Final Questions

7. A client is scheduled for surgery. Legally, the client may not sign the operative consent if: A. Ambivalent feelings are present and acknowledged B. Any sedative type of medication has been given recently C. A discussion of alternatives with two health care providers has not occurred D. A complete history and physical has not been performed and recorded

Correct Answer: B Sedation may interfere with the client's knowledge of the consent form

3. A nurse in charge in the surgical intensive care unit notes that a number of clients do not seem to be responding to morphine that was administered for pain. Later in the evening the nurse finds a staff nurse dozing in the nurses' lounge. When awakened, the staff nurse appears uncoordinated and drugged, with slurred speech. What should the nurse in charge do? A. Ask the nurse manager to be present before confronting the staff nurse. B. Ask other staff members whether they have noticed anything unusual lately. C. Tell the staff nurse that everyone now knows who has been stealing the morphine. D. Arrange to secretly observe the staff nurse the next time the staff nurse administers morphine.

Correct Answer: A Arranging for the nurse manager to be present before confronting the staff nurse is a serious allegation, and confrontation should occur in the presence of a person in a supervisory position.

1. A nurse plans to monitor for signs of autonomic dysreflexia in a client who sustained a spinal cord injury at the T2 level. This is necessary because: A. Reflexes have been lost. B. There is partial transection of the cord. C. There is damage above the sixth thoracic vertebra. D. Flaccid paralysis of the lower extremities has occurred

Correct Answer: C The T6 level is the sympathetic visceral outflow level, and any injury above this level may result in autonomic dysreflexia. The reflex arc remains after spinal cord injury.

4. The professional obligation of a nurse to assume responsibility for actions is referred to as: A. Accountability B. Individuality C. Responsibility D. Bioethics

Correct Answer: A Nurses have an obligation to uphold the highest standards of practice, assume full responsibility for actions, and maintain quality in the knowledge base and skill of the profession.

6. An older client is treated in the emergency department for soft-tissue injuries that the medical team suspects might be caused by physical abuse. An adult child states that the client is forgetful and confused and falls all the time. A mini-mental examination indicates that the client is oriented to person, place, and time, and the client does not comment when asked directly how the bruises and abrasions occurred. What is the next appropriate nursing action? A. Interview the client without the presence of family members. B. Report the abuse to the appropriate state agency for investigation. C. Accept the adult child's explanation until more data can be collected. D. Refer the client's clinical record to the hospital ethics committee for review.

Correct Answer: A Privacy may provide an environment that is conducive to the client sharing information about the situation. The client needs to be kept safe; this action ensures additional time for assessment to rule out the possibility of abuse.

16. The nurse manager is evaluating a primary nurse's ability to develop a therapeutic relationship. A client with a bipolar mood disorder, manic phase, has been hyperactive and sarcastic, but this behavior has been decreasing. The client states, "My husband and I have problems because we see things differently." What response indicates to the nurse manager that the primary nurse's approach is not therapeutic? A. "Do you know why you're feeling calmer today?" B. "Not getting along with your spouse is upsetting." C. "Tell me what you mean by seeing things differently?" D. "Tell me how you normally respond when you have problems with your husband."

Correct Answer: A The response "Do you know why you're feeling calmer today?" changes the subject; it is better to continue discussing the same subject.

18. A nurse in a public health clinic is teaching clients how to prevent toxoplasmosis. What should the nurse instruct the clients to avoid? A. Contact with cat feces B. Working with heavy metals C. Ingestion of freshwater fish D. Excessive radiation exposure

Correct Answer: A Toxoplasma gondii, a protozoan, can be transmitted by exposure to infected cat feces or by ingestion of undercooked, contaminated meat.

5. A nurse on the medical-surgical unit tells other staff members, "That client can just wait for the lorazepam (Ativan); I get so annoyed when people drink too much." What does this nurse's comment reflect? A. Demonstration of a personal bias B. Problem solving based on assessment C. Determination of client acuity to set priorities D. Consideration of the complexity of client care

Correct Answer: A When nurses make judgmental remarks and client needs are not placed first, the standards of care are violated and quality of care is compromised.

17. Which intervention may be delegated to nursing assistive personnel (NAP)? Select all that apply. A. Having a client care technician obtain routine vital signs B. Increasing oxygen from 2 to 3 L/minute if oxygen saturation is below 90% C. Evaluating a wound during a dressing change by a licensed practical nurse (LPN) or licensed vocational nurse (LVN) D. Having a client care technician ambulate a stable client E. Reading and evaluating telemetry monitors by a trained monitor technician

Correct Answer: A and D Some state boards of nursing identify specific activities that may be delegated to NAP, such as obtaining routine vital signs on stable clients, feeding or assisting clients at mealtimes, ambulating stable clients, and helping clients with bathing and hygiene.

12. A hospitalized client develops an infection at a catheter insertion site. The nurse uses the term iatrogenic when describing this infection because it resulted from: A. Poor personal hygiene B. A procedure performed at the hospital C. Inadequate dietary intake D. The client's developmental level

Correct Answer: B An iatrogenic infection is one caused by health care providers or therapy.

15. Based on the following scenario, the nurse leading a crisis intervention team on a mental health unit's initial intervention will be: A. Providing the client with one last opportunity to control his violent behavior B. Explaining to the client in a calm, confident manner why the restraints are necessary C. Presenting a show of force so the client will not resist the application of the restraints D. Assuring the client that the restraints will be removed as soon as he is in control again

Correct Answer: B Once it is determined that less restrictive deescalating methods are not effective, the nurse will inform the client that restraints will be applied to ensure the safety of the client, the milieu, and the staff.

2. A pregnant woman is admitted with a tentative diagnosis of placenta previa. The nurse implements prescriptions to start an intravenous (IV) infusion, administer oxygen, and draw blood for laboratory tests. The client's apprehension is increasing, and she asks the nurse what is happening. The nurse tells her not to worry, that she is going to be all right, and that everything is under control. What is the best interpretation of the nurse's statement? A. Adequate, because the preparations are routine and need no explanation B. Effective, because the client's anxieties would increase if she knew the danger involved C. Questionable, because the client has the right to know what treatment is being given and why D. Incorrect, because only the health care provider should offer assurances about management of care

Correct Answer: C The client's rights have been violated. All clients have the right to a complete and accurate explanation of treatment based on cognitive ability. All interventions should be explained because they are not routine to the client.

8. A client who is admitted to the hospital and requires a colon resection states, "I want to be made a do not resuscitate (DNR)." The nurse questions the client's understanding of a DNR order. Which response best indicates an understanding of a DNR order? A. "My doctor will know what to do." B. "My family can make the decisions for me." C. "If something happens to me, I would rather die." D. "If I have a heart attack, I do not want any medication."

Correct Answer: C The statement "If something happens to me, I would rather die." specifically states that if cardiac or respiratory arrest occurs, the client would rather die than live.

10. A nurse is assigned to change a central line dressing. The agency policy is to clean the site with Betadine and then cleanse with alcohol. The nurse recently attended a conference that presented information that alcohol should precede Betadine in a dressing change. In addition, an article in a nursing journal stated that a new product was a more effective antibacterial than alcohol and Betadine. The nurse has a sample of the new product. How should the nurse proceed? A. Use the new product sample when changing the dressing. B. Cleanse the site with alcohol first and then with Betadine. C. Cleanse the site with the new product first and then follow the agency's protocol. D. Follow the agency's policy unless it is contradicted by a health care provider's prescription.

Correct Answer: D Agency policy determines procedures; if the procedure is out of date or problematic, the nurse should contact the health care provider for a change in the prescription.

9. On a home visit to an older adult with chronic heart failure, the nurse notes that a 6-month-old grandchild lies quietly in a crib, rarely smiles or babbles, and barely has basic needs attended. The client is the primary caregiver for the infant. The nurse should: A. Advise the purchase of appropriate toys designed for this age level. B.Inform the client that the child will be cognitively impaired if he is not stimulated. C. Explain the need for the family to hire a mother's helper for the home. D. Initiate a referral to an appropriate agency to assess the need for a home health aide and schedule a family conference

Correct Answer: D Initiating a referral to an appropriate agency to assess the need for a home health aide and scheduling a family meeting will ensure that a thorough assessment of the family's needs is made and the appropriate assistance initiated.

14. A client suspected of having a hyperactive thyroid is scheduled for protein-bound iodine, T3, and T4 laboratory tests. To ensure accuracy of the test, the nurse asks if the client has: A. Allergies to seafood B. Consumed more protein than usual C. Had anything to drink before the test D. Had recent x-rays using radiopaque dye

Correct Answer: D Many radiopaque dyes contain iodine, which will alter the protein-bound iodine test results.

13. A client who is dying decides to consent to eye donation for organ transplantation. Statutes that address organ transplantation attempt to prevent abuse by: A. Permitting active euthanasia when necessary B. Preventing children from giving organs to others C. Allowing health care providers to control donors and recipients D. Requiring participating institutions to have review boards

Correct Answer: D Requiring participating institutions to have review boards is a legal requirement of participating institutions to protect the individuals involved.

11. A woman who has just delivered an infant asks to take the placenta home with her and her new baby on discharge. What is the most appropriate response? A. "I'll wrap that right up for you." B. "I'm sorry, but you can't do that." C. "I'll give it to you for your husband to take home now." D. "I need to check the hospital protocol for our policy on that practice."

Correct Answer: D The placenta is a part of the body and therefore contains body fluids. It must first be assessed by the health care provider to be sure that it is not infected and to be sure that all parts of the placenta have been accounted for.