips adhere to the skin and helps prevent skin irritation and excoriation from tape, adhesives, and wound drainage. The skin protectant should not be placed on the incision itself. Nothing should be placed over the incision site itself before the closure strips are applied.

Conflict has emerged on a nursing unit because new graduates have found that some of the more experienced nurses are manipulating the client assignment to ensure a lighter workload during night shifts. How should the manager of the unit best address this conflict? Arrange a meeting where the issue can be discussed and addressed by as many of the nurses as possible. Gather evidence over the next several weeks in order to determine if the practice is indeed happening. Arrange for the newer nurses to organize the client assignment for a trial period. Reassure the new graduates that the more experienced nurses are acting in the interests of both staff and clients.

Arrange a meeting where the issue can be discussed and addressed by as many of the nurses as possible. Open, explicit, and participatory conflict resolution that is based on collaboration is an effective strategy for the management of conflict. Gathering evidence does not directly address the conflict that currently exists and reassurance may be unwarranted and false. Allowing the new graduates to create the client assignment may perpetuate selfish practices and does not resolve animosity between the two camps.

When a nurse enters the patient's room to begin a nursing history, the patient's wife is there. After introducing herself to the patient and his wife, what should the nurse do? Thank the wife for being present. Ask the wife if she wants to remain. Ask the wife to leave. Ask the patient if he would like the wife to stay.

Ask the patient if he would like the wife to stay. The patient has the right to indicate whom he would like to be present for the nursing history and exam. The nurse should neither presume that he wants his wife there nor that he does not want her there. Similarly, the choice belongs to the patient, not the wife.

The nurse is delegating care to an unlicensed assistive personnel (UAP). Which intervention would be most important for the nurse to perform independently? Assess the client with difficulty breathing Obtain a postprandial blood sugar reading Measure the client's blood pressure Assist the client with turning in bed

Assess the client with difficulty breathing Any assessment is the responsibility of the registered nurse. A UAP is able to measure vital signs, assist with turning, and measure blood pressure or blood sugar.

A nurse is in charge of a large group of employees on a busy surgical floor. Today's care must be completed early due to a special event involving most of the employees. Which management style would work best in this situation? Authoritarian Coercive Democratic Laissez-faire

Authoritarian With authoritarian, or autocratic, leadership, the leader determines, dictates, and directs the activities of the group, with no input from the followers on decisions. It is particularly effective when decisions for a large group need to be made quickly and efficiently, as in this scenario. Coercion--involving forcing actions upon the staff--is not a recognized leadership style and, in any case, would not be an advisable approach as it would likely trigger resistance in the group and be counterproductive. Democratic leadership is appropriate when the task, or decision at hand, is not one that requires urgent action, when subordinates can be expected to make meaningful contributions, and when their input can be taken into account. Laissez-faire management provides little or no direction; coworkers develop their own goals, make their own decisions, and take responsibility for their own management.

A nurse is identifying outcomes for a patient who has a leg ulcer related to diabetes. What is an example of an affective outcome for this patient? Within 1 day after teaching, the patient will list three benefits of continuing to apply moist compresses to leg ulcer after discharge. By 6/12/20, the patient will correctly demonstrate application of wet-to-dry dressing on leg ulcer. By 6/19/20, the patient's ulcer will begin to show signs of healing (e.g., size shrinks from 3 to 2.5 in). By 6/12/20, the patient will verbalize valuing health sufficiently to practice new health behaviors to prevent recurrence of leg ulcer.

By 6/12/20, the patient will verbalize valuing health sufficiently to practice new health behaviors to prevent recurrence of leg ulcer. Affective outcomes describe changes in patient values, beliefs, and attitudes. Cognitive outcomes (a) describe increases in patient knowledge or intellectual behaviors; psychomotor outcomes (b) describe the patient's achievement of new skills; and (c) is an outcome describing a physical change in the patient.

Which is not considered a skin appendage? Hair Connective tissue Sebaceous gland Eccrine sweat glands

Connective Tissue Hair, the sebaceous gland, and eccrine sweat glands are skin appendages that are formed with the enfolding of the epidermis into the dermis. The dermis is composed of connective tissue.

The nurse is preparing to teach a client from Generation X about hypertension. Which teaching approach should the nurse plan to implement? Provide brochures about low-sodium foods. Ask a family member to do meal planning to alleviate the burden for the client. Demonstrate the MyFoodPyramid phone app, to show the best food choices on a lunch tray. Have the client repetitively choose appropriate foods from various menus.

Demonstrate the MyFoodPyramid phone app, to show the best food choices on a lunch tray. Those who represent Generations X, Y, and Z may share many learning characteristics. They are or will be technologically literate, having used or grown up with computers, smart phones, and tablet devices. Therefore, it is most appropriate to teach them using some form of multimedia, such as a phone app. The other teaching approaches are less appropriate for this client population.

A nurse manager who is attempting to institute the SBAR process to communicate with health care providers and transfer patient information to other nurses is meeting staff resistance to the change. Which action would be most effective in approaching this resistance? Containing the anxiety in a small group and moving forward with the initiative Explaining the change and listing the advantages to the person and the organization Reprimanding those who oppose the new initiative and praising those who willingly accept the change Introducing the change quickly and involving the staff in the implementation of the change

Explaining the change and listing the advantages to the person and the organization Change is ubiquitous, as is resistance to change. The manager should explain the proposed change to all affected, list the advantages of the proposed change for all parties, introduce the change gradually, and involve everyone affected by the change in the design and implementation of the process. The manager should not use the reward/punishment style to overcome resistance to change.

A nurse is performing an initial comprehensive assessment of a patient admitted to a long-term care facility from home. The nurse begins the assessment by asking the patient, "How would you describe your health status and well-being?" The nurse also asks the patient, "What do you do to keep yourself healthy?" Which model for organizing data is this nurse following? Maslow's human needs Gordon's functional health patterns Human response patterns Body system model

Gordon's functional health patterns Gordon's functional health patterns begin with the patient's perception of health and well-being and progress to data about nutritional-metabolic patterns, elimination patterns, activity, sleep/rest, self-perception, role relationship, sexuality, coping, and values/beliefs. Maslow's model is based on the human needs hierarchy. Human responses include exchanging, communicating, relating, valuing, choosing, moving, perceiving, knowing, and feeling. The body system model is based on the functioning of the major body systems.

The nurse is caring for a client who has a stage IV pressure injury. Based on the nurse's understanding of wound healing, arrange the following four phases of wound healing in the correct order. 1Hemostasis 2Inflammatory 3Proliferation 4Maturation

Hemostasis Inflammatory Proliferation Maturation

A nurse is counseling a 19-year-old athlete who had his right leg amputated below the knee following a motorcycle accident. During the rehabilitation process, the patient refuses to eat or get up to ambulate on his own. He says to the nurse, "What's the point. My life is over now and I'll never be the football player I dreamed of becoming." What is the nurse counselor's best response to this patient? "You're young and have your whole life ahead of you. You should focus on your rehabilitation and make something of your life." "I understand how you must feel. I wanted to be a famous singer, but I wasn't born with the talent to be successful at it." "You should concentrate on other sports that you could play even with prosthesis." "I understand this is difficult for you. Would you like to talk about it now or would you prefer me to make a referral to someone else?"

I understand this is difficult for you. Would you like to talk about it now or would you prefer me to make a referral to someone else?" This answer communicates respect and sensitivity to the patient's needs and offers an opportunity to discuss his feelings with the nurse or another health care professional. The other answers do not allow the patient to express his feelings and receive the counseling he needs.

I-SBAR-R stands for I___________-S______________B________________A_______________R______________________ -R_______________

I- yourself and the patient S- Situation B- Background A-Assessment R- RecommendationsR-readback

The nursing process ensures that nurses are person centered rather than task centered. Rather than simply approaching a patient to take vital signs, the nurse thinks, "How is Mrs. Barclay today? Are our nursing actions helping her to achieve her goals? How can we better help her?" This demonstrates which characteristic of the nursing process? Systematic Interpersonal Dynamic Universally applicable in nursing situations

Interpersonal interpersonal. All of the other options are characteristics of the nursing process, but the conversation and thinking quoted best illustrates the interpersonal dimension of the nursing process.

An experienced nurse tells a beginning nurse not to bother studying too hard, since most clinical reasoning becomes "second nature" and "intuitive" once you start practicing. What thinking below should underlie the beginning nurse's response? Intuitive problem solving comes with years of practice and observation, and novice nurses should base their care on scientific problem solving. For nursing to remain a science, nurses must continue to be vigilant about stamping out intuitive reasoning. The emphasis on logical, scientific, evidence-based reasoning has held nursing back for years; it is time to champion intuitive, creative thinking! It is simply a matter of preference; some nurses are logical, scientific thinkers, and some are intuitive, creative thinkers.

Intuitive problem solving comes with years of practice and observation, and novice nurses should base their care on scientific problem solving. Beginning nurses must use nursing knowledge and scientific problem solving as the basis of care they give; intuitive problem solving comes with years of practice and observation. If the beginning nurse has an intuition about a patient, that information should be discussed with the faculty member, preceptor, or supervisor. Answer b is incorrect because there is a place for intuitive reasoning in nursing, but it will never replace logical, scientific reasoning. Critical thinking is contextual and changes depending on the circumstances, not on personal preference.

The nurse is caring for a client who has a wound to the right forearm following a motor vehicle accident. The primary care provider has ordered culture of the wound. Which action should the nurse perform in obtaining a wound culture? Cleanse the wound after obtaining the wound culture. Stroke the culture swab on surrounding skin first. Utilize the culture swab to obtain cultures from multiple sites. Keep the swab and the inside of the culture tube sterile prior to collecting the culture.

Keep the swab and the inside of the culture tube sterile prior to collecting the culture. The swab and the inside of the culture tube should be kept sterile prior to the procedure. The wound should be cleansed prior to obtaining the culture. The culture swab should not touch the skin surrounding the wound site. In addition, if multiple sites have to be cultured then separate culture swabs should be used.

A nurse is measuring the depth of a patient's puncture wound. Which technique is recommended Moisten a sterile, flexible applicator with saline and insert it gently into the wound at a 90-degree angle with the tip down. Draw the shape of the wound and describe how deep it appears in centimeters. Gently insert a sterile applicator into the wound and move it in a clockwise direction. Insert a calibrated probe gently into the wound and mark the point that is even with the surrounding skin surface with a marker.

Moisten a sterile, flexible applicator with saline and insert it gently into the wound at a 90-degree angle with the tip down. To measure the depth of a wound, the nurse should perform hand hygiene and put on gloves; moisten a sterile, flexible applicator with saline and insert it gently into the wound at a 90-degree angle with the tip down; mark the point on the swab that is even with the surrounding skin surface, or grasp the applicator with the thumb and forefinger at the point corresponding to the wound's margin; and remove the swab and measure the depth with a ruler.

A nurse is counseling a patient who refuses to look at or care for a new colostomy. The patient tells the nurse, "I don't care what I look like anymore, I don't even feel like washing my hair, let alone changing this bag." The nurse diagnoses Altered Health Maintenance. This is an example of what type of problem? Collaborative problem Interdisciplinary problem Medical problem Nursing problem

Nursing problem Altered Health Maintenance is a nursing problem, because the diagnosis describes a problem that can be treated by nurses within the scope of independent nursing practice. Collaborative and interdisciplinary problems require a teamwork approach with other health care professionals to resolve the problem. A medical problem is a traumatic or disease condition validated by medical diagnostic studies.

A nurse manager has asked the staff to create a plan to improve client outcomes. In the past, the staff have not met deadlines. How can the nurse manager use transactional leadership style to ensure that the deadline is met? Ask politely. Demand efficiency. Give extensions as needed. Offer 2 days of paid vacation.

Offer 2 days of paid vacation. The transactional leadership style involves a task and reward system. Paid vacation is a reward for meeting the deadline. Asking politely, demanding efficiency, and giving extensions are not rewarding behaviors.

The nurse is helping a patient turn in bed and notices the patient's heels are red. The nurse places the patient on precautions for skin breakdown. This is an example of what type of planning? Initial planning Standardized planning Ongoing planning Discharge planning

Ongoing planning Ongoing planning is problem oriented and has as its purpose keeping the plan up to date as new actual or potential problems are identified. Initial planning addresses each problem listed in the prioritized nursing diagnoses and identifies appropriate patient goals and the related nursing care. Standardized care plans are prepared care plans that identify the nursing diagnoses, outcomes, and related nursing interventions common to a specific population or health problem. During discharge planning, the nurse uses teaching and counseling skills effectively to help the patient and family develop sufficient knowledge of the health problem and the therapeutic regimen to carry out necessary self-care behaviors competently at home.

A nurse notes that a shift report states that a patient has no special skin care needs. The nurse is surprised to observe reddened areas over bony prominences during the patient bath. What nursing action is appropriate? Correct the initial assessment form. Redo the initial assessment and document current findings. Conduct and document an emergency assessment. Perform and document a focused assessment of skin integrity.

Perform and document a focused assessment of skin integrity. Perform and document a focused assessment on skin integrity since this is a newly identified problem. The initial assessment stands as is and cannot be redone or corrected. This is not a life-threatening event; therefore, there is no need for an emergency assessment.

A nurse is caring for patients in a primary care center. What is the most likely role of this nurse based on the setting? Assisting with major surgery Performing a health assessment Maintaining patients' function and independence Keeping student immunization records up to date

Performing a health assessment Performing patient health assessments is a common role of the nurse in a primary care center. Assisting with major surgery is a role of the nurse in the hospital setting. Maintaining patients' function and independence is a role of the nurse in an extended-care facility, and keeping student immunization records up to date is a role of the school nurse.

A patient is admitted with a nonhealing surgical wound. Which nursing action is most effective in preventing a wound infection? Using sterile dressing supplies Suggesting dietary supplements Applying antibiotic ointment Performing careful hand hygiene

Performing careful hand hygiene Although all of the answers may help in preventing wound infections, careful hand washing (medical asepsis) is the most important.

A hospital nurse is admitting a patient who sustained a head injury in a motor vehicle accident. Which activity could the nurse delegate to licensed assistive personnel? Collecting information for a health history Performing a physical assessment Contacting the health care provider for medical orders Preparing the bed and collecting needed supplie

Preparing the bed and collecting needed supplie The nurse may delegate preparation of the bed and collection of needed supplies to unlicensed personnel but would perform the other activities listed.

new nurse manager at a small hospital is interested in achieving Magnet status. Which action would help the hospital to achieve this goal? Centralizing the decision-making process Promoting self-governance at the unit level Deterring professional autonomy to promote teamwork Promoting evidence-based practice over innovative nursing practice

Promoting self-governance at the unit level Magnet hospitals use a decentralized decision-making process, self-governance at the unit level, and respect for and acknowledgment of professional autonomy. In Magnet hospitals, 14 characteristics, the Forces of Magnetism, have been recognized that identify quality patient care, excellent nursing care, and innovations in professional nursing practice.

A nurse makes a clinical judgment that an African American man in a stressful job is more vulnerable to developing hypertension than a White man in the same or a similar situation. The nurse has formulated what type of nursing diagnosis? Actual Risk Possible Wellness

Risk A clinical judgment that an individual, family, or community is more vulnerable to develop the problem than others in the same or similar situation is a Risk nursing diagnosis.

A nurse is using time management techniques when planning activities for patients. Which nursing action reflects effective time management? The nurse asks patients to prioritize what they want to accomplish each day The nurse includes a "nice to do" for every "need to do" task on the list The nurse "front loads" the schedule with "must do" priorities The nurse avoids helping other nurses if scheduling does not permit it

The nurse asks patients to prioritize what they want to accomplish each day By asking the patient to prioritize what they want to accomplish each day, the nurse is demonstrating an effective time management technique. In order to manage time, the nurse should establish goals and priorities for each day, differentiating "need to do" from "nice to do" tasks; the nurse should include the patient in this process. The nurse should also establish a time line, allocating priorities to hours in the workday in order to keep track of falling behind and correct the problem before the day is lost. The nurse should use teamwork appropriately to enhance the schedule.

A nurse is asked to act as a mentor to a new nurse. Which nursing action is related to this process? The nurse mentor accepts payment to introduce the new nurse to his or her responsibilities The nurse mentor hires the new nurse and assigns duties related to the position The nurse mentor makes it possible for the new nurse to participate in professional organizations The nurse mentor advises and assists the new nurse to adjust to the work environment of a busy emergency department

The nurse mentor advises and assists the new nurse to adjust to the work environment of a busy emergency department Mentorship is a relationship in which an experienced person (the mentor) advises and assists a less experienced person (protégé). This is an effective way of easing a new nurse into leadership responsibilities. An experienced nurse who is paid to introduce an employee to new responsibilities through teaching and guidance describes a preceptor, not a mentor. The nurse mentor does not hire or schedule new nurses. Nurses do not need mentors to join professional organizations.

A female patient who is receiving chemotherapy for breast cancer tells the nurse, "The treatment for this cancer is worse than the disease itself. I'm not going to come for my therapy anymore." The nurse responds by using critical thinking skills to address this patient problem. Which action is the first step the nurse would take in this process? The nurse judges whether the patient database is adequate to address the problem. The nurse considers whether or not to suggest a counseling session for the patient. The nurse reassesses the patient and decides how best to intervene in her care. The nurse identifies several options for intervening in the patient's care and critiques the merit of each option.

The nurse reassesses the patient and decides how best to intervene in her care. The first step when thinking critically about a situation is to identify the purpose or goal of your thinking. Reassessing the patient helps to discipline thinking by directing all thoughts toward the goal. Once the problem is addressed, it is important for the nurse to judge the adequacy of the knowledge, identify potential problems, use helpful resources, and critique the decision.

A registered nurse assumes the role of nurse coach to provide teaching to patients who are recovering from a stroke. Which nursing intervention directly relates to this role? The nurse uses discovery to identify the patients' personal goals and create an agenda that will result in change. The nurse is the expert in providing teaching and education strategies to provide dietary and activity modifications. The nurse becomes a mentor to the patients and encourages them to create their own fitness programs. The nurse assumes an authoritative role to design the structure of the coaching session and support the achievement of patient goals.

The nurse uses discovery to identify the patients' personal goals and create an agenda that will result in change A nurse coach establishes a partnership with a patient and, using discovery, facilitates the identification of the patient's personal goals and agenda to lead to change rather than using teaching and education strategies with the nurse as the expert. A nurse coach explores the patient's readiness for coaching, designs the structure of a coaching session, supports the achievement of the patient's desired goals, and with the patient determines how to evaluate the attainment of patient goals.

The nurse is preparing to measure the depth of a client's tunneled wound. Which implement should the nurse use to measure the depth accurately? a) a sterile, flexible applicator moistened with saline b) an otic curette c) a small plastic ruler d) a sterile tongue blade lubricated with water soluble gel

a) a sterile, flexible applicator moistened with saline

When clients are pulled up in bed rather than lifted, they are at increased risk for the development of a decubitus ulcer. What is the name given to the factor responsible for this risk? a) shearing force b) ischemia c) friction d) necrosis of tissue

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

A public health nurse is leaving the home of a young mother who has a special needs baby. The neighbor states, "How is she doing, since the baby's father is no help?" What is the nurse's BEST response to the neighbor? "New mothers need support." "The lack of a father is difficult." "How are you today?" "It is a very sad situation."

a. "New mothers need support." The nurse must maintain confidentiality when providing care. The statement "New mothers need support" is a general statement that all new parents need help. The statement is not judgmental of the family's roles.

The nurse is caring for a client who has a heavily exudating wound that needs autolytic debridement. Which wound dressing/product is most appropriate to use on the wound? an alginate dressing transparent film a hydrogel dressing an antimicrobial dressing

an alginate dressing Alginate dressings contain alginic acid from brown seaweed. Covered in calcium-sodium salts, they absorb exudate, maintain a moist wound environment, and facilitate autolytic debridement. A secondary dressing is required to secure them. Transparent film allows frequent assessment of the site but provides a barrier. A hydrogel dressing comprises an 80%-99% water base and is used with partial- and full-thickness wounds. An antimicrobial dressing has an antibiotic that reduces bacterial growth.

Upon review of a postoperative client's medication list, the nurse recognizes that which medication will delay the healing of the operative wound? corticosteroids antihypertensive drugs potassium supplements laxatives

corticosteroids Clients who are taking corticosteroids or require postoperative radiation therapy are at high risk for delayed healing and wound complications. Corticosteroids decrease the inflammatory process, which may delay healing. Antihypertensive drugs, potassium supplements, and laxatives do not delay wound healing.

A postoperative client says during a transfer, "I feel like something just popped." The nurse immediately assesses for: infection. herniation. dehiscence. evisceration.

ehiscence. Dehiscence is a total or partial disruption of wound edges. Clients often report feeling that the incision has given way. Manifestations of infection include redness, warmth, swelling, and fever. With herniation, there is protrusion through a bodily opening. Evisceration is a term that describes protrusion of intra-abdominal contents.

A nurse is assessing a client's surgical wound and sees drainage that is pale pink-yellow and thin and contains plasma and red cells. What is this type of drainage? serous purulent serosanguineous sanguineous

serosanguineous This describes serosanguineous wound drainage. Drainage that is pale yellow, watery, and like the fluid from a blister is called serous. Drainage that is bloody is called sanguineous. Drainage that contains white cells and microorganisms is called purulent.

Which statement made by a client who was recently admitted to the medical unit with a diagnosis of pneumonia indicates a physical inability to learn? "May I have something to eat?" "The pain in my chest has gone." "I am having difficulty breathing." "Finally, I am getting medical attention."

"I am having difficulty breathing." The statement "I am having difficulty breathing" indicates that the client is not physically well and that the client is unable to learn effectively until comfort is restored. "The pain in my chest has gone" and "May I have something to eat?" is suggesting that the client is physically well and is ready to learn. "Finally, I am getting medical attention" is suggesting that the client is psychologically ready to learn.

The nurse is discussing the use of the client-controlled analgesia pump with the postoperative client. Which statement by the client indicates a need for additional education? "I am able to push the button when I am in pain." "The dose is set so I cannot overdose myself." "I should not press the button more often than every 3 to 4 hours." "The medicine will help me control my pain."

"I should not press the button more often than every 3 to 4 hours." Specific dosages and time intervals can be programmed into the machine to prevent overdose; medication is delivered when the client pushes a control button. The medicine will help the client control pain. The client need not worry about pressing the button too often, as the machine has been programmed to not allow delivery of too much medication.

A nurse is explaining to a patient the anticipated effect of the application of cold to an injured area. What response indicates that the patient understands the explanation? I can expect to have more discomfort in the area where the cold is applied." "I should expect more drainage from the incision after the ice has been in place." "I should see less swelling and redness with the cold treatment." "My incision may bleed more when the ice is first applied."

"I should see less swelling and redness with the cold treatment." The local application of cold constricts peripheral blood vessels, reduces muscle spasms, and promotes comfort. Cold reduces blood flow to tissues, decreases the local release of pain-producing substances, decreases metabolic needs, and capillary permeability. The resulting effects include decreased edema, coagulation of blood at the wound site, promotion of comfort, decreased drainage from wound, and decreased bleeding.

A nurse in the rehabilitation division states to the head nurse: "I need the day off and you didn't give it to me!" The head nurse replies, "Well, I wasn't aware you needed the day off, and it isn't possible since staffing is so inadequate." Instead of this exchange, what communication by the nurse would have been more effective? "I placed a request to have 8th of August off, but I'm working and I have a doctor's appointment." "I would like to discuss my schedule with you. I requested the 8th of August off for a doctor's appointment. Could I make an appointment?" "I will need to call in on the 8th of August because I have a doctor's appointment." "Since you didn't give me the 8th of August off, will I need to find someone to work for me?"

"I would like to discuss my schedule with you. I requested the 8th of August off for a doctor's appointment. Could I make an appointment?" Effective communication by the sender involves the implementation of nonthreatening information by showing respect to the receiver. The nurse should identify the subject of the meeting and be sure it occurs at a mutually agreed upon time.

Which statement regarding health care reform trends is most accurate? "Systems are in place to pay for performance and penalize hospitals for excessive readmissions." "Distinctive to the United States is the dominance of the public element over the private one." "The United States is second in the world in total health care dollars spent annually." "Spending on medical services will rise to almost 32% of the U.S. gross domestic product by 2021."

"Systems are in place to pay for performance and penalize hospitals for excessive readmissions." Health care trends already include paying for performance (HEDIS, HCAHPS) and penalizing hospitals for excess readmissions. In the United States, private insurers dominate over public, unlike in most countries. The United States is first in health care spending worldwide, and it is estimated that 20% of the gross domestic product will be spent on medical services by 2021.

The nurse and client are looking at the client's heel pressure injury. The client asks, "Why does my heel look black?" What is the nurse's appropriate response? "This is normal tissue." "That is old clotted blood underneath the wound" "That is called undermining, a type of tissue erosion." "That is necrotic tissue, which must be removed to promote healing."

"That is necrotic tissue, which must be removed to promote healing." Wounds that are brown or black are necrotic and not considered normal. Slough is dead moist, stringy dead tissue on the wound surface that is yellow, tan, gray, or green. Undermining is tissue erosion from underneath intact skin at the wound edge.

A nurse forms a contractual agreement with a morbidly obese patient to achieve optimal weight goals. Which statement best describes the nature of this agreement? "This agreement forms a legal bond between the two of us to achieve your weight goals." "This agreement will motivate the two of us to do what is necessary to meet your weight goals." "This agreement will help us determine what learning outcomes are necessary to achieve your weight goals." "This agreement will limit the scope of the teaching session and make stated weight goals more attainable

"This agreement will motivate the two of us to do what is necessary to meet your weight goals. A contractual agreement is a pact two people make, setting out mutually agreed-on goals. Contracts are usually informal and not legally binding. When teaching a patient, such an agreement can help motivate both the patient and the teacher to do what is necessary to meet the patient's learning outcomes. The agreement notes the responsibilities of both the teacher and the learner, emphasizing the importance of the mutual commitment.

When the initial nursing assessment revealed that a patient had not had a bowel movement for 2 days, the student nurse wrote the diagnostic label "constipation." What would be the instructor's BEST response to this student's diagnosis? "Was this diagnosis derived from a cluster of significant data or a single clue?" "This early diagnosis will help us manage the problem before it becomes more acute." "Have you determined if this is an actual or a possible diagnosis?" "This condition is a medical problem that should not have a nursing diagnosis."

"Was this diagnosis derived from a cluster of significant data or a single clue?" Nursing diagnoses should always be derived from clusters of significant data rather than from a single cue. A data cluster is a grouping of patient data or cues that point to the existence of a patient health problem. There may be a reason for the lack of a bowel movement for 2 days, or it might be this person's normal pattern.

Which statement or question MOST exemplifies the role of the nurse in establishing a discharge plan for a patient who has had major abdominal surgery? "I'll bet you will be so glad to be home in your own bed." "What are your expectations for recovery from your surgery?" "Be sure to take your pain medications and change your dressing." "You will just be fine! Please stop worrying."

"What are your expectations for recovery from your surgery?" . The purpose of planning for continuity of care, commonly referred to in hospitals and community facilities as discharge planning, is to ensure that patient and family needs are consistently met as the patient moves from a care setting to home. Essential components of discharge planning include assessing the strengths and limitations of the patient, the family or support person, and the environment; implementing and coordinating the care plan; considering individual, family, and community resources; and evaluating the effectiveness of care. Answers a and c are not MOST reflective of the role of the nurse in discharge planning, although teaching and communication are elements of this process. The statement "You will just be fine! Please stop worrying." is a cliché and should not be used.

A patient states, "I have been experiencing complications of diabetes." The nurse needs to direct the patient to gain more information. What is the MOST appropriate comment or question to elicit additional information? "Do you take two injections of insulin to decrease the complications?" "Most health care providers recommend diet and exercise to regulate blood sugar." "Most complications of diabetes are related to neuropathy." "What specific complications have you experienced?"

"What specific complications have you experienced?" Requesting specific information regarding complications of diabetes will elicit specific information to guide the nurse in further interview questions and specific assessment techniques.

A student nurse attempts to perform a nursing history for the first time. The student nurse asks the instructor how anyone ever learns all the questions the nurse must ask to get good baseline data. What would be the instructor's best reply? "There's a lot to learn at first, but once it becomes part of you, you just keep asking the same questions over and over in each situation until you can do it in your sleep!" "You make the basic questions a part of you and then learn to modify them for each unique situation, asking yourself how much you need to know to plan good care." "No one ever really learns how to do this well because each history is different! I often feel like I'm starting afresh with each new patient." "Don't worry about learning all of the questions to ask. Every facility has its own assessment form you must use."

"You make the basic questions a part of you and then learn to modify them for each unique situation, asking yourself how much you need to know to plan good care. Once a nurse learns what constitutes the minimum data set, it can be adapted to any patient situation. It is not true that each assessment is the same even when using the same minimum data set, nor is it true that each assessment is uniquely different. Nurses committed to thoughtful, person-centered practice tailor their questions to the uniqueness of each patient and situation. Answer d is incorrect because relying solely on standard facility assessment tools does not allow for individualized patient care or critical thinking.

It is recommended that a client go to a convalescent center upon discharge following a minor stroke. The client says, "I don't want to go anywhere, I want to go home." Which information should the nurse offer? "You may go home if you wish." "You are not able to care for yourself anymore and need help." "There are so many activities that I think you will like the nursing home." "You will only stay until you are well enough to go home."

"You will only stay until you are well enough to go home." Those entering convalescent centers remain only until they have recovered. The nurse should explain this even though the client does have the right to refuse. There is no indication that the client will not be able to care for oneself again. There is a difference between a convalescent center and a nursing home.

The nurse assesses the wound of a patient who was cut on the upper thigh with a chain saw. The nurse documents the presence of biofilms in the wound. What is the effect of this condition on the wound? Select all that apply. Enhanced healing due to the presence of sugars and proteins Delayed healing due to dead tissue present in the wound Decreased effectiveness of antibiotics against the bacteria Impaired skin integrity due to overhydration of the cells of the wound Delayed healing due to cells dehydrating and dying Decreased effectiveness of the patient's normal immune process

-Decreased effectiveness of the patient's normal immune process -Decreased effectiveness of antibiotics against the bacteria Wound biofilms are the result of wound bacteria growing in clumps, embedded in a thick, self-made, protective, slimy barrier of sugars and proteins. This barrier contributes to decreased effectiveness of antibiotics against the bacteria (antibiotic resistance) and decreases the effectiveness of the normal immune response by the patient Necrosis (dead tissue) in the wound delays healing. Maceration or overhydration of cells related to urinary and fecal incontinence can lead to impaired skin integrity. Desiccation is the process of drying up, in which cells dehydrate and die in a dry environment.

A nurse who is changing dressings of postoperative patients in the hospital documents various phases of wound healing on the patient charts. Which statements accurately describe these stages? Select all that apply. Hemostasis occurs immediately after the initial injury. A liquid called exudate is formed during the proliferation phase. White blood cells move to the wound in the inflammatory phase. Granulation tissue forms in the inflammatory phase. During the inflammatory phase, the patient has generalized body response. A scar forms during the proliferation phase.

-Hemostasis occurs immediately after the initial injury -White blood cells move to the wound in the inflammatory phase. -During the inflammatory phase, the patient has generalized body response. . Hemostasis occurs immediately after the initial injury and exudate occurs in this phase due to the leaking of plasma and blood components out into the injured area. White blood cells, predominantly leukocytes and macrophages, move to the wound in the inflammatory phase to ingest bacteria and cellular debris. During the inflammatory phase, the patient has a generalized body response, including a mildly elevated temperature, leukocytosis (increased number of white blood cells in the blood), and generalized malaise. New tissue, called granulation tissue, forms the foundation for scar tissue development in the proliferation phase. New collagen continues to be deposited in the maturation phase, which forms a scar.

A nurse caring for patients in the PACU teaches a novice nurse how to assess and document wound drainage. Which statements accurately describe a characteristic of wound drainage? Select all that apply. Serous drainage is composed of the clear portion of the blood and serous membranes. Sanguineous drainage is composed of a large number of red blood cells and looks like blood. Bright-red sanguineous drainage indicates fresh bleeding and darker drainage indicates older bleeding. Purulent drainage is composed of white blood cells, dead tissue, and bacteria. Purulent drainage is thin, cloudy, and watery and may have a musty or foul odor. Serosanguineous drainage can be dark yellow or green depending on the causative organism.

-Serous drainage is composed of the clear portion of the blood and serous membranes. -Sanguineous drainage is composed of a large number of red blood cells and looks like blood. -Bright-red sanguineous drainage indicates fresh bleeding and darker drainage indicates older bleeding. -Purulent drainage is composed of white blood cells, dead tissue, and bacteria. Serous drainage is composed primarily of the clear, serous portion of the blood and serous membranes. Serous drainage is clear and watery. Sanguineous drainage consists of large numbers of red blood cells and looks like blood. Bright-red sanguineous drainage is indicative of fresh bleeding, whereas darker drainage indicates older bleeding. Purulent drainage is made up of white blood cells, liquefied dead tissue debris, and both dead and live bacteria. Purulent drainage is thick, often has a musty or foul odor, and varies in color (such as dark yellow or green), depending on the causative organism. Serosanguineous drainage is a mixture of serum and red blood cells. It is light pink to blood tinged.

A nurse is teaching patients of all ages in a hospital setting. Which examples demonstrate teaching that is appropriately based on the patient's developmental level? Select all that apply. The nurse plans long teaching sessions to discuss diet modifications for an older adult diagnosed with type 2 diabetes. The nurse recognizes that a female adolescent diagnosed with anorexia is still dependent on her parents and includes them in all teaching sessions. The nurse designs an exercise program for a sedentary older adult male patient based on the activities he prefers. The nurse includes an 8-year-old patient in the teaching plan for managing cystic fibrosis. The nurse demonstrates how to use an inhaler to an 11-year-old male patient and includes his mother in the session to reinforce the teaching. The nurse continues a teaching session on STIs for a sexually active male adolescent despite his protest that "I've heard enough already!"

-The nurse designs an exercise program for a sedentary older adult male patient based on the activities he prefers. -The nurse includes an 8-year-old patient in the teaching plan for managing cystic fibrosis. -The nurse demonstrates how to use an inhaler to an 11-year-old male patient and includes his mother in the session to reinforce the teaching. Successful teaching plans for older adults incorporate extra time, short teaching sessions, accommodation for sensory deficits, and reduction of environmental distractions. Older adults also benefit from instruction that relates new information to familiar activities or information. School-aged children are capable of logical reasoning and should be included in the teaching-learning process whenever possible; they are also open to new learning experiences but need learning to be reinforced by either a parent or health care provider as they become more involved with their friends and school activities. Teaching strategies designed for an adolescent patient should recognize the adolescent's need for independence, as well as the need to establish a trusting relationship that demonstrates respect for the adolescent's opinions.

A nurse is planning teaching strategies based on the affective domain of learning for patients addicted to alcohol. What are examples of teaching methods and learning activities promoting behaviors in this domain? Select all that apply. The nurse prepares a lecture on the harmful long-term effects of alcohol on the body. The nurse explores the reasons alcoholics drink and promotes other methods of coping with problems. The nurse asks patients for a return demonstration for using relaxation exercises to relieve stress. The nurse helps patients to reaffirm their feelings of self-worth and relate this to their addiction problem. The nurse uses a pamphlet to discuss the tenants of the Alcoholics Anonymous program to patients. The nurse reinforces the mental benefits of gaining self-control over an addiction.

-The nurse explores the reasons alcoholics drink and promotes other methods of coping with problems. -The nurse helps patients to reaffirm their feelings of self-worth and relate this to their addiction problem. -The nurse reinforces the mental benefits of gaining self-control over an addiction. Affective learning includes changes in attitudes, values, and feelings (e.g., the patient expresses renewed self-confidence to be able to give up drinking). Cognitive learning involves the storing and recalling of new knowledge in the brain, such as the learning that occurs during a lecture or by using a pamphlet for teaching. Learning a physical skill involving the integration of mental and muscular activity is called psychomotor learning, which may involve a return demonstration of a skill.

The nurse is cleaning an open abdominal wound that has unapproximated edges. What are accurate steps in this procedure? Select all that apply. Use standard precautions or transmission-based precautions when indicated. Moisten a sterile gauze pad or swab with the prescribed cleansing agent and squeeze out excess solution. Clean the wound in full or half circles beginning on the outside and working toward the center. Work outward from the incision in lines that are parallel to it from the dirty area to the clean area. Clean to at least 1 in beyond the end of the new dressing if one is being applied. Clean to at least 3 in beyond the wound if a new dressing is not being applied.

-Use standard precautions or transmission-based precautions when indicated. -Moisten a sterile gauze pad or swab with the prescribed cleansing agent and squeeze out excess solution. -Clean to at least 1 in beyond the end of the new dressing if one is being applied. The correct procedure for cleaning a wound with unapproximated edges is: (1) use standard precautions and appropriate transmission-based precautions when indicated, (2) moisten sterile gauze pad or swab with prescribed cleansing agent and squeeze out excess solution, (3) use a new swab or gauze for each circle, (4) clean the wound in full or half circles beginning in the center and working toward the outside, (5) clean to at least 1 in beyond the end of the new dressing, and (6) clean to at least 2 in beyond the wound margins if a dressing is not being applied.

A nurse is prioritizing the following patient diagnoses according to Maslow's hierarchy of human needs: (1) Disturbed Body Image (2) Ineffective Airway Clearance (3) Spiritual Distress (4) Impaired Social Interaction Which answer choice below lists the problems in order of highest priority to lowest priority based on Maslow's model? 2, 4, 1, 3 3, 1, 4, 2 2, 4, 3, 1 3, 2, 4, 1

2, 4, 1, 3 . Because basic needs must be met before a person can focus on higher ones, patient needs may be prioritized according to Maslow's hierarchy: (1) physiologic needs, (2) safety needs, (3) love and belonging needs, (4) self-esteem needs, and (5) self-actualization needs. #2 is an example of a physiologic need, #4 is an example of a love and belonging need, #1 is an example of a self-esteem need, and #3 is an example of a self-actualization need.

A patient who has a large abdominal wound suddenly calls out for help because the patient feels as though something is falling out of her incision. Inspection reveals a gaping open wound with tissue bulging outward. In which order should the nurse perform the following interventions? Arrange from first to last. 1. Notify the health care provider of the situation. 2. Cover the exposed tissue with sterile towels moistened with sterile 0.9% sodium chloride solution. 3. Place the patient in the low Fowler's position.

3. Place the patient in the low Fowler's position. 2. Cover the exposed tissue with sterile towels moistened with sterile 0.9% sodium chloride solution. 1. Notify the health care provider of the situation. Dehiscence and evisceration is a postoperative emergency that requires prompt surgical repair. The correct order of implementation by the nurse is to place the patient in the low Fowler's position (to prevent further physical damage), cover the exposed tissue with sterile towels moistened with sterile 0.9% sodium chloride solution (to protect the viscera), and notify the health care provider of the situation (to address the issue, likely with surgery). Note that the interprofessional team may be completing the activities simultaneously in the clinical setting, but the priority identified above is important to understand.

A nurse is caring for a client who has had a left-side mastectomy. The nurse notes an intact Penrose drain. Which statement about Penrose drains is true? A Penrose drain promotes passive drainage into a dressing. A Penrose drain is a closed drainage system that is connected to an electronic suction device. A Penrose drain has a small bulblike collection chamber that is kept under negative pressure. A Penrose drain has a round collection chamber with a spring that is kept under negative pressure.

A Penrose drain promotes passive drainage into a dressing. A Penrose drain is an open drainage system that promotes passive drainage of fluid into a dressing. The Jackson-Pratt drain has a small bulblike collection chamber that is kept under negative pressure. A Hemovac is a round collection chamber with a spring inside that also must be kept under negative pressure.

Which nurse leader most clearly exemplifies transformational leadership? A leader who is dynamic and inspiring and promotes change by the power of the leader's convictions A leader who is careful to thoughtfully assess the issues and priorities surrounding a problem prior to acting A leader who prioritizes the delegation of leadership to the individual members of the group A leader who prioritizes the fact that every member of the team is considered valuable and equa

A leader who is dynamic and inspiring and promotes change by the power of the leader's convictions Transformational leaders can create revolutionary change. They are often described as charismatic, and they are unique in their ability to inspire and motivate others. A careful examination of contextual factors is associated with situational leadership. Delegation to group members and an emphasis on equality are typical of laissez-faire and democratic leadership styles, respectively.

The nurse has received an order to apply a saline-moistened dressing to a client's wound. Which action should the nurse perform? Avoid using irrigation to clean the wound before changing the dressing. Apply dry gauze to the wound and carefully apply saline to saturate it. Exert firm pressure using forceps to pack the wound tightly with moistened dressing. Apply dry gauze pads over the wet gauze and place the abdominal pad over the gauzes.

Apply dry gauze pads over the wet gauze and place the abdominal pad over the gauzes. Dry gauze is applied over wet gauze and then covered with an ABD pad. The wound should be cleaned, if needed, using sterile forceps. Irrigation may be used as ordered or required. The wound should be cleaned from the top to the bottom and from the center to the outside. The fine-mesh gauze should be placed into the basin and the ordered solution poured over the mesh to saturate it. The wound should be packed gently and loosely.

The client has Alzheimer disease and is a new admission to the nursing home. The client was transferred from the hospital. When first meeting the client, what technique(s) will the nurse use to facilitate communication with this client? Select all that apply. Approach the client from the front of the client. Call the client by the client's preferred name. Use simple words and short sentences when talking with the client. Correct the client when the client communicates erroneous information. Fill in information when the client has difficulty answering questions.

Approach the client from the front of the client. Call the client by the client's preferred name. Use simple words and short sentences when talking with the client. When communicating with a client who has Alzheimer disease, the nurse must use techniques that will facilitate communication. The nurse will approach from the front of the client to obtain the attention of the client. Coming from the side or the back of the client may startle or agitate the client. Using the client's preferred name will also gain the client's attention. The nurse will use simple words and short sentences to allow the client to understand the nurse. The nurse must show patience and allow the client time to respond. The client may have difficulty finding the correct words or expressing thoughts. Correcting the client or providing information may confuse or agitate the client even more.

When preparing client teaching materials, how does the nurse best assess a client's preferred learning style? Observe the client's behaviors. Provide teaching that works for the broadest base of clients. Ask the client, "Do you learn best by observing, valuing, or doing?" Determine client learning needs based on age and ability to hear effectively.

Ask the client, "Do you learn best by observing, valuing, or doing?" One way to determine the client's preferred learning style is to ask the client about the client's personal learning preference--whether cognitive, affective, or psychomotor. Simply observing the client's behavior or considering the client's age and hearing ability would not provide as much information about the client's preferred learning style as would directly asking the client. Providing teaching using a broad-based approach would not help determine the client's preferred learning style and would not be as effective as providing teaching that is tailored to the client's preferred learning style.

A nurse is working with a 15-year-old client with sickle cell anemia. The client was started on a new pain management plan today, and the nurse is evaluating the effectiveness of the plan. Which is not appropriate to include in the nursing care? Asking only the client's parents to be present at the education session Including a note about who was taught this new information in the client's chart Assuring the client that the conversation is confidential except under extreme circumstances Answering questions openly and honestly

Asking only the client's parents to be present at the education session Peers are often more influential than parents, nurses, or teachers at this age. It is often appropriate to include a close friend in on the education session. The other answers are developmentally appropriate for a 15-year-old.

A nurse states the following to another nurse who is constantly forgetting to wash hands between clients: "It looks like you keep forgetting to wash your hands between clients. It's really not safe for your clients. Let's think of some type of reminder we can use to help you remember." This communication is an example of what type of speech? Aggressive Assertive Nonassertive Therapeutic

Assertive The communication is an example of assertive speech. Assertive communication is the ability to stand up for oneself and others using open, honest, and direct communication. Aggressive communication involves asserting one's rights in a negative manner that violates the rights of others. Therapeutic speech is speech a nurse uses when communicating with a client that has a specific purpose or goal. Nonassertive speech would be the opposite of assertive speech, as described above.

When caring for a client at the health care facility, the nurse observes that the client is having difficulty understanding the health education. Which action is most appropriate? Assess for cultural differences. Boost the morale of the client. Delegate the health education to a colleague. Replace one-on-one teaching with written materials.

Assess for cultural differences. When the client is having difficulty learning, it may be possible that the client does not understand the language that the nurse speaks. In such a case, the nurse should take the necessary steps to break the cultural barrier and then proceed with the education. Written materials can enhance many clients' learning, but will not necessarily overcome many of the common barriers to understanding, including cultural and linguistic factors. The nurse should take action to overcome any barriers to the learning process before delegating to a colleague. The client's morale is not pertinent to the client's difficulty understanding the teaching.

The nurse and unlicensed assistive personnel (UAP) are working together in the emergency room. Which task should the nurse avoid delegating to the UAP? Assessing a rash on the arm Emptying an indwelling catheter bag Obtaining an electrocardiogram (EKG) Placing electrodes for cardiac monitoring

Assessing a rash on the arm When delegating, the RN must determine the skill level and education of the UAP, the client's condition and the complexity of the condition, and the potential for harm. Assessment of conditions should be reserved for the nurse. UAPs can be trained to empty indwelling catheter bags, perform EKGs, and place electrodes.

A client informs the nurse about being committed to quitting smoking to improve health. During discussion, the nurse asks the client "on a scale of 0 to 10, how likely are you to attend a support group?" Which strategy of motivational interviewing is the nurse using with the client? Assessing importance Elicit-provide-elicit Evoking change talk Prioritizing

Assessing importance Using the 0 to 10 scale is a key aspect of assessing importance with motivational interviewing. It helps the nurse to understand the client's feelings toward the recommended activity and can help start a conversation about why the client chose that rating number-and what the nurse could do to increase the number. In the elicit-provide-elicit strategy, the nurse elicits information from the client about a topic, provides teaching on the topic, and then further elicits information from the client. Evoking change talk is when the nurse presents a potential change to the client for consideration. Prioritizing is helping a client determine how to order one's priorities.

A nurse is caring for a client who has a pressure injury on the left great toe. The client is scheduled for debridement the next morning. Based on the red-yellow-black (RYB) Wound Classification System, which classification should the nurse document? Red classification Yellow classification Black classification Unstageable

Black classification A wound that requires debridement would be classified in the black category. The red classification would indicate dressing changes for treatment. The yellow classification would indicate cleansing of the wound related to the drainage or slough in the wound. Unstageable is not a classification in the RYB Wound Classification System.

A nurse has taught a patient with diabetes how to administer his daily insulin. How should the nurse evaluate the teaching-learning process? By determining the patient's motivation to learn By deciding if the learning outcomes have been achieved By allowing the patient to practice the skill he has just learned By documenting the teaching session in the patient's medical record

By deciding if the learning outcomes have been achieved The nurse cannot assume that the patient has actually learned the content unless there is some type of proof of learning. The key to evaluation is meeting the learner outcomes stated in the teaching plan.

During an interaction with a patient diagnosed with epilepsy, a nurse notes that the patient is silent after communicating the nursing care plan. What would be appropriate nurse responses in this situation? Select all that apply. Fill the silence with lighter conversation directed at the patient. Use the time to perform the care that is needed uninterrupted. Discuss the silence with the patient to ascertain its meaning. Allow the patient time to think and explore inner thoughts. Determine if the patient's culture requires pauses between conversation. Arrange for a counselor to help the patient cope with emotional issues.

C) Discuss the silence with the patient to ascertain its meaning. D) Allow the patient time to think and explore inner thoughts. E) Determine if the patient's culture requires pauses between conversation. the nurse can use silence appropriately by taking the time to wait for the patient to initiate or to continue speaking. During periods of silence, the nurse should reflect on what has already been shared and observe the patient without having to concentrate simultaneously on the spoken word. In due time, the nurse might discuss the silence with the patient in order to understand its meaning. Also, the patient's culture may require longer pauses between verbal communication. Fear of silence sometimes leads to too much talking by the nurse, and excessive talking tends to place the focus on the nurse rather than on the patient. The nurse should not assume silence requires a consult with a counselor.

A nurse is assessing a patient who is diagnosed with anorexia. Following the assessment, the nurse recommends that the patient meet with a nutritionist. This action best exemplifies the use of: Clinical judgment Clinical reasoning Critical thinking Blended competencies

Clinical judgment Although all the options refer to the skills used by nurses in practice, the best choice is clinical judgment as it refers to the result or outcome of critical thinking or clinical reasoning—in this case, the recommendation to meet with a nutritionist. Clinical reasoning usually refers to ways of thinking about patient care issues (determining, preventing, and managing patient problems). Critical thinking is a broad term that includes reasoning both outside and inside of the clinical setting. Blended competencies are the cognitive, technical, interpersonal, and ethical and legal skills combined with the willingness to use them creatively and critically when working with patients.

Based on the Patient Protection and Affordable Care Act (ACA), nurses are to assume an important new role in health care. Which is an example of this new role? Identifying individuals who are at risk of developing diabetes mellitus Collaborating with all agencies to provide for the client's home health needs Verifying that all documentation is updated prior to surgery Providing client education related to colostomy care

Collaborating with all agencies to provide for the client's home health needs As the various components of the ACA are phased in, nurses have begun to play an influential role in the implementation of new health policy. The newest opportunity is collaborating with all agencies to provide for the client's home health needs. Nurses have already been involved in screening individuals for type 2 diabetes mellitus and providing postoperative teaching for ostomy care. Nurses recheck paperwork for consent prior to surgery, but this is not just limited to nurses. Other health care providers also review consent prior to surgery.

The nurse records a patient's blood pressure as 148/100. What is the priority action of the nurse when determining the significance of this reading? Compare this reading to standards. Check the taxonomy of nursing diagnoses for a pertinent label. Check a medical text for the signs and symptoms of high blood pressure. Consult with colleagues.

Compare this reading to standards. A standard, or a norm, is a generally accepted rule, measure, pattern, or model to which data can be compared in the same class or category. For example, when determining the significance of a patient's blood pressure reading, appropriate standards include normative values for the patient's age group, race, and illness category. Deviation from an appropriate norm may be the basis for writing a diagnosis.

A nurse enters a patient's room and examines the patient's IV fluids and cardiac monitor. The patient states, "Well, I haven't seen you before. Who are you?" What is the nurse's BEST response? "I'm just the IV therapist checking your IV." "I've been transferred to this division and will be caring for you." "I'm sorry, my name is John Smith and I am your nurse." "My name is John Smith, I am your nurse and I'll be caring for you until 11 PM."

D) "My name is John Smith, I am your nurse and I'll be caring for you until 11 PM." The nurse should identify himself, be sure the patient knows what will be happening, and the time period he will be with his patient.

A nurse enters the room of a patient with cancer. The patient is crying and states, "I feel so alone." Which response by the nurse is the most therapeutic action? The nurse stands at the patient's bedside and states, "I understand how you feel. My mother said the same thing when she was ill." The nurse places a hand on the patient's arm and states, "You feel so alone." The nurse stands in the patient's room and asks, "Why do you feel so alone? Your wife has been here every day." The nurse holds the patient's hand and asks, "What makes you feel so alone?"

D) The nurse holds the patient's hand and asks, "What makes you feel so alone?" The use of touch conveys acceptance, and the implementation of an open-ended question allows the patient time to verbalize freely.

A nurse manager of a hospital unit is working within a decentralized management structure. Which nursing action best exemplifies this type of system? Senior managers make all the decisions. Nurses are not intimately involved in decisions involving client care. Decisions are made by those who are most knowledgeable about the issue. Nurse managers are not accountable for clients, staffing, supplies, or budgets.

Decisions are made by those who are most knowledgeable about the issue. The best example of a nurse manager of a hospital unit working within a decentralized management structure would be that decisions are made by those who are most knowledgeable about the issue. Nurses would be greatly involved in decisions involving client care. Senior managers would not make all the decisions within a decentralized management structure. Nurse managers could be accountable for clients, staffing, supplies, and/or budgets.

A nurse is preparing to teach a patient with asthma how to use his inhaler. Which teaching method would be the BEST choice to teach the patient this skill? Demonstration Lecture Discovery Panel session

Demonstration Demonstration of techniques, procedures, exercises, and the use of special equipment is an effective patient-teaching strategy for a skill. Lecture can be used to deliver information to a large group of patients but is more effective when the session is interactive; it is rarely used for individual instruction, except in combination with other strategies. Discovery is a good method for teaching problem-solving techniques and independent thinking. Panel discussions can be used to impart factual material but are also effective for sharing experiences and emotions.

A nurse caring for a patient who is hospitalized following a double mastectomy is preparing a discharge plan for the patient. Which action should be the focus of this termination phase of the helping relationship? Determining the progress made in achieving established goals Clarifying when the patient should take medications Reporting the progress made in teaching to the staff Including all family members in the teaching session

Determining the progress made in achieving established goals The termination phase occurs when the conclusion of the initial agreement is acknowledged. Discharge planning coordinates with the termination phase of a helping relationship. The nurse should determine the progress made in achieving the goals related to the patient's care.

A patient was in an automobile accident and received a wound across the nose and cheek. After surgery to repair the wound, the patient says, "I am so ugly now." Based on this statement, what nursing diagnosis would be most appropriate? Pain Impaired Skin Integrity Disturbed Body Image Disturbed Thought Processes

Disturbed Body Image Wounds cause emotional as well as physical stress.

An RN on a surgical unit is behind schedule administering medications. Which of the RN's other tasks can be safely delegated to a UAP? The assessment of a patient who has just arrived on the unit Teaching a patient with newly diagnosed diabetes about foot care Documentation of a patient's I & O on the flow chart Helping a patient who has recently undergone surgery out of bed for the first time

Documentation of a patient's I & O on the flow chart Documenting a patient's I & O on a flow chart may be delegated to a UAP. Professional nurses are responsible for the initial patient assessment, discharge planning, health education, care planning, triage, interpretation of patient data, care of invasive lines, administering parenteral medications. What they can delegate are assistance with basic care activities (bathing, grooming, ambulation, feeding) and things like taking vital signs, measuring intake and output, weighing, simple dressing changes, transfers, and post mortem care.

A nurse is caring for a patient who is receiving fluids for dehydration. Which outcome for this patient is correctly written? Offer the patient 60-mL fluid every 2 hours while awake. During the next 24-hour period, the patient's fluid intake will total at least 2,000 mL. Teach the patient the importance of drinking enough fluids to prevent dehydration by 1/15/20. At the next visit on 12/23/20, the patient will know that he should drink at least 3 L of water per day.

During the next 24-hour period, the patient's fluid intake will total at least 2,000 mL. The outcomes in (a) and (c) make the error of expressing the patient goal as a nursing intervention. Incorrect: "Offer the patient 60-mL fluid every 2 hours while awake." Correct: "The patient will drink 60-mL fluid every 2 hours while awake, beginning 1/3/20." The outcome in (d) makes the error of using verbs that are not observable and measurable. Verbs to be avoided when writing outcomes include "know," "understand," "learn," and "become aware."

A nursing student is nervous and concerned about working at a clinical facility. Which action would BEST decrease anxiety and ensure success in the student's provision of patient care? Determining the established goals of the institution Ensuring that verbal and nonverbal communication is congruent Engaging in self-talk to plan the day and decrease fear Speaking with fellow colleagues about how they feel

Engaging in self-talk to plan the day and decrease fear By engaging in self-talk, or intrapersonal communication, the nursing student can plan her day and enhance her clinical performance to decrease fear and anxiety.

A nurse can improve one's skill with time management by taking which action? Allowing the flow of the day to control how time is managed Setting priorities without involving clients or their families Starting each day as a new day without considering the previous day Evaluating success with accomplishment of goals in client care

Evaluating success with accomplishment of goals in client care Time management is a skill that can be improved for nurses by taking time during the day to evaluate whether goals have been accomplished and then setting new priorities based on this. Goals and priorities should be established at the beginning of each day, and clients and their families should be involved in this. At the end of the day, a nurse should look back and determine what has and has not been accomplished; this helps to set a time line for the next day. If a timeline is not set each day, then the nurse will allow the flow of the day to control the day, rather than having a plan for what needs to be accomplished.

The nurse practices using critical thinking indicators (CTIs) when caring for patients in the hospital setting. The best description of CTIs is: Evidence-based descriptions of behaviors that demonstrate the knowledge that promotes critical thinking in clinical practice Evidence-based descriptions of behaviors that demonstrate the knowledge and skills that promote critical thinking in clinical practice Evidence-based descriptions of behaviors that demonstrate the knowledge, characteristics, and skills that promote critical thinking in clinical practice Evidence-based descriptions of behaviors that demonstrate the knowledge, characteristics, standards, and skills that promote critical thinking in clinical practice

Evidence-based descriptions of behaviors that demonstrate the knowledge, characteristics, and skills that promote critical thinking in clinical practice.

A registered nurse is delegating activities to unlicensed assistive personnel (UAP) on a hospital unit. Which activities could this nurse normally delegate? Select all that apply. The determination of a nursing diagnosis for a client with breast cancer Giving a bed bath to a client Planning education for a client with a colostomy Taking routine vital signs Administering medications to clients Transferring a client to another floor

Giving a bed bath to a client Taking routine vital signs Transferring a client to another floor The nurse should be familiar with guidelines for delegating nursing care. The nurse could delegate the following tasks to UAP: giving a bed bath to a client, taking routine vital signs, and transferring a client to another floor. The nurse could not delegate the administering of medications, planning client education for a client with a colostomy, or the determination of a nursing diagnosis.

During a nursing staff meeting, the nurses resolve a problem of delayed documentation by agreeing unanimously that they will make sure all vital signs are reported and charted within 15 minutes following assessment. This is an example of which characteristics of effective communication? Select all that apply. Group decision making Group leadership Group power Group identity Group patterns of interaction Group cohesiveness

Group decision making Group identity Group patterns of interaction Group cohesiveness Solving problems involves group decision making; ascertaining that the staff completes a task on time and that all members agree the task is important is a characteristic of group identity; group patterns of interaction involve honest communication and member support; and cohesiveness occurs when members generally trust each other, have a high commitment to the group, and a high degree of cooperation. Group leadership occurs when groups use effective styles of leadership to meet goals; with group power, sources of power are recognized and used appropriately to accomplish group outcomes.

A nurse cares for dying patients by providing physical, psychological, social, and spiritual care for the patients, their families, and other loved ones. What type of care is the nurse providing? Respite care Palliative care Hospice care Extended care

Hospice care The hospice nurse combines the skills of the home care nurse with the ability to provide daily emotional support to dying patients and their families. Respite care is a type of care provided for caregivers of homebound ill, disabled, or older adults. Palliative care, which can be used in conjunction with medical treatment and in all types of health care settings, is focused on the relief of physical, mental, and spiritual distress. Extended-care facilities include transitional subacute care, assisted-living facilities, intermediate and long-term care, homes for medically fragile children, retirement centers, and residential institutions for mentally and developmentally or physically disabled patients of all ages.

The spouse of a client who has recently been diagnosed with early-stage Alzheimer's disease asks the nurse to recommend websites that may supplement the spouse's learning about this diagnosis. How should the nurse respond to the spouse's request? Identify and recommend some credible websites appropriate to the spouse's learning needs. Encourage the spouse to avoid online resources due to the unregulated nature of the Internet. Direct the spouse to online databases such as the Cumulative Index to Nursing and Allied Health Literature. Provide the spouse with print-based materials that are clearly referenced and reflect the spouse's learning style.

Identify and recommend some credible websites appropriate to the spouse's learning needs. Web-based resources can be a useful tool in client education, but suitability and accuracy need to be carefully considered. Many online databases exist for health professionals, but these are less likely to be accessible to or appropriate for those outside the health professions. The client has requested online resources, so providing print-based materials is not warranted at this time.

The spouse of a client who has recently been diagnosed with early-stage Alzheimer's disease asks the nurse to recommend websites that may supplement the spouse's learning about this diagnosis. How should the nurse respond to the spouse's request? Identify and recommend some credible websites appropriate to the spouse's learning needs. Encourage the spouse to avoid online resources due to the unregulated nature of the Internet. Direct the spouse to online databases such as the Cumulative Index to Nursing and Allied Health Literature. Provide the spouse with print-based materials that are clearly referenced and reflect the spouse's learning style.

Identify and recommend some credible websites appropriate to the spouse's learning needs. Web-based resources can be a useful tool in client education, but suitability and accuracy need to be carefully considered. Many online databases exist for health professionals, but these are less likely to be accessible to or appropriate for those outside the health professions. The client has requested online resources, so providing print-based materials is not warranted at this time.

It is important for the nurse to empathize with the client to develop a positive, therapeutic relationship. What is a characteristic of empathy? Identifying with the client's feelings Experiencing feelings similar to those of the client Conveying genuine care to the client Caring for the client without negative judgment

Identifying with the client's feelings Empathy is the ability to identify with client feelings. Congruence refers to feelings that match the expressions of the client. Positive regard means conveying genuine care to clients without passing any negative judgment on them.

A nurse working in a pediatric clinic provides codes for a patient's services to a third-party payer who pays all or most of the care. This is an example of what mode of health care payment? Out-of-pocket payment Individual private insurance Employer-based group private insurance Government financing

Individual private insurance The four basic modes of paying for health care are out-of-pocket payment, individual private insurance, employer-based group private insurance, and government financing. With individual private insurance, members pay monthly premiums either by themselves or in combination with employer payments. These plans are called third-party payers because the insurance company pays all or most of the cost of care. Out-of-pocket payment is paying for health care with cash payments. Employer-based private insurance is employer-sponsored coverage and government financing is provided through Medicare and Medicaid, and other federally funded programs.

A nurse is providing instruction to a patient regarding the procedure to change a colostomy bag. During the teaching session, the patient asks, "What type of foods should I avoid to prevent gas?" The patient's question allows for what type of communication on the nurse's part? A closed-ended answer Information clarification The nurse to give advice Assertive behavior

Information clarification The patient's question allows the nurse to clarify information that is new to the patient or that requires further explanation.

The charge nurse on the orthopedic unit believes in giving the staff as much power as possible. The nurses are allowed, among other things, to create their own work schedules, provide dates and times for unit meetings, and create the agendas, to which the charge nurse contributes. The charge nurse's style of leadership can be described as which? Democratic Laissez-faire Autocratic Transformational

Laissez-faire With laissez-faire leadership, the leader relinquishes power to the group. Autocratic leadership involves the leader assuming complete control. Democratic leadership displays a sense of equality among the leader and other participants. Transformational leaders create intellectually stimulating practice environments and challenge themselves and others to grow personally and professionally and to learn.

When applying an external heating pad, which prescription from the health care provider would the nurse question? Leave heating pad on for 45 minutes Assess site frequently during application of the heating pad Use gauze to secure the heating pad to the site of application Maintain the temperature between 105°F to 109°F (40.5°C to 43°C)

Leave heating pad on for 45 minutes The nurse should question the prescription to leave the heating pad on for 45 minutes, because this is too long and could cause complications such as burns. The maximum time limit should be no more than 30 minutes. Using heat for more than 30 minutes can result in tissue congestion, vasoconstriction, and increases the risk of tissue damage. It is important for the nurse to frequently assess the site during the application to ensure no adverse affects are occurring. The nurse should use either gauze or tape to hold the heating pad in the correct location; however, pins should not be used as they may puncture and damage the pad. The temperature should be maintained between 105°F to 109°F (40.5°C to 43°C) to ensure the best therapeutic results.

A new client comes into the urgent care center with the spouse with a report of severe itchy rash with small blisters on the arms and hands. The nurse is documenting assessment data for the client. What is the nurse's best assessment action? Ask the spouse about know allergies. Ask the client about known allergies. Make an open-ended statement to the client to elicit the history of the rash. Make an open-ended statement to the spouse to elicit the history of the rash.

Make an open-ended statement to the client to elicit the history of the rash. The best source of assessment information for the nurse is the client. Nursing care is individualized to the needs of the client. In emergency situations, other sources might be used, such as family and friends. The rash could be due to an allergic reaction; however, asking a closed question about a specific topic will result in a list of responses and limit the information shared by the client, family member, or friend. Making an open-ended statement, such as, "tell me about this rash," will give the client the opportunity to share everything the client knows about the rash, such as when it was first noticed, if it spread, and what home treatment the client has tried.

A hospital system has adopted the Institute for Healthcare Improvement's "Triple Aim" dimensions and has surveyed nurses for planning ideas. Which strategies will help the hospital comply with this framework? Select all that apply. Do away with client satisfaction surveys. Make results of quality studies available to nurses in a timelier manner. Create outreach education programs to improve the overall health of the community served. Reduce redundancy in diagnostic tests. Increase staff salaries.

Make results of quality studies available to nurses in a timelier manner. Create outreach education programs to improve the overall health of the community served. Reduce redundancy in diagnostic tests. The Triple Aim framework has three dimensions: 1) improving the client experience of care (including satisfaction and quality); 2) improving the health of populations; and 3) reducing the per capita cost of health care. Making quality information available more quickly would encourage nurses to change practices that result in poorer quality. Reducing redundancy would reduce per capita costs. Educating the public would eventually increase the health of the population. Doing away with client satisfaction surveys would make satisfaction data difficult to track trends. There is no indication that increasing staff salaries would help meet these goals.

A nurse is caring for a client admitted to the hospital for dehydration. Which physical findings should the nurse acknowledge as nonverbal communication concerning this diagnosis? easy wrinkling of the skin and sunken eyes. slow heart rate and prolonged capillary refill. pallor and diaphoresis. cold intolerance and brittle nails.

Most illnesses cause at least some alterations in general physical appearance. Observing for changes in appearance is an important nursing responsibility for detecting illness or evaluating the effectiveness of care and therapy. For example, a person with an insufficient intake of fluids has dry skin that wrinkles easily, eyes that might be sunken and dull in appearance, and poor muscle tone. On the other hand, a person in good health tends to radiate this healthy status through general appearance. Although prolonged capillary refill is consistent with dehydration, slow heart rate is not. Pallor may be associated with dehydration but diaphoresis is not associated with this condition. Cold intolerance and brittle nails are consistent physiologic changes seen in clients with hypothyroidism.

When a client says, "I don't care if I get better; I have nothing to live for, anyway," which type of counseling would be appropriate? Long-term counseling Motivational counseling Short-term counseling Professional counseling

Motivational counseling The most appropriate counseling for the situation at hand would be motivational counseling. With motivational counseling, the nurse would discuss feelings and incentives with the client. Short-term counseling focuses on the immediate problem or concern of the client or family. It can be a relatively minor concern or a major crisis, but in any case, it needs immediate attention. Long-term counseling extends over a prolonged period. A client might need the counsel of the nurse at daily, weekly, or monthly intervals. A client experiencing a developmental crisis, for example, might need long-term counseling. Professional counseling is a general term.

A nurse caring for a client who has a surgical wound after a caesarean birth notes dehiscence of the wound, what is the main priority of nursing care? Notify the surgeon STAT Notify the surgeon, apply a sterile saline-moistened dressing to the open areas, and support the wound during coughing or abdominal movement Approximate the wound edges and use wound closure tapes to hold it together and contact the surgeon Irrigate the open wound areas with sterile normal saline, apply a sterile dressing, and contact the surgeon

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

A nurse arranges all the resources available to teach an adolescent client how to manage asthma. Which role is this nurse performing? Planning Organizing Directing Controlling

Organizing The role of management is to plan, organize, direct, and control available human, material, and financial resources to deliver quality care to clients and families. Organizing would include acquiring, managing, and mobilizing resources to meet both clinical and financial objectives. Planning would include identifying problems and developing goals, objectives, and related strategies to meet the demands identified. Directing would include leading others in achieving goals within the constraints of the setting. Controlling would include implementing mechanisms for ongoing evaluation in the setting.

A nurse demonstrates understanding of Healthy People 2030 by supporting which statement? Establish a set of nursing skills that focuses on quick resolution to clients' needs. A client's health is affected by social, economic, and political factors. Clinical care supports wellness in the environment. Physical therapy supports client safety at home.

People believe "quality of life" to be synonymous with a healthy community. There is growing recognition that to achieve the goals of Healthy People 2030 a model inclusive of multiple health determinants is needed. Clinical care has typically focused on diagnosing and treating symptoms. Understanding health in relation to personal behaviors, social factors, and other determinants provides a holistic context and not a quick resolution of needs. As an example, it is important to know whether an individual has access to a grocery store with fresh fruits and vegetables to comprehend that client's nutritional needs. To affect social, economic, political, and educational health determinants, health initiatives are more effective if they are based in the community and incorporate community collaboration. While physical therapy can be helpful for a client in the home, it does not have a basis for the community emphasis in Health People 2030.

A nurse is caring for a client with quadriplegia. Which intervention by the nurse will prevent a heel or ankle pressure injury for the client? Placing the client in a side-lying position with a pillow between the mattress and the lower leg, and a pillow between the lower legs Placing the client in the supine position with a pillow under the knees Placing the client in a side-lying position with a pillow between the lower legs Placing the client in a wheelchair with the back of the feet resting against the heel loo

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

After assessing a patient who is recovering from a stroke in a rehabilitation facility, a nurse interprets and analyzes the patient data. Which of the four basic conclusions has the nurse reached when identifying the need to collect more data to confirm a diagnosis of situational low self-esteem? No problem Possible problem Actual nursing diagnosis Clinical problem other than nursing diagnosis

Possible problem When a possible problem exists, such as situational low self-esteem related to effects of stroke, the nurse must collect more data to confirm or disprove the suspected problem. The conclusion "no problem" means no nursing response is indicated. When an actual problem exists, the nurse begins planning, implementing, and evaluating care to prevent, reduce, or resolve the problem. A clinical problem other than nursing diagnosis requires that the nurse consult with the appropriate health care professional to work collaboratively on the problem.

A nurse is teaching first aid to counselors of a summer camp for children with asthma. This is an example of what aim of health teaching? Promoting health Preventing illness Restoring health Facilitating coping

Preventing illness Teaching first aid is a function of the goal to prevent illness. Promoting health involves helping patients to value health and develop specific health practices that promote wellness. Restoring health occurs once a patient is ill, and teaching focuses on developing self-care practices that promote recovery. When facilitating coping, nurses help patients come to terms with whatever lifestyle modification is needed for their recovery or to enable them to cope with permanent health alterations.

A nurse has very strong client education skills. In which health care setting would the nurse make best use of these skills? Primary care center Emergency department Same-day surgery unit Tertiary care medical center

Primary care center Primary health care provides care for common health problems and provides preventative measures. Client education is a common part of the nurse's activities in this setting. While teaching does (and should) occur in the other environments, the nurse does not have the opportunity to see the client repeatedly to teach and reinforce teaching.

A patient is being transferred from the ICU to a regular hospital room. What must the ICU nurse be prepared to do as part of this transfer? Provide a verbal report to the nurse on the new unit. Provide a detailed written report to the unit secretary. Delegate the responsibility for providing information. Make a copy of the patient's medical record.

Provide a verbal report to the nurse on the new unit. . The ICU nurse gives a verbal report on the patient's condition and nursing care needs to the nurse on the new unit. This information is not given to a unit secretary, nor is its provision delegated to others. The medical record is transferred with the patient; a copy is not made.

The nurse uses the RYB wound classification system to assess the wound of a patient whose arm was cut on a factory machine. The nurse documents the wound as "red." What would be the priority nursing intervention for this type of wound Irrigate the wound. Provide gentle cleansing of the wound. Debride the wound. Change the dressing frequently.

Provide gentle cleansing of the wound. Red wounds are in the proliferative stage of healing and reflect the color of normal granulation tissue. Wounds in this stage need protection with nursing interventions that include gentle cleansing, use of moist dressings, and changing of the dressing only when necessary, and/or based on product manufacturer's recommendations. To cleanse yellow wounds, nursing interventions include the use of wound cleansers and irrigating the wound. The eschar found in black wounds requires debridement (removal) before the wound can heal.

A nurse is caring for a patient who has complications related to type 2 diabetes mellitus. The nurse researches new procedures to care for foot ulcers when developing a care plan for this patient. Which QSEN competency does this action represent? Patient-centered care Evidence-based practice Quality improvement Informatics

Quality improvement Quality improvement involves routinely updating nursing policies and procedures. Providing patient-centered care involves listening to the patient and demonstrating respect and compassion. Evidence-based practice is used when adhering to internal policies and standardized skills. The nurse is employing informatics by using information and technology to communicate, manage knowledge, and support decision making.

The nurse practitioner is performing a short assessment of a newborn who is displaying signs of jaundice. The nurse observes the infant's skin color and orders a test for bilirubin levels to report to the primary care provider. What type of assessment has this nurse performed? Comprehensive Initial Time-lapsed Quick priority

Quick priority Quick priority assessments (QPAs) are short, focused, prioritized assessments nurses do to gain the most important information they need to have first. The comprehensive initial assessment is performed shortly after the patient is admitted to a health care facility or service. The time-lapsed assessment is scheduled to compare a patient's current status to baseline data obtained earlier.

During a skin assessment, the nurse recognizes the first indication that a pressure injury may be developing when the skin is which color during the application of light pressure? White Red Blue-grey Yellow

Red Nonblanching erythema is one of the earliest signs of impending skin breakdown. Blue-greyish color is pallor. Yellow is jaundice and related to liver issues. White skin is associated with no blood supply.

The nurse is caring for a client who has a deep wound and whose saline-moistened wound dressing has been changed every 12 hours. While removing the old dressing, the nurse notes that the packing material is dry and adheres to the wound bed. Which modification is most appropriate? Reduce the time interval between dressing changes. Assure that the packing material is completely saturated when placed in the wound. Use less packing material. Discontinue application of saline-moistened packing and apply a hydrocolloid dressing instead.

Reduce the time interval between dressing changes Allowing the dressing material to dry will disrupt healing tissue. Therefore, the time interval between dressing changes should be reduced to prevent the dressing from drying out. Too much moisture in the dressing may cause maceration. Shortening the time interval between dressing changes is more appropriate than increasing dressing moisture. There is no indication that too much packing material was used. A hydrocolloid dressing in not indicated.

A nurse assesses a patient and formulates the following nursing diagnosis: Risk for Impaired Skin Integrity related to prescribed bed rest as evidenced by reddened areas of skin on the heels and back. Which phrase represents the etiology of this diagnostic statement? Risk for Impaired Skin Integrity Related to prescribed bed rest As evidenced by As evidenced by reddened areas of skin on the heels and back

Related to prescribed bed rest "Related to prescribed bed rest" is the etiology of the statement. The etiology identifies the contributing or causative factors of the problem. "Risk for Impaired Skin Integrity" is the problem, and "as evidenced by reddened areas of skin on the heels and back" are the defining characteristics of the problem.

A nurse is providing care to a client recently admitted to the health care facility for treatment of an infection. The client experienced a traumatic brain injury several months ago that resulted in paralysis of both lower extremities and difficulty swallowing and speaking. The client's spouse is the primary caregiver. The client's spouse says to the nurse, "It's been really tough this last month caring for my spouse. Even though I have an aide who comes in to help for a couple of hours a week, I'm just spent, physically and emotionally." A referral for which service would be appropriate? Respite care Parish nursing services Palliative care Hospice care

Respite care Respite care is a type of care provided for caregivers of homebound ill, disabled, or older clients. The main purpose is to give the primary caregiver some time away from the responsibilities of day-to-day care. Although parish nursing and palliative care may be helpful in providing the spouse with support, it would not necessarily provide the respite needed. Parish nursing emphasizes holistic health care, health promotion, and disease-prevention activities and combines professional nursing practice with health ministry, emphasizing health and healing within a faith community. Palliative care evolved from the hospice experience but also exists outside of hospice programs. It is not restricted to the end of life and can be used from the point of initial diagnosis. Palliative care, which may be given in conjunction with medical treatment and in all types of health care settings, is client- and family-centered. Hospice care is typically provided to clients with less than 6 months to live. There is no indication that the client is at this stage.

Collection of a wound culture has been ordered for a client whose traumatic hand wound is showing signs of infection. When collecting this laboratory specimen, which action should the nurse take? Remove the swab from the client's room immediately after collection and insert it in the culture tube at the nurse's station. Apply a topical anesthetic to the wound bed 30 minutes before collecting the specimen to prevent pain. Rotate the swab several times over the wound surface to obtain an adequate specimen. Apply a small amount of normal saline to the swab after collection to prevent drying and contamination of the specimen.

Rotate the swab several times over the wound surface to obtain an adequate specimen The nurse should press and rotate the swab several times over the wound surface. The swab should be inserted into the culture tube at the bedside, immediately after collection. Saline or any other fluid is not added to the tube and anesthetics are not applied prior to collection.

A nurse is caring for a patient who is admitted to the hospital with injuries sustained in a motor vehicle accident. While he is in the hospital, his wife tells him that the bottom level of their house flooded, damaging their belongings. When the nurse enters his room, she notes that the patient is visibly upset. The nurse is aware that the patient will most likely be in need of which type of counseling? Long-term developmental Short-term situational Short-term motivational Long-term motivational

Short-term situational Short-term counseling might be used during a situational crisis, which occurs when a patient faces an event or situation that causes a disruption in life, such as a flood. Long-term counseling extends over a prolonged period; a patient experiencing a developmental crisis, for example, might need long-term counseling. Motivational interviewing is an evidence-based counseling approach that involves discussing feelings and incentives with the patient. A caring nurse can motivate patients to become interested in promoting their own health.

A nurse manager of a busy cardiac unit observes disagreements between the RNs and the LPNs related to schedules and nursing responsibilities. At a staff meeting, the manager compliments all the nurses on a job well done and points out that expected goals and outcomes for the month have been met. The nurse concludes the meeting without addressing the disagreements between the two groups of nurses. Which conflict resolution strategy is being employed by this manager? Collaborating Competing Compromising Smoothing

Smoothing The manager who resolves conflict by complimenting the parties involved and focusing on agreement rather than disagreement is using smoothing to reduce the emotion in the conflict. The original conflict is rarely resolved with this technique. Collaborating is a joint effort to resolve the conflict with a win-win solution. All parties set aside previously determined goals, determine a priority common goal, and accept mutual responsibility for achieving this goal. Competing results in a win for one party at the expense of the other group. Compromising occurs when both parties relinquish something of equal value.

After an initial skin assessment, the nurse documents the presence of a reddened area that has blistered. According to recognized staging systems, this pressure injury would be classified as: Stage 1 Stage 2 Stage 3 Stage 4

Stage 2 . A stage 2 pressure injury involves partial-thickness loss of dermis and presents as a shallow open ulcer with a red pink wound bed, without slough. It may also present as an intact or open/ruptured serum-filled blister.

A client's pressure injury is superficial and presents clinically as an abrasion, blister, or shallow crater. How would the nurse document this pressure injury? Stage I Stage II Stage III Stage IV

Stage II A stage II pressure injury involves partial thickness loss of dermis and presents as a shallow, open ulcer. A stage II injury could present as a blister, abrasion, or shallow crater. A stage I pressure injury is a defined area of intact skin with nonblanchable redness of a localized area, usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding skin. The area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue. A stage III injury presents with full-thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed. Slough that may be present does not obscure the depth of tissue loss. Injuries at this stage may include undermining and tunneling. Stage IV injuries involve full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some part of the wound bed and often include undermining and tunneling. Reference:

A nurse is removing the staples from a client's surgical incision, as ordered. After removing the first few staples, the nurse notes that the edges of the wound pull apart as each staple is removed. What is the nurse's best action? Stop removing staples and inform the surgeon Apply adhesive wound closure strips after each staple is removed. Apply an occlusive pressure dressing after removing the staples. Stop removing staples and apply an abdominal pad over the incision.

Stop removing staples and inform the surgeon If there are signs of dehiscence, the nurse should stop removing staples and inform the surgeon. The surgeon may or may not order further staple removal. An occlusive dressing or ABD pad will not adequately prevent further dehiscence.

A nurse working in a long-term care facility bases patient care on five caring processes: knowing, being with, doing for, enabling, and maintaining belief. This approach to patient care best describes whose theory? Travelbee's Watson's Benner's Swanson's

Swanson's Swanson (1991) identifies five caring processes and defines caring as "a nurturing way of relating to a valued other toward whom one feels a personal sense of commitment and responsibility." Travelbee (1971), an early nurse theorist, developed the Human-to-Human Relationship Model, and defined nursing as an interpersonal process whereby the professional nurse practitioner assists an individual, family, or community to prevent or cope with the experience of illness and suffering, and if necessary to find meaning in these experiences. Benner and Wrubel (1989) wrote that caring is a basic way of being in the world, and that caring is central to human expertise, curing, and healing. Watson's theory is based on the belief that all humans are to be valued, cared for, respected, nurtured, understood, and assisted.

A nurse is teaching a 50-year-old male patient how to care for his new ostomy appliance. Which teaching aid would be most appropriate to confirm that the patient has learned the information? Ask Me 3 Newest Vital Sign (NVS) Teach-back method TEACH acronym

Teach-back method The teach-back tool is a method of assessing literacy and confirming that the learner understands health information received from a health professional. The Ask Me 3 is a brief tool intended to promote understanding and improve communication between patients and their providers. The NVS is a reliable screening tool to assess low health literacy, developed to improve communications between patients and providers. The TEACH acronym is used to maximize the effectiveness of patient teaching by tuning into the patient, editing patient information, acting on every teaching moment, clarifying often, and honoring the patient as a partner in the process.

A nurse is providing teaching to clients in a short-term rehabilitation facility. Which examples are common teaching mistakes made by health care professionals? Select all that apply. The nurse fails to accept that clients have the right to change their minds. The nurse negotiates goals with the client. The nurse uses medical jargon frequently when discussing the teaching plan. The nurse ignores the restrictions of the client's environment. The nurse evaluates what the client has learned. The nurse reviews educational media when planning learner objectives.

The nurse fails to accept that clients have the right to change their minds. The nurse uses medical jargon frequently when discussing the teaching plan. The nurse ignores the restrictions of the client's environment. Common teaching mistakes made by health care professionals would include the following: the nurse failing to accept that clients have the right to change their minds; the nurse using medical jargon frequently when discussing the teaching plan; and the nurse ignoring the restrictions of the client's environment. The nurse does negotiate goals with the client. The nurse would evaluate what the client had learned. The nurse would review educational media when planning learner objectives.

A nurse is using a concept map care plan to devise interventions for a patient with sickle cell anemia. What is the BEST description of the "concepts" that are being diagrammed in this plan? Protocols for treating the patient problem Standardized treatment guidelines The nurse's ideas about the patient problem and treatment Clinical pathways for the treatment of sickle cell anemia

The nurse's ideas about the patient problem and treatment A concept map care plan is a diagram of patient problems and interventions. The nurse's ideas about patient problems and treatments are the "concepts" that are diagrammed. These maps are used to organize patient data, analyze relationships in the data, and enable the nurse to take a holistic view of the patient's situation. Answers (a) and (b) are incomplete because the concepts being diagrammed may include protocols and standardized treatment guidelines but the patient problems are also diagrammed concepts. Clinical pathways are tools used in case management to communicate the standardized, interdisciplinary care plan for patients.

A nurse is developing a care plan for an 86-year-old patient who has been admitted for right hip arthroplasty (hip replacement). Which assessment finding(s) indicate a high risk for pressure injury development for this patient? Select all that apply The patient takes time to think about responses to questions. The patient is 86 years old. The patient reports inability to control urine. The patient is scheduled for a hip arthroplasty. Lab findings include BUN 12 (older adult normal 8 to 23 mg/dL) and creatinine 0.9 (adult female normal 0.61 to 1 mg/dL). The patient reports increased pain in right hip when repositioning in bed or chair.

The patient is 86 years old. The patient reports inability to control urine. The patient is scheduled for a hip arthroplasty The patient reports increased pain in right hip when repositioning in bed or chair. . Pressure, friction, and shear, as well as other factors, usually combine to contribute to pressure injury development. The skin of older adults is more susceptible to injury; incontinence contributes to prolonged moisture on the skin, as well as negative effects related to urine in contact with skin; hip surgery involves decreased mobility during the postoperative period, as well as pain with movement, contributing to immobility; and increased pain in the hip may contribute to increased immobility. All these factors are related to an increased risk for pressure injury development. Apathy, confusion, and/or altered mental status are risk factors for pressure injury development. Dehydration (indicated by an elevated BUN and creatinine) is a risk for pressure injury development.

A nurse is providing patient teaching regarding the use of negative pressure wound therapy. Which explanation provides the most accurate information to the patient? The therapy is used to collect excess blood loss and prevent the formation of a scab. The therapy will prevent infection, ensuring that the wound heals with less scar tissue. The therapy provides a moist environment and stimulates blood flow to the wound. The therapy irrigates the wound to keep it free from debris and excess wound fluid.

The therapy provides a moist environment and stimulates blood flow to the wound. Negative pressure wound therapy (NPWT) promotes wound healing and wound closure through the application of uniform negative pressure on the wound bed, reduction in bacteria in the wound, and the removal of excess wound fluid, while providing a moist wound healing environment. The negative pressure results in mechanical tension on the wound tissues, stimulating cell proliferation, blood flow to wounds, and the growth of new blood vessels. It is used to treat a variety of acute or chronic wounds, wounds with heavy drainage, wounds failing to heal, or healing slowly.

A parish nurse is preparing to provide a health promotion class to a group of adults in the parish. In preparing to meet the learning needs of this group, the nurse recognizes which as a characteristic of an adult learner? Their readiness to learn is often related to a developmental task or social role. Peer group acceptance is a critical issue for this age group. The material presented should focus on future application. Previous experiences have little impact on learning.

Their readiness to learn is often related to a developmental task or social role. An adult's readiness to learn is often related to a developmental task or social role. The previous experience of the adult is a rich resource for learning. Most adults' orientation to learning is that material should be useful immediately. Peer group acceptance is a critical issue for the adolescent group and not adults.

A nurse is preparing an infant and his family for a hernia repair to be performed in an ambulatory care facility. What is the primary role of the nurse during the admission process? To assist with screening tests To provide patient teaching To assess what has been done and what still needs to be done To assist with hernia repair

To assess what has been done and what still needs to be done Although all the actions may be performed by the ambulatory care nurse, it is the nurse's primary responsibility to assess what has been done and to tailor the care plan to the patient's needs. Screening tests and teaching are usually completed before the patient enters an ambulatory care facility.

A nurse is counseling an older woman who has been hospitalized for dehydration secondary to a urinary tract infection. The patient tells the nurse: "I don't like being in the hospital. There are too many bad bugs in here. I'll probably go home sicker than I came in." She also insists that she is going to get dressed and go home. She has the capacity to make these decisions. What is the legal responsibility of the nurse in this situation? To inform the patient that only the primary health care provider can authorize discharge from a hospital To collect the patient's belongings and prepare the paperwork for the patient's discharge To request a psychiatric consult for the patient and inform her PCP of the results To explain that the choice carries a risk for increased complications and make sure that the patient has signed a release form

To explain that the choice carries a risk for increased complications and make sure that the patient has signed a release form The patient is legally free to leave the hospital AMA; however, patients who leave the hospital AMA must sign a form releasing the health care provider and hospital from legal responsibility for their health status. This signed form becomes part of the medical record.

A nurse is developing a care plan related to prevention of pressure injuries for residents in a long-term care facility. Which action accurately describes a priority intervention in preventing a patient from developing a pressure injury? Keeping the head of the bed elevated as often as possible Massaging over bony prominences Repositioning bed-bound patients every 4 hours Using a mild cleansing agent when cleansing the skin

Using a mild cleansing agent when cleansing the skin To prevent pressure injuries, the nurse should cleanse the skin routinely and whenever any soiling occurs by using a mild cleansing agent with minimal friction, and avoiding hot water. The nurse should minimize the effects of shearing force by limiting the amount of time the head of the bed is elevated, when possible. Bony prominences should not be massaged, and bed-bound patients should be repositioned every 2 hours.

The nurse is surprised to detect an elevated temperature (102°F) in a patient scheduled for surgery. The patient has been afebrile and shows no other signs of being febrile. What is the priority nursing action? Inform the charge nurse. Inform the surgeon. Validate the finding. Document the finding.

Validate the finding. The nurse should first validate the finding if it is unusual, deviates from normal, and is unsupported by other data. Should the initial recording prove to be in error, it would have been premature to notify the charge nurse or the surgeon. The nurse should be sure that all data recorded are accurate; thus, all data should be validated before documentation if there are any doubts about accuracy.

Thirty-six hours after having surgery, a patient has a slightly elevated body temperature and generalized malaise, as well as pain and redness at the surgical site. Which intervention is most important to include in this patient's nursing care plan? Document the findings and continue to monitor the patient. Administer antipyretics, as prescribed. Increase the frequency of assessment to every hour and notify the patient's primary care provider. Increase the frequency of wound care and contact the primary care provider for an antibiotic prescription.

a. Document the findings and continue to monitor the patient. The assessment findings are normal for this stage of healing following surgery. The patient is in the inflammatory phase of the healing process, which involves a response by the immune system. This acute inflammation is characterized by pain, heat, redness, and swelling at the site of the injury (surgery, in this case). The patient also has a generalized body response, including a mildly elevated temperature, leukocytosis, and generalized malaise.

A client recovering from abdominal surgery sneezes and then screams, "My insides are hanging out!" What is the initial nursing intervention? contacting the surgeon applying sterile dressings with normal saline over the protruding organs and tissue assessing for impaired blood flow to the area of evisceration. monitoring for pallor and mottled appearance of the wound

applying sterile dressings with normal saline over the protruding organs and tissue The nurse will immediately apply sterile dressing moistened with normal saline over the protruding organs and tissue and call out for someone to contact the surgeon. While waiting for the surgeon, the nurse will continue to assess the area of evisceration and monitor the client's status.

A medical-surgical nurse is assisting a wound care nurse with the debridement of a client's coccyx wound. What is the primary goal of this action? a) Stimulating the wound bed to promote the growth of granulation tissue b) Removing dead or infected tissue to promote wound healing c) Removing excess drainage and wet tissue to prevent maceration of surrounding skin d) Removing purulent drainage from the wound bed in order to accurately assess it

b) Removing dead or infected tissue to promote wound healing

Which action should the nurse perform when applying negative pressure wound therapy? a) Irrigate the wound thoroughly using normal saline and clean technique. b) Test the seal of the completed dressing by briefly attaching it to wall suction. c) Increase the negative pressure setting until drainage is brisk. d) Cut foam to the shape of the wound and place it in the wound.

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

During rounds, a charge nurse hears the patient care technician yelling loudly to a patient regarding a transfer from the bed to chair. Upon entering the room, what is the nurse's BEST response? "You need to speak to the patient quietly so you don't disturb the other patients." "Let me help you with your transfer technique." "When you are finished, be sure to apologize for your rough demeanor." "When your patient is safe and comfortable, meet me at the desk.

d. "When your patient is safe and comfortable, meet me at the desk. The charge nurse should direct the patient care technician to determine the patient's safety. Then the nurse should address any concerns regarding the patient care technician's communication techniques privately. The nurse should direct the patient care technician on aspects of therapeutic communication.

A 3-year-old child is being admitted to a medical division for vomiting, diarrhea, and dehydration. During the admission interview, the nurse should implement which communication techniques to elicit the most information from the parents? The use of reflective questions The use of closed questions The use of assertive questions The use of clarifying questions

d. The use of assertive questions The use of clarifying questions The use of the clarifying question or comment allows the nurse to gain an understanding of a patient's comment. When used properly, this technique can avert possible misconceptions that could lead to an inappropriate nursing diagnosis. The reflective question technique involves repeating what the person has said or describing the person's feelings. Open-ended questions encourage free verbalization and expression of what the parents believe to be true. Assertive behavior is the ability to stand up for yourself and others using open, honest, and direct communication.

The nurse is preparing to apply a roller bandage to the stump of a client who had a below-the-knee amputation. What is the nurse's first action? exerting equal, but not excessive, tension with each turn of the bandage wrapping distally to proximally elevating and supporting the stump keeping the bandage free of gaps between turn

elevating and supporting the stump The nurse will first elevate and support the stump, then begin the process of bandaging. The bandage will be applied distally to proximally with equal tension at each turn; the nurse will monitor throughout the application to keep the bandage free from gaps between turns.

What type of dressing is occlusive or semi-occlusive, limits exchange of oxygen between wound and environment, provides minimal to moderate absorption of drainage, maintains a moist wound environment, and may be left in place for three to seven days, thus resulting in less interference with healing? transparent film hydrocolloid hydrogel alginate

hydrocolloid Hydrocolloids are occlusive or semi-occlusive dressings that limit exchange of oxygen between wound and environment, provide minimal to moderate absorption of drainage, maintain a moist wound environment, and may be left in place for three to seven days, thus resulting in less interference with healing. Hydrogels maintain a moist wound environment and are best for partial or full-thickness wounds. Alginates absorb exudate and maintain a moist wound environment. They are best for wounds with heavy exudate. Transparent films allow exchange of oxygen between wound and environment. They are best for small partial-thickness wounds with minimal drainage.

A nurse manager is educating the staff on new forms of charting. Within the education session, the manager sets a goal for complete use of the charting. Through goal setting, the manager is acting as an educator. a leader. a guide. a clinical specialist.

leader Leadership is the ability to influence others to strive for a vision or goal or to change. Thus, goal setting is the act of a leader. Although educators may set educational goals, the primary focus of an educator is teaching. A guide provides advice but does not set goals. A clinical specialist develops expert skills and knowledge in one specific area of practice.

A nurse notices a patient is walking to the bathroom with a stooped gait, facial grimacing, and gasping sounds. Based on these nonverbal clues, for which condition would the nurse assess? Pain Anxiety Depression Fluid volume deficit

pain A patient who presents with nonverbal communication of a stooped gait, facial grimacing, and gasping sounds is most likely experiencing pain. The nurse should clarify this nonverbal behavior.

Organizational communication

process of communication that involves individuals and groups to achieve established goals

What intervention(s) should be included in a plan of care to prevent pressure injury development in health care settings? Select all that apply. proper client nutrition 2-hour turn schedule pressure redistribution support surfaces head of bed positioned at 45 degrees pillow placed under knees client repositioning with a lift

proper client nutrition 2-hour turn schedule pressure redistribution support surfaces client repositioning with a lift To protect clients at risk for the adverse effects of pressure, the nurse will implement turning on an every-2-hours schedule in the health care setting. More frequent position changes may be necessary, depending on the client. Use of a pressure redistribution support surface can be expensive, but it is an effective way to prevent a pressure injury. The nurse will also keep heels from pressing on the bed for immobile clients and advise against prolonged sitting. While sitting or lying, the client will use positioning devices or pillows to keep boney prominences from rubbing on each other or pressing onto a surface. Placing pillows under the knees while supine puts pressure on the heels against the mattress. The nurse will protect the client's skin from friction and shear by lifting the client when moving or repositioning and keep the head of bed at 30 degrees or less. Positioning at client on a bed while the head of the bed is at a 45 degree angle could cause the client to have a skin shear or friction injury. The nurse will provide adequate calories and nutrients.

An experienced nurse has been working with a client with heart failure. The client's lungs were clear to auscultation during the morning assessment; however, the afternoon assessment revealed bibasilar crackles and tachypnea. The nurse calls to give SBAR report to the covering health care provider. In the final step of the report the nurse should: recommend 40 mg of furosemide be administered because the client had improvement with past administration. discuss the client's situation and request a chest x-ray to assess lung function. detail the client's past medical history and active medication orders. provide detailed findings of the head-to-toe assessment.

recommend 40 mg of furosemide be administered because the client had improvement with past administration. An experienced nurse has been working with a client with heart failure. The client's lungs were clear to auscultation during the morning assessment; however, the afternoon assessment revealed bibasilar crackles and tachypnea. The nurse calls to give SBAR report to the covering health care provider. In the final step of the report the nurse should: recommend 40 mg of furosemide be administered because the client had improvement with past administration. discuss the client's situation and request a chest x-ray to assess lung function. detail the client's past medical history and active medication orders. provide detailed findings of the head-to-toe assessment.

A nurse is treating a client who has a wound with full-thickness tissue loss and edges that do not readily approximate. The nurse knows that the open wound will gradually fill with granulation tissue. Which type of wound healing is this? primary intention maturation secondary intention tertiary intention

secondary intention Healing by secondary intention occurs in wounds with edges that do not readily approximate. The wound gradually fills with granulation tissue, and eventually epithelial cells migrate across the granulation base. Wounds with minimal tissue loss, such as clean surgical incisions and shallow sutured wounds, heal by primary intention. The edges of the wound are approximated and the risk of infection is lower when a wound heals in this manner. Maturation is the final stage of full-thickness wound healing. Tertiary intention occurs when there is a delay between injury and wound closure. The delay may occur when a deep wound is not sutured immediately or is left open until no sign of infection is evident.

The nurse in the long-term care facility observes that a client has developed a sacral pressure wound, which is very red and surrounded by blisters. Which stage of pressure injury does this client present? stage I stage II stage III stage IV

stage II The area of redness and blister formation indicate that the client is experiencing a stage II pressure injury. A stage I pressure injury is intact but reddened. A stage III pressure injury has a shallow skin crater that extends to the subcutaneous tissue. A stage IV pressure injury is severe; the tissue is deeply ulcerated and exposes muscle and bone with the presence of necrotic tissue likely.

A nurse finds that a client has infiltration around the IV line that needs to be removed. What explanation should the nurse give to reduce the client's anxiety? "This must have been caused from you moving your arm around." "Just be very still; the procedure is very minimal and will be over soon." "I know that you are anxious, but the IV location needs to be changed." "It will be a painless procedure and there is nothing to worry about; many clients experience this."

"I know that you are anxious, but the IV location needs to be changed." The nurse uses therapeutic communication by both acknowledging the client's anxiety and giving honest information that another IV line needs to be started. Telling the client that infiltration is causing pain but will be relieved upon removal of the IV line does not address the client's anxiety and does not inform the client about restarting another IV line. Also, the nurse telling the client to take deep breaths, or stating that the procedure is minimal and will be over soon, does not consider the client's anxiety. Finally, telling the client that "many clients experience this" is generalizing and is not appropriate.

The acute care nurse is caring for a client whose large surgical wound is healing by secondary intention. The client asks, "Why is my wound still open? Will it ever heal?" Which response by the nurse is most appropriate? "Your wound will heal slowly as granulation tissue forms and fills the wound." "Your surgeon may not have been skilled enough to close such a large wound, but it will eventually heal." "If less scar tissue is essential, wounds are allowed to heal slowly through a process called secondary intention." "As soon as the infection clears, your surgeon will staple the wound closed."

"Your wound will heal slowly as granulation tissue forms and fills the wound." This statement is correct, because it provides education to the client: "Your wound will heal slowly as granulation tissue forms and fills the wound." Large wounds with extensive tissue loss may not be able to be closed by primary intention, which is surgical intervention. Secondary intention, in which the wound is left open and closes naturally, is not done if less of a scar is necessary. Third intention is when a wound is left open for a few days and then, if there is no indication of infection, closed by a surgeon.

The nurse is caring for an older adult client in a long-term care facility. What nurse action is important to maintain skin integrity? Use soap liberally when bathing Check pressure points for redness after 60 minutes Clean perineal area daily but do not bathe full body on a daily basis Limit fluid intake

Clean perineal area daily but do not bathe full body on a daily basis' Because activity of the sebaceous and sweat glands decreases, the skin will become dryer and the client may have pruritis. The perineal area should be washed daily but the nurse should avoid full bathing of the body on a daily basis. Harsh soaps should be avoided and only used sparingly. The fluid intake should be increased unless otherwise contraindicated by medical condition. Pressure points are not related to the action of sebaceous and sweat gland activity, but the pressure points should be checked for redness after 30 minutes.

A nursing instructor is teaching a student nurse about the layers of the skin. Which layer should the student nurse understand is a potential source of energy in an undernourished client? Epidermis Dermis Subcutaneous tissue Muscle layer

Subcutaneous tissue The subcutaneous tissue is the skin layer that is responsible for storing fat for energy. The epidermis is the outer layer that protects the body with a waterproof layer of cells. The dermis contains the nerves, hair follicles, blood vessels, and glands. The muscle layer moves the skeleton.

A nurse is caring for a client who has an avulsion of her left thumb. Which description should the nurse understand as being the definition of avulsion? Tearing of the skin and tissue with some type of instrument; tissue not aligned Cutting with a sharp instrument with wound edges in close approximation with correct alignment Tearing of a structure from its normal position Puncture of the skin

Tearing of a structure from its normal position An avulsion involves tearing of a structure from its normal position on the body. Tearing of the skin and tissue with some type of instrument with the tissue not aligned is a laceration. Cutting with a sharp instrument with wound edges in close approximation and correct alignment is an incision. A puncture of the skin is simply a puncture.

The nurse is changing the dressing of a client with a gunshot wound. What nursing action would the nurse provide? The nurse uses wet-to-dry dressings continuously. The nurse keeps the intact, healthy skin surrounding the ulcer moist because it is susceptible to breakdown. The nurse selects a dressing that absorbs exudate, if it is present, but still maintains a moist environment. The nurse packs the wound cavity tightly with dressing material.

The nurse selects a dressing that absorbs exudate, if it is present, but still maintains a moist environment. A wound with heavy exudate will need a more absorptive dressing and a dry wound will require rehydration with a dressing that keeps the wound moist. The nurse would not keep the surrounding tissue moist. The nurse would not pack the wound cavity tightly, rather loosely. The nurse would not use wet-to-dry dressings continuously.

The nurse caring for a postoperative client is cleaning the client's wound. Which nursing action reflects the proper procedure for wound care? The nurse works outward from the wound in lines parallel to it. The nurse uses friction when cleaning the wound to loosen dead cells. The nurse swabs the wound with povidone-iodine to fight infection in the wound. The nurse swabs the wound from the bottom to the top.

The nurse works outward from the wound in lines parallel to it. A postoperative wound has well-approximated edges. With a postoperative wound, the nurse should work from the incision outward, in lines parallel to the incision. This method would be considered from clean to dirty. The nurse would not use friction when cleaning the wound. The nurse would not use povidone-iodine to fight infection in the wound. The nurse would not swab the wound from the bottom to the top.

The nurse is performing pressure injury assessment for clients in a hospital setting. Which client would the nurse consider to be at greatest risk for developing a pressure injury? a newborn a client with cardiovascular disease an older client with arthritis a critical care client

a critical care client Various factors are assessed to predicate a client's risk for pressure injury development. Client mobility, nutritional status, sensory perception, and activity are assessed. The client would also be assessed for possible moisture/incontinence issues as well as possible friction and sheer issues. Considering these factors, the individual that would be at greatest risk of developing a pressure injury would be a critical care client.

A client's risk for the development of a pressure injury is most likely due to which lab result? albumin 2.5 mg/dL glucose 110 mg/dL hemoglobin A1C 7% sodium 135 mEq/L

albumin 2.5 mg/dL An albumin level of less than 3.2 mg/dL indicates that the client is nutritionally at risk for the development of a pressure injury. A hemoglobin A1C level greater than 8% puts the client at risk for the development of pressure injuries due to a prolonged high glucose level. Glucose levels greater than 120 mg/dL are a risk factor for the development of pressure injuries. Sodium of 135 mEq/L is normal and would not put the client at risk for the development of a pressure injuries

A client's hand was severely wounded upon coming in contact with a running lawn mower blade. The nurse notes that large amounts of flesh are missing and the bones of two fingers are visible. How will the nurse document this assessment finding? puncture laceration contusion avulsion

avulsion An avulsion involves the stripping away of large areas of tissue, leaving cartilage and bone exposed. Therefore the nurse will document this assessment finding as an avulsion. A puncture is an opening of the skin caused by a narrow, sharp, pointed object. A laceration is the separation of skin and tissue with torn, irregular edges. A contusion is an injury to soft tissue. Therefore the nurse would not document the finding as a puncture, laceration, or contusion.

The nurse is caring for a client with a stage 2 pressure injury. Which intervention will help prevent shearing force? preventing the client from sliding in bed pulling the sheets to reposition the client every 2 hours improving the client's hydration pulling the client up from under the arms

preventing the client from sliding in bed Shearing force occurs when tissue layers move on one another, causing vessels to stretch as they pass through the subcutaneous tissue. Pulling up from under the arms and pulling the sheets to reposition the client cause shearing force. Improving the client's hydration status could help with wound healing, but not in the prevention of shearing force.

A nurse is teaching a nursing student about surgical drains and their purposes. The nursing student understands that the purpose for a T-tube drain is: to provide a sinus tract for drainage. to provide drainage for bile. to decrease dead space by decreasing drainage. to divert drainage to the peritoneal cavity.

to provide drainage for bile. A T-tube is used to drain bile, such as after a cholecystectomy. A Penrose drain provides a sinus tract for drainage. Hemovac and Jackson-Pratt drains both decrease dead space by decreasing drainage. A ventriculoperitoneal shunt diverts drainage to the peritoneal cavity.

A nurse is caring for a client who is newly diagnosed with terminal cancer. The nurse enters the client's room and finds the client sitting in the dark crying. Which statement conveys empathy by the nurse? "I am so sorry you are going through this. Can we talk?" "I know this is hard for you. Is there any way I can help?" "Sitting in the dark is not going to cure your cancer. Let's open the curtains." "Can you please tell me why you are crying?"

"I know this is hard for you. Is there any way I can help?" Empathy is identifying with the way another person feels. An empathic nurse is sensitive to the client's feelings and problems but remains objective enough to help the client work to attain positive outcomes. By retaining this quality, you can establish successful helping relationships without appearing cold or stern. The statement "I am so sorry you are going through this" demonstrates sympathy. Sympathy differs from empathy because it shifts the emphasis from the client to the nurse as the nurse shares feelings and personal concerns and projects them onto the client, limiting the ability to focus objectively on the client's needs. Asking about why the client is crying is part of information gathering but is not empathy. Stating that sitting in the dark will not cure cancer is an abrasive statement that may work against the nurse-client relationship.

A client comes into the urgent care center to have sutures removed on an arm. The nurse finds significant crusting along the suture line. The client states not having time to get the sutures removed a week prior, as directed. The nurse soaks the crust and attempts to remove the sutures. As the nurse attempts the suture removal, the client frequently pulls the arm away and tells the nurse, "You are taking too long and it is hurting a little bit. Just pull them out and get it over with." Which statement is an example of appropriate therapeutic response? "I am sorry it is taking so long. Tell me how you hurt your arm?" "I am sorry it is taking so long and I am hurting you; next time do not wait too long to get sutures removed or the same thing will happen" "It will not hurt if you relax and stop pulling your arm away." "It is taking longer for me to remove the sutures because the delay allowed the crust to form and adhere to the sutures, making it harder and sometimes painful to remove them."

"It is taking longer for me to remove the sutures because the delay allowed the crust to form and adhere to the sutures, making it harder and sometimes painful to remove them." Sharing information about why the removal of the sutures hurts and is taking longer is a teaching moment which helps the client make better decisions about health care. Telling the client not to wait so long for removal is not therapeutic because it diminishes the client's ability to make choices. Changing the subject is not therapeutic and is a way for the nurse to avoid listening and addressing the client's concerns. Telling the client it will not hurt if the client relaxes is an example of false reassurance.

The nurse and client are looking at a client's heel pressure injury. The client asks, "Why is there a small part of this wound that is dry and brown?" What is the nurse's appropriate response? "This is normal tissue." "That is called slough, and it will usually fall off." "You are seeing undermining, a type of tissue erosion." "Necrotic tissue is devitalized tissue that must be removed to promote healing."

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

The registered nurse (RN) observes the licensed practical nurse (LPN) preforming this action when applying a topical gel to a client's surgical wound during a dressing change. What instructions should the RN provide the LPN regarding this action? pic has LPN applying gel via gloved finger "Be sure to initially apply the gel to the center of the wound working outward toward the unaffected skin." "This procedure can be safely preformed using clean technique if care is taken not to touch the wound." "Be sure to apply a thin layer of gel to both the wound and to the surrounding unaffected skin for at least 1 inch (2.5 centimeters)." "To best avoid further traumatizing the wound bed, apply the gel with a sterile cotton tip applicator."

"To best avoid further traumatizing the wound bed, apply the gel with a sterile cotton tip applicator." The nurse should apply any topical medications, foams, gels, and/or gauze to the wound as prescribed; ensuring that the product stays confined to the wound and does not impact on intact surrounding tissue/skin. Applying the medicated gel with an applicator allows for better control over the application, thus minimizing any additional trauma to wound. The procedure should be preformed using sterile technique, but clean technique can be used when proving care to chronic or pressure injury wounds. To manage contamination risk, cleansing of a wound should be done from top to center to outside.

The nurse completes the admission process of a client to an acute care facility. Which statement by the nurse demonstrates the communication technique of focusing? "You have been having a great deal of fatigue for the last 3 months." "You are hoping to figure out the cause of your extreme fatigue during this hospital stay." "You are frustrated because you are too tired to perform normal activities." "You are unsure of what helps or prevents your fatigue."

"You are hoping to figure out the cause of your extreme fatigue during this hospital stay." The statement "You are hoping to figure out the cause of your extreme fatigue during this hospital stay" focuses on the main problem that the client has been reporting and the goal for this admission. The other statements demonstrate the communication technique of clarifying.

he nurse is visiting a client who was released from inpatient rehabilitation 6 weeks ago after a 5-month recovery from a motor vehicle accident that left the client immobile. As the nurse enters the home, the client braces hands on the arms of a chair to rise and uses crutches to walk across the room. What is the best response by the nurse? "Let me document that you can walk." "Those physical therapists work wonders. "You have made an amazing recovery." "Are you supposed to be out of the wheelchair?"

"You have made an amazing recovery." Reinforcement of learning shows that the nurse supports and wants to encourage the client. Giving credit where it is due communicates these values. Documenting is necessary, but stating this does not show interest in the client's progress. Crediting the therapists does not encourage the client. Asking about permission to ambulate negates the goal for improving wellness.

Which is an emerging trend in health care delivery? Active involvement of consumers Resolution of the nursing shortage Simplification of client care Reduction in the use of technology at the bedside

Active involvement of consumers Trends in health care delivery include the active involvement of consumers, continuing nursing shortage, increased complexity of client care, and a technology explosion. Other trends include changing demographics, increasing diversity, globalization of economy and society, increasing costs of health care, and the effects of health policy and regulation.

The new nurse is having difficulty managing the time required to care for a group of complex clients and is several hours behind in completing nursing interventions. Which intervention should the nurse complete first? Administer a dose of digoxin that is two hours behind schedule. Perform a dressing change to an abdominal abscess that is three hours behind schedule. Obtain discharge orders for a client who is ready to be transferred to a long-term nursing facility. Complete a medication reconciliation form on a client who has recently been admitted to the hospital.

Administer a dose of digoxin that is two hours behind schedule. The first step in time management is to determine which tasks are priority. Digoxin is a critical client medication and therefore takes priority over the other options. Dressing changes, discharge orders, and completing facility forms can be delayed until critical tasks are complete.

The nurse observes the presence of intestinal contents protruding from the client's surgical wound after colon resection. What action will the nurse take? Allow the wound and intestinal contents to remain open to air. Apply saline solution-moistened gauze over the protruding area. Pack the wound with gauze pads and a dry sterile dressing. Inform the client that this is an expected occurrence and not to worry.

Apply saline solution-moistened gauze over the protruding area. The first thing the nurse will do is cover the protruding intestine with a saline solution-moistened gauze. The nurse will then notify the health care provider of wound evisceration. If the protruding intestine is left open to the air, it may cause drying of the fragile tissue and necrosis to the area. The nurse should not pack anything into the wound since foreign body retention may cause complications at a later time if the gauze is not recovered. The occurrence of wound evisceration is not an expected finding and may be serious depending upon whether the protruding area is viable.

What should the nurse assess before application of sitz bath therapy? Select all that apply. Client's ability to ambulate to the bathroom Client's ability to sit for 15 to 20 minutes Client's perineal/rectal area Client's need to void Client's serum sodium levels

Client's ability to ambulate to the bathroom Client's ability to sit for 15 to 20 minutes Client's perineal/rectal area Client's need to void Before application of sitz bath therapy, the nurse should assess the client's ability to ambulate to the bathroom; ability to sit for 15 to 20 minutes; appearance of the perineal/rectal area for swelling, drainage, tenderness; and the client's bladder fullness and need to void. Electrolyte levels are not affected by sitz bath therapy.

The nurse is caring for a client who had abdominal surgery 12 hours ago and notes a small amount of sanguineous drainage on the abdominal surgical dressing. What is the appropriate action by the nurse? Contact the health care provider. Change the dressing. Document the findings. Notify the wound care nurse.

Document the findings. The nurse should document the findings and continue to monitor the dressing. Because it is a small amount of drainage, there is no need to contact the health care provider or the wound care nurse. The nurse should not change the surgical dressing. Most often, the surgeon will change the first dressing in 24 to 48 hours. For this reason, the wound care nurse does not need to be notified.

Two nurses, an RN and a wound care nurse, are discussing care of a client's wound that has nonviable tissue in the base. The wound care nurse recommends that the RN utilize a dressing that would promote autolytic debridement of the wound. Which dressing should the nurse select? Hydrocolloid Wet to dry Negative wound pressure therapy Telfa

Hydrocolloid The nurse should select the hydrocolloid dressing to promote autolytic debridement of the wound. Wet to dry dressings promote mechanical debridement. Telfa pads are nonstick and do not promote debridement. Negative wound pressure therapy is not utilized to promote debridement.

A nurse is collecting a wound culture from a client from two different sites. Which actions should the nurse take while performing this procedure? Select all that apply. Insert a swab into the wound. Press and rotate the swab several times over the wound surfaces. Place the swab in the culture tube when done. Use the same swab for both wound sites. Touch the swab to the intact skin at the wound edges. Tap the outside of the culture tube with the swab before placing it in the tube.

Insert a swab into the wound. Press and rotate the swab several times over the wound surfaces. Place the swab in the culture tube when done. The nurse should carefully insert the swab into the wound and then press and rotate the swab several times over the wound surfaces. After collecting the specimen, the nurse should place the swab back in the culture tube. The nurse should be careful to keep the swab and the inside of the culture tube sterile at all times. This means that the nurse should avoid touching the swab to intact skin at the wound edges or to the outside of the tube, as this would contaminate both the swab with organisms not in the wound and the areas that the swab touches with organisms found in the wound. A different swab, not the same, should be used for each wound site to prevent cross-contamination.

Which style of leadership is rarely used in a hospital setting because of the difficulty of task achievement by independent nurses? Democratic Autocratic Laissez-faire Transformational

Laissez-faire In laissez-faire leadership, also called nondirective leadership, the leader relinquishes power to the group, such that an outsider could not identify the leader in the group. Autocratic leadership, also called directive leadership or authoritarian leadership, involves the leader assuming control over the decisions and activities of the group. Transformational is often described as charismatic; transformational leaders are unique in their ability to inspire and motivate others. Democratic leadership, also called participative leadership, is characterized by a sense of equality among the leader and other participants.

A nurse is caring for a client on a medical-surgical unit. The client has a wound on the ankle that is covered in eschar and slough. The primary care provider has ordered debridement in the surgical department for the following morning. Which type of debridement does the nurse understand has been ordered on this client? autolytic debridement biosurgical debridement enzymatic debridement mechanical debridement

Mechanical debridement involves physical removal of necrotic tissue, such as surgical debridement. Biosurgical debridement utilizes fly larvae to clear the wound of necrotic tissue. This is accomplished through an enzyme the larvae release. Autolytic debridement involves using the client's own body to break down the necrotic tissue. Enzymatic debridement involves the use of synthetic enzymes that break down necrotic tissue when applied to the wound bed.

When assessing the right heel of a client who is confined to bed, the nurse notes a thick, leathery, black scab. What is the correct action by the nurse? Contact the surgeon for debridement. Using sterile technique, debride the wound. Off-load pressure from the heel. Place an antiembolism stocking on the client's leg.

Off-load pressure from the heel. The correct action by the nurse is to off-load pressure from the heel. This can be accomplished by placing a pillow under the client's leg so that the heel is touching neither the bed or the pillow. The hard leathery, black scar is an eschar that forms a protective covering over the heel and should not be debrided. The surgeon does not need to be consulted for a debridement. Utilizing an antiembolism stocking on the client will not impact the status of the heel wound.

A client is admitted to the facility after fracturing a hip. The client has undergone surgery to repair the fracture and is receiving services to promote healing of the surgical site and regain mobility. Which discussion should the nurse have with a member of the interdisciplinary team member to promote the goal of regaining mobility? Speak with the physical therapist about exercises to strengthen muscles. Discuss oxygen administration with the respiratory therapist. Talk with the occupational therapist about providing assistance with activities of daily living. Discuss transfer to a rehabilitation facility with the social worker.

Speak with the physical therapist about exercises to strengthen muscles. the nurse should discuss the goal of regaining mobility with a physical therapist. A physical therapist assists with restoring mobility, strengthens muscle groups, and teaches ambulation with new devices. Respiratory therapists are trained in techniques that improve pulmonary function and oxygenation. Occupational therapists evaluate functional level and teach activities to promote self-care in activities of daily living. Speech therapists deal with swallowing difficulties and help clients speak more clearly.

The nurse is caring for a client who has a pressure injury on the back. What nursing intervention would the nurse perform? The nurse elevates the foot of the bed. The nurse uses a ring cushion to protect reddened areas from additional pressure. The nurse increases the amount of time the head of the bed is elevated. The nurse uses positioning devices and techniques to maintain posture and distribute weight evenly for the client in a chair.

The nurse uses positioning devices and techniques to maintain posture and distribute weight evenly for the client in a chair. Positioning devices such as pillows, foam wedges, or pressure-reducing boots can prove helpful to keep body weight off bony prominences. For example, a standard pillow placed under the calves raises the heels off the bed and alleviates pressure. The nurse should never use ring cushions, or "donuts," because they increase venous pressure. The nurse should minimize the effects of shearing force by limiting the amount of time the head of the bed is elevated, when possible.

When communicating with a client, the nurse uses reflection for which purpose? To have the client elaborate on thoughts and feelings To determine the sequence of events in the conversation To investigate the situation to help problem solve To keep the client on the topic of concern

To have the client elaborate on thoughts and feelings The reflective question technique involves repeating what the person has said or describing the person's feelings. It encourages clients to elaborate on their thoughts and feelings. Exploring helps clients express their concerns and solve their problems by investigating the situation, exploring how they feel about it, and what some alternatives might be. Focusing helps the client stay on the topic. Sequencing determines events in chronological order.

What intervention should the nurse teach the client to support the underlying tissues and decrease discomfort after removal of surgical staples? To splint the area when engaging in activity To ambulate using a cane or walker To remain in bed for the next 4 hours To turn the head away from the area whenever coughing

To splint the area when engaging in activity To support the underlying tissues and decrease discomfort, the nurse should teach the client to splint the area when engaging in activities such as changing positions, coughing, or ambulating. Teaching the client to ambulate using a cane or walker may be necessary but is not done to support the underlying tissues or to decrease discomfort. It is done to ensure the client can use the ambulatory devices correctly. There is no indication that the client needs to stay in bed; in fact, ambulation should be encouraged. Teaching the client to turn the head away while coughing is done to aid in prevention of infection.

The nurse considers the impact of shearing forces in the development of pressure injuries in clients. Which client would be most likely to develop a pressure injury from shearing forces? a client sitting in a chair who slides down a client who lifts himself up on the elbows a client who lies on wrinkled sheets a client who must remain on the back for long periods of time

a client sitting in a chair who slides down Shear results when one layer of tissue slides over another layer. Shear separates the skin from underlying tissues. The small blood vessels and capillaries in the area are stretched and possibly tear, resulting in decreased circulation to the tissue cells under the skin. Clients who are pulled, rather than lifted, when being moved up in bed (or from bed to chair or stretcher) are at risk for injury from shearing forces. A client who is partially sitting up in bed is susceptible to shearing force when the skin sticks to the sheet and underlying tissues move downward with the body toward the foot of the bed. This may also occur in a client who sits in a chair but slides down. The client that is most likely to develop a pressure injury from shearing forces would be a client sitting in a chair who slides down.

A nursing student is providing a complete bed bath to a 60-year-old diabetic client. The student is conducting an assessment during the bath. The student observes a red, raised rash under the client's breasts. This manifestation is most consistent with: an allergic reaction to medications. an allergic reaction to detergent. a rash related to a yeast infection. a rash related to immobility.

a rash related to a yeast infection. Diaphoresis or inadequate drying after hygiene, especially in skin folds, can increase moisture and encourage the growth of yeast. In addition, the client's history of diabetes will increase the risk for the development of a yeast infection. The rash resulting from an allergic reaction would not likely be limited to the region beneath the breast. Immobility will not directly result in a rash.

The nurse is assessing the wounds of clients. Which clients would the nurse place at risk for delayed wound healing? Select all that apply. an older adult who is confined to bed a client with a peripheral vascular disorder a client who is obese a client who eats a diet high in vitamins A and C a client who is taking corticosteroid drugs a 10-year-old client with a surgical incision

an older adult who is confined to bed a client with a peripheral vascular disorder a client who is obese a client who is taking corticosteroid drugs There are several clients that would be at risk for delayed wound healing. The older adult who is bedridden would be at risk. Older adults are at a greater risk for pressure injury formation because the aging skin is more susceptible to injury. Chronic and debilitating diseases, more common in this age group, may adversely affect circulation and oxygenation of dermal structures. Other problems, such as malnutrition and immobility, compound the risk of pressure injury development in older adults. A client with a peripheral vascular disorder would also be at risk due to issues with the peripheral circulation to the wound. An obese client would be at risk. The obese client may be malnourished or, simply because of the obesity, the client could be at risk. A client who is taking corticosteroid drugs would also be at risk. Corticosteroid drugs interfere with the immune system of the client. A client who eats a diet high in vitamins A and C would not be at risk for delayed wound healing. A 10-year old client with a surgical incision would not be at risk for delayed wound healing.

The nurse is preparing to insert an IV for a client with dehydration. Which dressing supply will the nurse gather to take in the client's room? gauze adhesive strips with eyelets transparent hydrocolloid

transparent Transparent dressings are used to protect intravenous insertion sites. Adhesive strips with eyelets are used with gauze dressings to absorb blood or drainage. Hydrocolloid dressings are used to used keep a wound moist.

A nurse is caring for a 78-year-old client who was admitted after a femur fracture. The primary care provider placed the client on bed rest. Which action should the nurse perform to prevent a pressure injury? elevate the head of the bed 90 degrees use pillows to maintain a side-lying position as needed provide incontinent care every 4 hours as needed place a foot board on the bed

use pillows to maintain a side-lying position as needed Using pillows to maintain a side-lying position allows the nursing staff to change position to alleviate and alternate pressure on client's bony prominences. The client's position should be changed a minimum of every 2 hours. In addition, incontinent care should be performed a minimum of every 2 hours and as needed to decrease moisture and irritation of the skin. A foot board prevents foot drop but does not decrease the risk for pressure injury.