fundamentals
What are the instances when an adult can give consent for medical treatment? Select all that apply.
Any guardian for the adult's ward Any parent for the adult's unemancipated minor Any adult for the treatment of his or her minor brother or sister (if an emergency and parents are not present)
While visiting the hospital, the spouse of a client slips and falls on a recently washed floor in the hallway leading to the client's room. To meet the criteria of ethical practice, what action should the nurse who witnessed the occurrence take?
Initiate an agency incident report.
What is a living will?
It is a written document that directs treatment according to the client's wishes, in case of a terminal illness or condition.
To prevent septic shock in the hospitalized client, what should the nurse do?
Use aseptic technique during all invasive procedures. rationale: Septic shock occurs as a result of an uncontrolled infection, which may be prevented by using correct infection control practices. These include aseptic technique during all invasive procedures.
The nurse should suspect that a client who had a recent myocardial infarction is experiencing denial when the client does what?
Attempts to minimize the illness rationale: Attempts to minimize the illness is a classic sign of denial; by reducing the importance or extent of the problem, the individual is able to cope. Not acknowledging that it is really a problem is a form of denial.
Which risks would the nurse state may be associated with adults who work on or around automobiles? Select all that apply.
Asbestosis Dermatitis rationale: Automobile workers are at greater risk of asbestosis (a lung disease resulting from the inhalation of asbestos particles) and dermatitis (skin becomes red, swollen, and sore, sometimes with small blisters).
ADPIE
Assessment : identify the problem review literature formulate theoretical work identify study eriables Diagnosis: Develop hypothesis Planning: ( Goals/ patient outcomes) Design the study select research design/ methodology identify sample population selecr data collection groups selects instrumentation Implementation: conduct the study obtain necessary approvals recruit subjects inpement the study protocol/ collect data Evaluation: analyze the results use the findings
The nurse plans care for a client who has anxiety related to uncertainty over the course of recovery. Which action of the client would indicate that the desired goal is achieved?
The client expresses acceptance of health status by the day of discharge. rationale: A goal is a desired change in a client's condition or behavior. Therefore, when a client who is anxious about the disease recovery starts expressing acceptance of his or her health status by the day of discharge, it reflects that the desired nursing goal is achieved.
Following a surgery on the neck, the client asks the nurse why the head of the bed is up so high. The nurse should tell the client that the high-Fowler position is preferred for what reason?
To reduce edema at the operative site rationale: This position prevents fluid accumulation in the tissue, thereby minimizing edema.
A client with a leg fracture is hospitalized. The registered nurse instructs the nursing student to interrogate the client to ascertain the reason for the injury. Which question would help to determine an extrinsic factor?
Were you wearing inappropriate shoes? rationale: Extrinsic factors include environmental hazards outside and within the home. Asking the client about his or her footwear will help to ascertain whether there was an extrinsic factor that may have caused the fall. Intrinsic factors include impaired vision, the taking of sedatives or hypnotics, and a history of a postural hypotension.
A registered nurse is educating a nursing student about the process of resolving an ethical dilemma. What information should the nurse provide regarding negotiation of outcomes?
"A nurse should provide a personal point of view."
A client complains of pain. Which question asked by the nurse are most appropriate to assess the nature of the pain?
"Can you describe your pain to me?"
A client injured in a motor vehicle accident was brought to the emergency and taken immediately for a scan. The client's family arrives later and asks about the client's health. What should the nurse tell the client's family?
"Please wait; I will update you as soon as I have any information." rationale: The nurse should update the client's relatives once he or she receives relevant information. This action helps the nurse to maintain the nurse-client relationship. The nurse must not provide false reassurances because this action affects the family's ability to adjust to any bad news. If the nurse does not have any information about the client, the nurse must find out details and inform the client's family.
A nurse anticipates that a hospitalized client will be transferred to a nursing home. When should the nurse begin preparing the client and the client's family for the transfer?
At the time of admission
Which action by the nurse is appropriate when caring for an elderly client admitted to a healthcare facility?
Invite a family member to join the conversation.
A nurse is caring for a client with hemiplegia who becomes frustrated when performing skills. How can the nurse motivate the client toward independence?
Reinforce success in tasks accomplished.
The primary healthcare provider instructs the nurse to manage fluid replacement therapy in a client with cancer. What type of care is the client receiving?
supportive care rationale: In oncology departments, medical professionals use supportive care to improve the client's quality of life. Supportive care is mainly based on the use of medical interventions to support client health. Medical interventions during supportive care include managing fluid replacement therapy, providing blood transfusions, and administering bone marrow-stimulating agents.
A nurse educates a client about the role played by an individual in taking responsibility for health and wellness and its impact. What instructions should the nurse give? Select all that apply.
"An individual should know that lifestyle choices affect his or her quality of life and well-being." "An individual should take responsibility of health and wellness by making proper lifestyle choices." "An individual should realize that illness prevention has a positive economic impact on his or her life."
The chief operational officer (COO) interviews a nurse and asks, "Tell me about your practical experiences in clinical decision making." Which example would the nurse give?
"I identified impaired skin integrity in a pressure ulcer form upon finding redness in the client's hip." rationale: Clinical decision making is a problem-solving activity that focuses on defining a problem and selecting an appropriate action. So as a part of clinical decision making, the nurse identified impaired skin integrity in a pressure ulcer form upon finding redness in the client's hip.
A student nurse is describing palliative care to a client's family. Which statement made by the student nurse indicates a need for correction by the registered nurse?
"Palliative care is the same as hospice care."
In what order should a nurse follow steps of risk management to identify potential hazards and to eliminate them before harm occurs?
2. Identifying possible risks 1. Analyzing the possible risks 3. Acting to reduce the risks 4. Evaluating the steps taken
A pregnant woman in her second trimester arrives at the local health department, requesting a flu shot. The client states that she gets the flu vaccine every year and has never had an adverse reaction. What action should the nurse perform?
Administer the usual dose of the vaccine. rationale: Influenza is more likely to cause severe illness in pregnant women than in women who are not pregnant. Changes in the immune system, heart, and lungs during pregnancy make pregnant women more prone to severe illness from influenza as well as hospitalizations and even death. T
In the clinical setting, which clients exhibit affiliative motivation? Select all that apply.
An obese teenager who follows dietary restrictions to fit in with a peer group A client who complies with taking their medication to please the client's spouse rationale" Affiliative motivation is usually seen in people who are nonassertive and dependent on others. Their health-seeking actions are usually directed towards establishing, maintaining, and restoring close personal relationships with others. The client who complies with taking medication to please his or her spouse is exhibiting affiliative motivation, because self-care behavior is not intended for restoring health, but to please someone else. The teenager who follows dietary restrictions to lose weight to fit into a peer group exhibits affiliative motivation. The teenager follows the dietary restrictions not to become healthy, but to get peer approval.
The nurse is providing postprocedure care for a client who had a central venous access device (CVAD) inserted. Before the CVAD is used, what procedure is performed to verify placement?
Chest x-ray rationale: The insertion of a central venous catheter (CVC) into the subclavian vein can result in a pneumothorax, which would be seen on a chest x-ray. Indications of a pneumothorax before the chest x-ray would include shortness of breath and anxiety. If the chest x-ray is negative for pneumothorax, the CVC line may be used. The central line should not be flushed until placement is verified. Blood withdrawal is utilized once placement is verified, but is not used to verify initial placement. Fluoroscopy may be used during placement in certain settings, but not for placement verification.
The nurse introduces him or herself and explains a procedure to be performed to clean and dress a surgical wound. Which critical thinking attitude is the nurse applying?
Confidence rationale: The critical thinking attitude of confidence grows with experience and the nurse is able to shift the focus from remembering the procedure to caring for the client's needs. The nurse builds a bond of trust by displaying confidence while performing a procedure.
While caring for a family, the nurse finds that the family has accepted the shifts of generational roles. Which change in the family status for proceeding developmentally would the nurse observe?
Dealing with retirement rationale: A family with members in the later life stage may involve the acceptance of the shifting of generational roles. Therefore, dealing with retirement would be an appropriate change for the family status that requires a developmental proceeding.
The nursing student accompanies a group of registered nurses in a campaign that promotes the participation of parents to get their children immunized. After the campaign's completion, the group prepares a report that counts the number of immunizations and compares it to last year's report. Which type of research does the nursing student think that the group is doing?
Evaluation research Rationale: Evaluation research tests the effectiveness of a program, practice, or policy. It measures the outcomes of a campaign. Descriptive research measures the characteristics of persons, situations, or groups. For example, this study would measure the frequency of an occurrence of an event. Experimental research is a study where the investigator controls the study variable and randomly assigns the subjects to different conditions for the variable test. Correlational research explores the interrelationships among variables of interest; this study does not include any active intervention by the researcher.
A client has an open reduction and internal fixation of the hip. The client is to be transferred to a chair for a half hour on the second postoperative day. Before transferring the client, what should the nurse do?
Explain the transfer procedure step by step.
A client complains to the nurse manager about a coworker. The nurse manager listens to both the client's and the coworker's side of the story. Which critical thinking quality is shown in this situation?
Fairness
A nurse educator is presenting information about the nursing process to a class of nursing students. What definition of the nursing process should be included in the presentation?
Sequence of steps used to meet the client's needs rationale: The nursing process is a step-by-step method that scientifically provides for a client's nursing needs.
Which carative factor of Watson's transpersonal caring theory is reflected when the nurse practices loving kindness in practice?
Forming a human-altruistic value system rationale: A human-altruistic value system is formed in nursing practice by using loving kindness. The nurse should use self-disclosure appropriately to promote a therapeutic alliance with the client. T
The nurse is caring for a dying client. Which interventions should the nurse implement for the client and family? Select all that apply.
Help the family set up home care if required. Know the client and family's strengths and weaknesses Arrange for church or community support for the family.
While instructing a community group regarding risk factors for coronary artery disease, the nurse provides a list of risk factors that cannot be modified. What should be included on the list?
Heredity
A nurse is caring for an elderly client who has constipation. Which independent nursing intervention helps to reestablish a normal bowel pattern?
Offer a cup of prune juice.
The way individuals cope with an unexpected hospitalization depends on many factors. However, what is the one that is most significant?
Past coping styles rationale: past coping ability is the most significant factor to predict future coping.
A nurse preceptor is evaluating a nurse who is preparing to administer digoxin intravenously (IV) to a client. The preceptor should stop the nurse from continuing with the procedure when the preceptor observes the nurse doing what?
Piggybacking the digoxin in an existing infusion rationale: The nurse preceptor needs to stop the nurse because this action is unsafe. The manufacturer recommends that digoxin be infused alone, because there may be an incompatibility with other medications. A low serum level of potassium and the administration of digoxin can cause toxicity. An elevated serum level of digoxin and the administration of another dose of digoxin can result in toxicity. Digoxin IV is given over a 5-minute period through a Y-site connector.
A staff nurse on a medical-surgical unit has been assigned to care for a number of clients. The nurse decides to review their individual records before client contact. Which phase of the nurse-client relationship does this represent?
Preinteraction phase
A nurse is hired to work in a facility where the nurse assumes responsibility for a number of clients' needs. What is this nursing care delivery system called?
Primary care nursing
An older adult who is in acute care has a risk of skin breakdown. Which interventions are beneficial to the client? Select all that apply.
Providing meticulous skin care Reducing shear forces and friction Avoiding pressure with proper positioning
The nurse is assessing a young couple planning to start a family. What should the nurse tell the couple about the change that they will have to encounter in their family life-cycle?
Realign relationships with extended family
A client with a terminal illness is grateful for the care received in the hospital and has slowly started to come to terms with imminent death. The nurse recognizes that the client's behavior and attitude is most consistent with which cultural group?
Somalian culture rationale: Terminally ill clients who belong to the Somalian culture may slowly accept their imminent death and have faith in God. Somalian clients will generally express their gratitude to the care received in the hospital.
A nurse is caring for a client on bed rest. How can the nurse help prevent a pulmonary embolus?
Teach the client how to exercise the legs.
A nursing student notes that a nurse is required to integrate best current research with clinical expertise and client preferences and values in order to provide quality healthcare. Which Quality and Safety Education for Nurses (QSEN) competency does this comply with?
The QSEN competency evidence-based practice states that a nurse should integrate best current research with clinical expertise and client's preferences and values in order to provide quality healthcare.
What should the nurse teach the parents about introducing a 6-month-old infant to solid foods?
The infant should be offered one new solid food at a time.
A registered nurse is educating a nursing student on the various classifications of torts. What acts are classified as intentional torts in nursing practice? Select all that apply.
battery assault false imprisonment
