fundamentals HESI

A nurse is working within the managed care delivery model. Which of the following is true regarding managed care? a) There are no conflicts between cost-effectiveness and respectful care. b) Their values are not reflected in the decision making. c) All plans have the same values underlying the delivery of care. d) All systems reflect the values of efficiency and effectiveness.

All systems reflect the values of efficiency and effectiveness. Correct Explanation: All systems in the managed care delivery model reflect the values of efficiency and effectiveness. Different plans may have different values underlying the delivery of care. However, they all reflect the business plan values of efficiency and effectiveness. Their values are reflected in the decision making and the policy development of the organization. Value conflicts between cost-effectiveness and respectful care may be seen

A client is being discharged after abdominal surgery and colostomy formation to treat colon cancer. Which nursing action is most likely to promote continuity of care? a) Advocating for the client by ordering Meals on Wheels 5 days a week b) Notifying the American Cancer Society (Canadian Cancer Society) of the client's diagnosis c) Asking the physician to write an order for home skilled nursing assessments and interventions d) Asking an occupational therapist to evaluate the client at home

Asking the physician to write an order for home skilled nursing assessments and interventions Correct Explanation: Many clients are discharged from acute care settings so quickly that they don't receive complete instructions. Therefore, the first priority is to arrange for home health care. The American Cancer Society (Canadian Cancer Society) often sponsors support groups, which are helpful when the person is ready. However, contacting this organization would break client confidentiality, and even with the client's consent does not take precedence over ensuring proper home health care. Advocating for Meals On Wheels and asking for an occupational therapy evaluation are important, but these actions can occur later in rehabilitation.

A nurse has been teaching a client about a high-protein diet. The teaching is successful if the client identifies which meal as high in protein? a) Chicken cutlet, spinach, and soda b) Baked beans, hamburger, and milk c) Bouillon, spinach, and soda d) Spaghetti with cream sauce, broccoli, and tea

Baked beans, hamburger, and milk Correct Explanation: Beans, hamburger, and milk are all excellent sources of protein. The spaghetti-broccoli-tea choice is high in carbohydrates. The bouillon-spinach-soda choice provides liquid and sodium as well as some iron, vitamins, and carbohydrates. Chicken provides protein but the chicken-spinach-soda combination provides less protein than the beans-hamburger-milk selection

Before assisting a client to ambulate after surgery, the nurse helps the client to dangle the feet over the side of the bed. Which action will best prepare the client to dangle the feet over the side of the bed? a) Position the client on his or her side for 5 minutes. b) Administer a prescribed analgesic 10 minutes prior to getting out of bed. c) Have the client flex and extend the feet while in a recumbent position. d) Place the client in a high Fowler's position.

Place the client in a high Fowler's position. Correct Explanation: Many clients feel faint and weak when helped to ambulate for the first time after surgery. The client's circulatory system needs time to adjust to an upright position before the client is helped to a standing position. This is best done by placing the client in high Fowler's position in bed for a few minutes. After becoming accustomed to a sitting position, the client can then be helped to dangle the feet at the edge of the bed before ambulating. Although analgesics can promote comfort for the postoperative client, some can sedate the client and should not be given at the time the client is assisted out of bed. Having the client lie on the side of the bed or do leg exercises will not prepare the client to dangle the legs.

Nurses' observance of professional rituals helps standardize practice and ensure efficiency. Which of the following is a characteristic of rituals? a) Preconceived and untested beliefs about people. b) Viewing one's own culture as the only correct standard. c) Common and observable expressions of culture. d) Belief system held to varying degrees as absolute truth.

Common and observable expressions of culture. Correct Explanation: Rituals are common and observable expressions of culture. A preconceived and untested belief about people is called a stereotype. Viewing one's own culture as the only correct standard is ethnocentrism. A belief system held to varying degrees as absolute truth is referred to as culture.

A nurse is required to irrigate a client's nasogastric tube, a procedure the nurse has not performed before. What is the most appropriate action by the nurse? a) Irrigate the nasogastric tube by following the steps outlined in the procedure manual. b) Contact the nurse educator for an in-service and support in performing the skill. c) Ask another nurse to irrigate the nasogastric tube for him/her each time it is required. d) Refuse the assignment because he/she has never irrigated a nasogastric tube.

Contact the nurse educator for an in-service and support in performing the skill. Correct Explanation: The nurse has a responsibility for recognizing his/her limitations and to seek assistance when necessary. Because the nurse has not performed this skill previously, the nurse educator is the appropriate person to provide inservice and support so the client receives safe and competent care. The other options are incorrect because they do not demonstrate expected behavior for a nurse who has identified a gap in his/her learning or expertise.

After a thoracotomy, the nurse instructs the client to perform deep-breathing exercises. What is an expected outcome of these exercises? a) The elevated diaphragm enlarges the thorax and increases the lung surface available for gas exchange. b) There is increased blood flow to the lungs to allow them to recover from the trauma of surgery. c) The rate of air flow to the remaining lobe is controlled so that it will not become hyperinflated. d) The alveoli expand and increase the lung surface available for ventilation.

Deep breathing helps prevent microatelectasis and pneumonitis and also helps force air and fluid out of the pleural space into the chest tubes. More than half of the ventilatory process is accomplished by the rise and fall of the diaphragm. The diaphragm is the major muscle of respiration; deep breathing causes it to descend, not elevate, thereby increasing the ventilating surface. Deep breathing increases blood flow to the lungs; however, the primary reason for deep breathing is to expand alveoli and prevent atelectasis. The remaining lobe naturally hyperinflates to fill the space created by the resected lobe. This is an expected phenomenon

For the past 24 hours, a client with dry skin and dry mucous membranes has had a urine output of 600 ml and a fluid intake of 800 ml. The client's urine is dark amber. These assessments indicate which nursing diagnosis? a) Deficient fluid volume b) Excess fluid volume c) Impaired urinary elimination d) Imbalanced nutrition: Less than body requirements

Deficient fluid volume Correct Explanation: Dark, concentrated urine, dry mucous membranes, and a urine output of less than 30 ml/hour (720 ml/24 hours) are symptoms of dehydration or Deficient fluid volume. Decreased urine output is related to deficient fluid volume, not Impaired urinary elimination. Nothing in the scenario suggests a nutritional problem. If a fluid volume excess were present, manifestations would most likely include signs of fluid overload such as edema

For the past 24 hours, a client with dry skin and dry mucous membranes has had a urine output of 600 ml and a fluid intake of 800 ml. The client's urine is dark amber. These assessments indicate which nursing diagnosis? a) Excess fluid volume b) Impaired urinary elimination c) Deficient fluid volume d) Imbalanced nutrition: Less than body requirements

Deficient fluid volume Correct Explanation: Dark, concentrated urine, dry mucous membranes, and a urine output of less than 30 ml/hour (720 ml/24 hours) are symptoms of dehydration or Deficient fluid volume. Decreased urine output is related to deficient fluid volume, not Impaired urinary elimination. Nothing in the scenario suggests a nutritional problem. If a fluid volume excess were present, manifestations would most likely include signs of fluid overload such as edema

A nurse is faxing client information to a nursing home. Which action should the nurse take to maintain client confidentiality? a) Reading all information to the client before faxing b) Obtaining a written order from the client's primary physician to fax the information c) Making sure the client's name and date of birth are displayed on the fax cover sheet d) Determining that the client has authorized release of the information

Determining that the client has authorized release of the information Correct Explanation: A nurse must obtain client authorization before sending any confidential information to a nursing home or other facility. A client's name and other protected information should never appear on a fax cover sheet. It isn't necessary to read the information to the client before sending it. A physician's order doesn't give a nurse the right to send confidential information without the client's permission

A nurse-manager appropriately behaves as an autocrat in which situation? a) Identifying the strengths and weaknesses of a client-education video b) Directing staff activities if a client experiences a cardiac arrest c) Evaluating a new medication-administration process d) Planning vacation time for staff

Directing staff activities if a client experiences a cardiac arrest Correct Explanation: In a crisis situation, the nurse-manager should take command for the benefit of the client. Planning vacation time and evaluating procedures and client resources require staff input and are actions characteristic of a democratic or participative manager.

A client with cancer-related pain has been prescribed a narcotic analgesic to be given around the clock. The client is competent and has been actively involved in decisions regarding care. What should the nurse do if the client refuses the next dose of analgesia? a) Ask the client's spouse wife to hold the client's hands while the nurse puts the pill under the tongue. b) Emphasize the rationale for taking the medication now as ordered. c) Try to persuade the client to take the medication as ordered by the doctor. d) Document the client's choice and re-assess pain in 1 hour.

Document the client's choice and re-assess pain in 1 hour. Correct Explanation: A client has the right to choose whether to take medication. The nurse should assess the client's pain regularly and educate the client that taking the medication before the pain gets out of control will be a better pain management plan. The other options do not reflect an understanding of the client's right to choice including the refusal of pain medication.

The client has been prescribed vaginal cream for a yeast infection to be administered via a vaginal applicator. In which position would the nurse instruct the client to take for appropriate administration? a) Low Fowler's position b) Supine position c) Sim's position d) Dorsal recumbent position

Dorsal recumbent position Explanation: The dorsal recumbent position (supine with the hips and knees bent) allows easy access to the vaginal orifice and proper placement for the medication. The other positions do not allow access to the vaginal orifice as the legs are closed.

A nurse is teaching the parents of a child with cystic fibrosis about proper nutrition. Which instruction should the nurse include? a) Encourage foods high in vitamin B. b) Encourage a high-calorie, high-protein diet. c) Limit salt intake to 2 g per day. d) Restrict fluids to 1,500 ml per day.

Encourage a high-calorie, high-protein diet. Correct Explanation: The child should be encouraged to eat a high-calorie, high-protein diet. In cystic fibrosis, the pancreatic enzymes (lipase, trypsin, and amylase) become so thick that they plug the ducts. In the absence of these enzymes, the duodenum can't digest fat, protein, and some sugars; therefore, the child can become malnourished. A child with cystic fibrosis needs to drink plenty of fluid and take salt supplements, especially on warm days or when exercising, to help maintain hydration and adequate sodium levels. Water-soluble forms of the fat-soluble vitamins (A, D, E, and K) are essential

A client hospitalized with pneumonia has thick, tenacious secretions. Which intervention should the nurse include when planning this client's care? a) Turning the client every 2 hours b) Maintaining a cool room temperature c) Encouraging increased fluid intake d) Elevating the head of the bed 30 degrees

Encouraging increased fluid intake Correct Explanation: Increasing the client's intake of oral or I.V. fluids helps liquefy thick, tenacious secretions and ensures adequate hydration. Turning the client every 2 hours would help prevent pressure ulcers but wouldn't help with the secretions. Elevating the head of the bed would reduce pressure on the diaphragm and ease breathing but wouldn't help the client with secretions. Maintaining a cool room temperature wouldn't help the client with secretions

Which would be most helpful when coaching a client to stop smoking? a) Review the negative effects of smoking on the body. b) Explain how smoking worsens high blood pressure. c) Discuss the effects of passive smoking on environmental pollution. d) Establish the client's daily smoking pattern.

Establish the client's daily smoking pattern. Correct Explanation: A plan to reduce or stop smoking begins with establishing the client's personal daily smoking pattern and activities associated with smoking. It is important that the client understands the associated health and environmental risks, but this knowledge has not been shown to help clients change their smoking behavior.

There is a predominant pattern of variations that occur during the male sexual response. Which of the following occurs during the orgasm phase? a) Expulsive contractions of the urethra. b) Rapid loss of vasocongestion. c) Thickening of the the scrotal skin. d) Thickening of the penis at the coronal ridge.

Expulsive contractions of the urethra. Correct Explanation: Expulsive contractions of the entire length of the urethra occur during orgasm. Rapid loss of vasocongestion is seen in the resolution phase, which is the fourth and final phase immediately after orgasm. Thickening of the scrotal skin occurs during the excitement phase. During the plateau phase, the penis circumference at the coronal ridge thickens

Two days after a right total knee replacement, a client rates his right-knee pain as 9 on a 10-point pain scale. A physician orders hydrocodone/APAP 1 tablet by mouth every 4 to 6 hours as needed for pain. When a nurse notifies the physician of the client's pain, the physician states that one hydrocodone/APAP tablet should be sufficient and refuses to order anything stronger for pain. Which measure should the nurse select to act as an advocate for the client? a) Give the client 2 hydrocodone/APAP tablets every 4 hours. b) Give the client 1 hydrocodone/APAP tablet every 3 hours. c) Document that the physician was notified of the client's pain and continue to administer hydrocodone/APAP as ordered. d) Follow the chain of command to obtain adequate pain relief for the client.

Follow the chain of command to obtain adequate pain relief for the client. Correct Explanation: Clients must receive adequate pain relief. Allowing a client to experience a pain score of 9 out of 10 is unacceptable nursing practice. Acting as a client advocate requires a nurse to be assertive, even if this means confronting a physician. If the physician doesn't give an order for adequate pain relief, the nurse should follow the chain of command to report the physician's inaction and obtain adequate pain relief for the client. A nurse may not adjust medication frequency or dosage without a physician's order.

A nurse is reluctant to provide care at an accident scene. Which of the following legal definitions is true regarding the provision of nursing care? a) Scope of practice involves general guidelines that define nursing. b) Malpractice is failure to perform professional duties that result in client injury. c) Good Samaritan laws are designed to protect the caregiver in emergency situations. d) Negligence is intentional failure to act responsibly or deliberate omission of a professional act.

Good Samaritan laws are designed to protect the caregiver in emergency situations. Explanation: Good Samaritan laws are designed to protect the caregiver in emergency situations. If the nurse stopped to provide care, legally there is protection. Failure to stop would constitute an issue. Malpractice involves the failure to perform professional duties; it may involve omissions of important care measures or performing care measures that are not appropriate in the situation. Negligence is failure to act professionally. Scope of practice includes specific guidelines of professional conduct

The nurse is preparing for the admission of a client on a stretcher. In what position should the nurse place the bed? a) High Fowler's position. b) Highest position. c) Middle position. d) Lowest position.

Highest position. Explanation: The nurse would place the bed in the highest position if the client will arrive on a stretcher. For ambulatory clients, the bed should be in the lowest position. The High Fowler's position is often used for clients with respiratory difficulties.

What would be an appropriate action for the nurse prior to performing deep tracheal suctioning due to increased secretions? a) Apply negative pressure as the catheter is being inserted. b) Hyperoxygenate the client before suctioning. c) Deflate the cuff of the tracheotomy during suctioning. d) Instill acetylcysteine into the tracheotomy before suctioning.

Hyperoxygenate the client before suctioning. Correct Explanation: Preoxygenation and deep breathing assist in reducing suction-induced hypoxemia because it decreases the risk of atelectasis caused by negative pressure of suctioning. Deflating the cuff is not necessary and there is no reason to instill acetylcysteine into the tracheotomy before suctioning. Pressure is applied only with the removal of the catheter

The selection of a nursing care delivery system (NCDS) is critical to the success of client care in a nursing area. Which factor is essential to the evaluation of an NCDS? a) Identifying salary ranges for various types of staff b) Identifying who will be responsible for making client care decisions c) Deciding what type of dress code will be implemented d) Determining how planned absences, such as vacation time, will be scheduled so that all staff are treated fairly

Identifying who will be responsible for making client care decisions Explanation: Determining who has responsibility for making decisions regarding client care is an essential element of all client care delivery systems. Dress code, salary, and scheduling planned staff absences are important to any organizations, but they are not actually determined by the NCDS

The nurse works in an institution that expects nurses to initiate referrals to social or spiritual resources. What might trigger a nurse to initiate such a referral? Select all that apply. a) A client expressing a cultural concern. b) Impending death. c) A client requesting occupational therapy. d) A client requesting time alone. e) Family conferences

Impending death. • Family conferences. • A client expressing a cultural concern. Explanation: Results that might trigger a consult include clients and families expressing social, cultural, or spiritual concerns; death; receiving a terminal diagnosis; comfort care; family conferences; and crisis. A client requesting time alone or occupational therapy would not usually trigger a social or spiritual referral.

A client has a wound with a drain. When performing wound cleansing around the drain, the nurse should cleanse in which direction? a) Laterally, from one side of the wound to the opposite side b) Laterally, from the distal area to the center c) From the superior portion of the wound to the inferior d) In a widening circle around the drain, outward from the center

In a widening circle around the drain, outward from the center Correct Explanation: When cleaning the area around the drain, the nurse should wipe in a circle around the drain, working from the center outward. The nurse wipes laterally, from the center to the opposite side, when cleaning a large horizontal wound and wipes from the superior portion of the wound to the inferior when cleaning a vertical incision. Cleaning the wound laterally from the distal area to the center increases the client's risk for infection

Which strategy can help make the nurse a more effective teacher? a) Using technical terms b) Including the client in the discussion c) Providing detailed explanations d) Using loosely structured teaching sessions

Including the client in the discussion Correct Explanation: An effective teacher always involves the client in the discussion. Using technical terms and providing detailed explanations usually confuse the client and act as barriers to learning. Using loosely structured teaching sessions permits distractions and deviations from teaching goals.

The nurse is planning care for a client with a Cantor tube. Which nursing measures should be included in the care plan? Select all that apply. a) Inject 10 mL of air into the tube to facilitate drainage. b) Coil extra tubing on the client's bed. c) Apply a water-soluble lubricant to the client's nares. d) Irrigate the tube with 50 mL of normal saline solution every 8 hours. e) Provide mouth care as needed.

Inject 10 mL of air into the tube to facilitate drainage. • Apply a water-soluble lubricant to the client's nares. • Coil extra tubing on the client's bed. • Provide mouth care as needed. Explanation: The nurse should provide mouth care as needed and apply a water-soluble lubricant to the nares. Extra tubing can be coiled to prevent kinking. The tube can be injected with air. Intestinal tubes are not irrigated.

A client has a cast applied to the left leg after sustaining a femur fracture during a skiing accident. Which interventions would the nurse provide to avoid complications from the cast application? Select all that apply. a) Bivalving the cast on both sides. b) Maintain the leg elevated above the level of the heart. c) Monitor distal pulses of the affected extremity d) Apply warm compresses to the casted leg. e) Administer anticoagulation per healthcare provider's order.

Monitor distal pulses of the affected extremity • Maintain the leg elevated above the level of the heart. • Administer anticoagulation per healthcare provider's order. Explanation: The nurse would monitor the tightness of the cast by assessing the distal pulses and tightness of the cast. Edema can cause the cast to become tight and lead to compartment syndrome. Unless contraindicated, the leg would be elevated above the heart in order to increase venous return and decrease edema. Prophylactic anticoagulation will decrease the risk of clot formation. The nurse would apply cool compresses not warm. It is not within the nurse's scope of practice to cut the cast or bivalve the cast.

A nurse is caring for a child with celiac disease. How should the nurse evaluate the effectiveness of nutritional therapy? a) Monitor vital signs every 4 hours. b) Measure blood urea nitrogen and serum creatinine levels. c) Measure intake and output. d) Monitor the appearance, size, and number of stools.

Monitor the appearance, size, and number of stools. Explanation: A gluten-free diet should eliminate fat, bulky, foul-smelling stools in a child with celiac disease. This finding indicates that the disease is controlled and the child is using nutrients effectively. Taking vital signs, measuring blood urea nitrogen and serum creatinine levels, and measuring intake and output don't indicate the effectiveness of nutritional therapy

Which nursing intervention is appropriate for a client with an arm restraint? a) Positioning the restrained arm in full extension b) Tying the restraint to the side rail c) Monitoring circulatory status every 2 hours d) Applying the restraint loosely to prevent pressure on the skin

Monitoring circulatory status every 2 hours Correct Explanation: A nurse must assess the circulatory status of a restrained extremity every 2 hours to prevent circulatory impairment. To make sure the restraint is secure without compromising the circulation, the nurse should leave approximately one fingerbreadth between the restraint and the extremity. Tying a restraint to the side rail or an immovable bed part may cause client injury if the rail or bed is moved before the restraint is released. The restrained arm or leg should be flexed slightly to allow joint movement without reducing the effectiveness of the restraint.

When assessing if a procedural risk to a client is justified, the ethical principle underlying the dilemma is known as which of the following? a) Informed consent b) Pro-choice c) Nonmaleficence d) Self-determination

Nonmaleficence Explanation: Nonmaleficence is the principle of creating no harm. It refers to preventing or minimizing harm to an individual. The other options do not represent the situation presented in the question

A physician orders supplemental oxygen for a client with a respiratory problem. Which oxygen delivery device should the nurse use to provide the highest possible oxygen concentration? a) Simple mask b) Nasal cannula c) Nonrebreather mask d) Venturi mask

Nonrebreather mask Explanation: A nonrebreather mask provides the highest possible oxygen concentration — up to 95%. A nasal cannula doesn't deliver concentrations above 40%. A Venturi mask delivers precise concentrations of 24% to 44%, regardless of the client's respiratory pattern, because the same amount of room air always enters the mask opening. A simple mask delivers 2 to 10 L/minute of oxygen in uncontrollable concentrations.

A client with a subdural hematoma needs a feeding tube inserted due to inadequate swallowing ability. How would the nurse best explain this to the family? a) Demonstrate to the family that pureed foods or liquids result in coughing. This signifies the importance of the need for a feeding tube. b) Nutrients are needed; however, eating and drinking without control of the swallowing reflex can result in aspirational pneumonia. c) Because of limited mobility, the client is susceptible to developing pneumonia. Extra nutrients are necessary to strengthen the immune system and promote recovery. d) Tube feedings are less invasive than total parenteral nutrition; either one can meet hydration and nutritional needs.

Nutrients are needed; however, eating and drinking without control of the swallowing reflex can result in aspirational pneumonia. Correct Explanation: A swallowing assessment will test whether there is complete closure of the epiglottis during swallowing. Incomplete closure indicates that there is not protection of the trachea during oral ingestion of food or fluids. This will necessitate insertion of a nasogastric tube and initiating tube feedings. Tube feedings are less invasive, but this does not answer the underlying basis for insertion of the feeding tube. Demonstrating to the family that the client will choke presents a hazard and is inappropriate when swallowing impairment has been diagnosed. Limited mobility and being susceptible to pneumonia does not answer the underlying reason for the feeding tube.

Which of the following is the recommended nursing assessment to confirm placement of the nasogastric (NG) tube into the stomach of a client? a) NG tube length is equal to the distance from the client's ear lobe to the nose, plus the distance from the nose to the tip of the xiphoid process; this will confirm correct placement. b) Obtain a chest X-ray and measure the pH of stomach contents. c) Measure to the second or third black marking on the NG tube. d) Apply the stethoscope to the xiphoid process and instill 50 mL of air into the tube and listen for a gurgling or popping sound.

Obtain a chest X-ray and measure the pH of stomach contents. Correct Explanation: A chest X-ray and pH that shows acidity are the only definitive diagnostic tools to confirm placement. The other choices are not best practice. Measuring the tube or using makings do not confirm placement, only approximate distance for insertion

Which assessment is most supportive of the nursing diagnosis, impaired skin integrity related to purulent inflammation of dermal layers as evidenced by purulent drainage and erythema? a) A heart rate of 88 beats/minute b) Dry and intact wound dressing c) Oral temperature of 101° F (38.3° C) d) Wound healing by primary intention

Oral temperature of 101° F (38.3° C) Correct Explanation: The nursing diagnosis indicates that the client's wound, which has purulent drainage, is infected. In response to the infection, the client's temperature would be elevated. A heart rate of 88 beats/minute, healing by primary intention, and a dry, intact dressing demonstrate normal assessment findings

A client returned from surgery eight hours ago and has not voided. Which action should the nurse take first? a) Catheterize the client with a straight catheter. b) Call the physician to report the client's condition. c) Palpate over the synthesis pubis for fullness. d) Tell the client to bear down and try to void.

Palpate over the synthesis pubis for fullness. Explanation: Before taking any action, the nurse must palpate over the client's synthesis pubis. If the client's is retaining urine there will be fullness over the bladder. Urine retention is a common adverse effect of anesthesia. After confirming retention, the nurse should call the physician and expect an order to catheterize the client. Telling the client to bear down and try to void is inappropriate

What should the nurse do to prevent pressure ulcers in an older adult? a) Clean the skin daily using mild soap and hot water. b) Encourage the client to sit in a chair as much as possible. c) Perform a systematic skin assessment at least once a day. d) Massage bony prominences gently every shift.

Perform a systematic skin assessment at least once a day. Correct Explanation: Daily skin inspection is essential in preventing pressure ulcers. Hot water is irritating to skin and should be avoided. Massaging bony prominences is contraindicated and may actually promote skin breakdown. Prolonged, uninterrupted chair sitting should be avoided; the client's position should be adjusted at least every hour.

Bacterial conjunctivitis has affected several children at a local day care center. A nurse should advise which measure to minimize the risk of infection? a) Perform thorough hand washing before and after touching any child in the day care center. b) Restrict the infected children from returning for 48 hours after treatment. c) Close the day care center for 1 week to control the outbreak. d) Set up a conference with the parents of each child to explain the situation carefully

Perform thorough hand washing before and after touching any child in the day care center. Correct Explanation: Bacterial conjunctivitis is very contagious. Attention should be paid to thorough hand washing, a major means of stopping the transmission of the disease. Closing the day care center for 1 week is not necessary because thorough hand washing will stop the spread of the infection. Keeping the children out for 48 hours is not necessary. A child may return to day care after being treated for 24 hours. Although the parents of each child should be told about the outbreak, doing so will not help to curtail or prevent the spread of the infection

Bacterial conjunctivitis has affected several children at a local day care center. A nurse should advise which measure to minimize the risk of infection? a) Set up a conference with the parents of each child to explain the situation carefully. b) Restrict the infected children from returning for 48 hours after treatment. c) Close the day care center for 1 week to control the outbreak. d) Perform thorough hand washing before and after touching any child in the day care center.

Perform thorough hand washing before and after touching any child in the day care center. Correct Explanation: Bacterial conjunctivitis is very contagious. Attention should be paid to thorough hand washing, a major means of stopping the transmission of the disease. Closing the day care center for 1 week is not necessary because thorough hand washing will stop the spread of the infection. Keeping the children out for 48 hours is not necessary. A child may return to day care after being treated for 24 hours. Although the parents of each child should be told about the outbreak, doing so will not help to curtail or prevent the spread of the infection

Which task should a nurse choose to delegate to a nursing assistant? Select all that apply. a) Documenting a client's oral intake b) Taking a client's vital signs c) Evaluating a client's response to a blood pressure medication d) Assessing a client's pain e) Performing a blood glucose check

Performing a blood glucose check • Documenting a client's oral intake • Taking a client's vital signs Correct Explanation: Registered nurses are responsible for all phases of the nursing process. These responsibilities include assessing a client's pain and evaluating a client's response to treatment. A nurse may delegate tasks such as taking vital signs, documenting intake and output, and performing blood glucose checks if she follows the five rights of delegation. The five rights of delegation include: right task (the task is within the delegate's scope of practice), right person (the person is competent to perform the task), right communication (the nurse gives the right directions to complete the task), right feedback (the nurse works collaboratively with the delegate), and right follow-up (the nurse follows-up on the task after it has been completed)

A nurse reports to the hospital occupational health nurse (OHN) that he/she was splashed with blood during the resuscitation of an HIV-positive client. The nurse asks the OHN when he/she will know whether he/she is positive or negative for HIV infection. Which of the following is the most appropriate response by the OHN? a) "The test results will vary during the first year of testing for the disease." b) "We will test you in 4 weeks, and then we will have a definitive answer." c) "Accurate results will be obtained by testing at 3 months and again at 6 months." d) "Most nurses who have been splashed do not test positive if they wash immediately."

"Accurate results will be obtained by testing at 3 months and again at 6 months." Correct Explanation: Ninety-five percent of exposed individuals will seroconvert within 3 months; 99% will convert by 6 months. The other options do not accurately reflect the timeline for seroconversion following exposure.

A client asks the nurse how frequently she should have a mammogram. The nurse assesses that there is no family history of breast cancer and no risk factors with this particular client. Which statement, if made by the client, shows an understanding of the nurse's teaching regarding the frequency of mammograms? a) "I should have a mammogram twice yearly until age 50, then only yearly." b) "I should have a mammogram every year beginning at age 40." c) "I should have a mammogram once a year at age 40, then annually." d) "I should have a mammogram only if I find a lump after self-breast examination."

"I should have a mammogram every year beginning at age 40." Explanation: Yearly mammograms should begin at age 40 and continue for as long as the woman is in good health. If health risks exist, such as family history, genetic tendency, or past breast cancer, more frequent examinations may be necessary.

A client with severe chest pain is brought to the emergency department. The client tells the nurse, "I just have a little indigestion." How should the nurse respond? a) "How will having chest pain change your life?" b) "Are you confused? You are having a heart attack." c) "We tried an antacid and it did not work. It is not indigestion." d) "You seem concerned about your chest pain."

"You seem concerned about your chest pain." Correct Explanation: During a crisis, it's common for a client to use denial, a coping mechanism exhibited by minimizing symptoms or avoiding discussion. The nurse must respond therapeutically to the client. Confrontation about the client's statement and asking the client if he/she is confused are not therapeutic. Asking how having chest pain will change the client's life is not appropriate in this acute phase

A nurse-manager of an intensive care unit (ICU) can't be held legally responsible in a court of law for which action performed by the unit's staff? a) A staff nurse fills a client prescription at the hospital pharmacy because the pharmacist on duty is busy. b) A nursing assistant attempts to initiate I.V. therapy. c) A staff nurse refuses to follow a physician's order to administer medication because administering the dosage ordered could seriously harm the client. d) A nursing assistant administers medications to a client in ICU.

A staff nurse refuses to follow a physician's order to administer medication because administering the dosage ordered could seriously harm the client. Correct Explanation: The nurse-manager is legally responsible for actions that fall within the scope of practice of the staff members who perform them. A nurse may not knowingly administer or perform tasks that will harm a client. It's within a nurse's scope of practice to refuse to carry out such orders. A nurse-manager can't be held legally responsible for the nurse's refusal in this situation. Administering medications and initiating I.V. therapy aren't within the scope of practice for nursing assistants, and a staff nurse isn't licensed to fill prescriptions.The nurse-manager can be held legally responsible for these actions

A nurse is performing an admission assessment on a client newly admitted to the hospital and has documented the client as being a member of the Native American subculture. A subculture is best described as which of the following? a) A cultural group with fewer than 5 million members in the United States. b) A unique cultural group that exists within the larger culture. c) A cultural group with values that are incongruent with those of the dominant culture. d) A unique cultural group with unspecified geographic origins.

A unique cultural group that exists within the larger culture. Correct Explanation: Subcultures are unique cultural groups that coexist within the dominant culture of the United States. Subcultures are not defined according to the size of their membership or the lack of specific geographic origins. Subcultures may have some values that differ from those of the dominant culture, but this is not their defining characteristic.

A nurse manager observes bruises in the shape of finger marks around the elbows of an elderly, immobile client. The nurse should next: a) Document the bruising and continue to assess the area over the next 72 hours. b) Report this finding to the physician. c) Report this finding to the Adult Protective Services (APS). d) Report this finding to the nurse who is taking care of the client.

Report this finding to the Adult Protective Services (APS). Explanation: Elderly clients are vulnerable to abuse. Bruising that is not located in areas typical for falls or bumps should be reported to the APS. The location and shape of this bruise are suggestive of abuse. The nurse taking care of this client and the physician should be alerted to the bruises after the APS is notified. The nurse should continue to assess the areas involved after notifying the APS

The nurse is caring for a client with a nasogastric tube who is receiving intermittent tube feedings by gravity every 4 hours. The nurse aspirates 75 mL of residual prior to the next feeding. What action should the nurse take next? a) Discard the residual, and subtract the residual amount from the feeding. b) Administer an amount of water equivalent to the feeding. c) Hold the feeding, and recheck the residual in 4 hours. d) Return the residual and begin the feeding.

Return the residual and begin the feeding. Explanation: The amount of residual is within normal limits, and the client should have the feeding started. The residual should be returned to help prevent electrolyte imbalances. The other options do not ensure adequate nutritional management for the client`

Which is the correct technique when the nurse is applying an elastic bandage to a leg? a) Increase tension with each successive turn of the bandage. b) Secure the bandage with clips over the area of the inner thigh. c) Overlap each layer twice when wrapping. d) Start at the distal end of the extremity and move toward the trunk.

Start at the distal end of the extremity and move toward the trunk. Correct Explanation: When applying an elastic bandage to a leg, start at the distal end and move toward the trunk in order to support venous return. Tension should be kept even and not increased with each turn to prevent circulatory impairment. Overlapping each layer twice when wrapping can also impair circulation. The clips securing the bandage should be placed on the outer aspect of the leg to avoid creating a pressure point on the other leg.

A client complains of abdominal discomfort and nausea while receiving tube feedings. Which intervention is most appropriate for this problem? a) Change the feeding container daily. b) Place the client in semi-Fowler's position while feeding. c) Give the feedings at room temperature. d) Stop the feedings and check for residual volume.

Stop the feedings and check for residual volume. Correct Explanation: Complaints of abdominal discomfort and nausea are common in clients receiving tube feedings. Stopping the feeding and checking for residual volume helps assess the reason for the client's nausea and discomfort. If residual volume is greater than 100 ml, hold the feeding and notify the physician. Feedings are normally given at room temperature to minimize abdominal cramping; however, this action doesn't help assess why nausea and discomfort are occurring. Elevating the head of the client's bed to at least 30 degrees prevents aspiration during feeding. Also, feeding containers are changed daily to prevent bacterial growth

A client involved in a motor vehicle accident is admitted to the intensive care unit. The emergency department admission record indicates that the client hit her head on the steering wheel. The client complains of a headache, and a nursing assessment reveals that she has difficulty comprehending language and diminished hearing. Based on these findings, the nurse suspects injury to which lobe of the brain? a) Occipital b) Frontal c) Temporal d) Parietal

Temporal Correct Explanation: The temporal lobe controls hearing, language comprehension, and storage and recall memory. The frontal lobe influences personality, judgment, abstract reasoning, social behavior, language expression, and movement. The occipital lobe functions primarily in interpreting visual stimuli. The parietal lobe interprets and integrates sensations, including pain, temperature, and touch.

The nurse is planning care with the parents of a child who requires continuous peritoneal dialysis. Which finding should be discussed with the health care provider (HCP)? a) The child reports having a previous surgery for a ruptured appendix. b) The family lives a long distance from the medical facility. c) The family feels the child cannot self-regulate to wake at night and change bags. d) The child attends a large public school.

The child reports having a previous surgery for a ruptured appendix. Explanation: A client who has had a ruptured appendix may have peritoneal scarring that may alter the effectiveness of treatment. Living a long distance from a medical facility is typically a reason to select peritoneal dialysis. Attending a large school is not a problem, but the school nurse needs to be included as part of the health care team. Typically the treatment schedule can be planned to allow for uninterrupted sleep at night.

The nurse notes that which statement concerning informed consent is true? a) Mentally incompetent clients may legally give informed consent only if they are hospitalized under a mental health regulatory law. b) The client must be fully informed regarding treatment, tests, alternative treatments, and the risks and benefits of each. c) The professional nurse and physician must each obtain informed consent because the practice of medicine and of nursing are two distinct entities. d) Minors may give informed consent to all medical and nursing procedures without consent of the parent(s).

The client must be fully informed regarding treatment, tests, alternative treatments, and the risks and benefits of each. Correct Explanation: Before giving informed consent, the physician performing the procedure must tell the client about the treatment, tests, alternative treatments, and the risks and benefits of each. A professional nurse involved in the informed consent process witnesses the consent and doesn't actually obtain the consent. The physician is responsible for obtaining consent. Only a minor who is married or emancipated may give informed consent. A client must be mentally competent to legally give informed consent for procedures

A nurse is providing home care to a client with a foot ulcer related to diabetes. The client needs daily insulin injections. Family caregivers do not possess the technical skills to inject insulin. Which of the following should the nurse keep in mind? a) The current reimbursement system recognizes the family's nontechnical value priorities. b) Family caregivers are always perceived to be supportive of good care. c) Nurses should avoid asking the family caregivers to conduct the skilled task. d) The nurse needs to be creative in integrating the technical and relational aspects of care.

The nurse needs to be creative in integrating the technical and relational aspects of care. Explanation: The nurse needs to be creative in integrating the technical and relational aspects of care. The current reimbursement system does not recognize the family's nontechnical value priorities. Nurses are expected to educate the family caregivers to conduct the skilled task where possible. In this case, the nurse can teach the family caregivers to inject insulin. Family caregivers can be perceived to be nonsupportive of good care if the families do not follow through.

When teaching the client to care for an ileal conduit, the nurse instructs the client to empty the appliance frequently. Which outcome indicates that the client is following instructions? a) The skin around the stoma is red. b) The seal around the stoma is intact. c) There is no odor present. d) The urine is a deep yellow.

The seal around the stoma is intact. Correct Explanation: If the appliance becomes too full, it is likely to pull away from the skin completely or to leak urine onto the skin; thus if the seal is intact, the client is emptying the appliance regularly. The skin around the seal should not be red or irritated, which could indicate a leak. There will likely be an odor from the urine. Deep yellow urine indicates that the client should be increasing fluid intake

During a teaching session, a nurse demonstrates to a client how to change a tracheostomy dressing. Then the nurse watches as the client returns the demonstration. Which client action indicates an accurate understanding of the procedure? a) The client rinses around the clean incision site, using gauze squares moistened with tap water. b) The client cleans around the incision site, using gauze squares and full-strength hydrogen peroxide. c) After cleaning around the incision site, the client applies cotton-filled gauze squares as the sterile dressing. d) The client rinses around the clean incision site, using gauze squares moistened with normal saline.

To change a tracheostomy dressing effectively, the client should rinse around the clean incision site, using gauze squares moistened with normal saline. If crusts are difficult to remove, the client may use a solution of 50% hydrogen peroxide and 50% sterile saline — not full-strength hydrogen peroxide. The client shouldn't use tap water, which may contain chemicals and other harmful substances. To prevent lint or fiber aspiration and subsequent tracheal abscess, the client should use sterile dressings made of nonraveling material instead of cotton-filled gauze squares.

A client who's scheduled for open-heart surgery in 2 days has been having circulation problems in the feet and legs. The physician orders antiembolism stockings. The nurse is teaching the client about this treatment. What is the purpose of antiembolism stockings? a) To reduce or prevent edema of the legs and feet b) To maintain warmth in the legs c) To decrease arterial blood circulation to the legs and feet d) To decrease venous blood circulation from the legs and feet

To reduce or prevent edema of the legs and feet Correct Explanation: Made of elastic material, antiembolism stockings are designed to reduce or prevent edema of the legs or feet by promoting venous return. They do this by increasing — not decreasing — arterial and venous blood circulation to the legs and feet. They don't maintain warmth in the legs. Blankets can be used for this purpose.

A client reports for a preoperative appointment in preparation for surgery that will change his body from female to male. The client has expressed to the nurse and physician that she should have been born a man. What identity is the client demonstrating? a) Transsexual. b) Bisexual. c) Transvestite. d) Homosexual.

Transsexual. Explanation: A transsexual is a person of a certain biologic gender who has the feelings of the opposite sex and of being trapped within the body of the wrong sex. For many transsexuals, the solution is to change their bodies. A homosexual experiences sexual fulfillment with a person of the same gender. A bisexual finds pleasure with both opposite-sex and same-sex partners. A transvestite desires to take on the role or wear the clothes of the opposite sex.

The nurse instructs the unlicensed assistive personnel (UAP) on how to provide oral hygiene for clients who cannot perform this task for themselves. Which technique should the nurse ask the UAP to incorporate into the client's daily care? a) Use a soft toothbrush to brush the client's teeth after each meal. b) Swab the client's tongue, gums, and lips with a soft foam applicator every 2 hours. c) Rinse the client's mouth with mouthwash several times a day. d) Assess the oral cavity each time mouth care is given and record observations.

Use a soft toothbrush to brush the client's teeth after each meal. Correct Explanation: A soft toothbrush should be used to brush the client's teeth after every meal and more often as needed. Mechanical cleaning is necessary to maintain oral health, stimulate gingiva, and remove plaque. Assessing the oral cavity and recording observations is the responsibility of the nurse, not the UAP. Swabbing with a safe foam applicator does not provide enough friction to clean the mouth. Mouthwash can be a drying irritant and is not recommended for frequent use.

When caring for a client with a 3-cm stage I pressure ulcer on the coccyx, which action may the nurse institute independently? a) Applying an antibiotic cream to the area three times per day b) Massaging the area with an astringent every 2 hours c) Using a povidone-iodine wash on the ulceration three times per day d) Using normal saline solution to clean the ulcer and applying a protective dressing as necessary

Using normal saline solution to clean the ulcer and applying a protective dressing as necessary Correct Explanation: The nurse may wash the area with normal saline solution and apply a protective dressing. These interventions will protect the area and are within the nurse's scope of practice. A nurse must obtain a physician's order to use a povidone-iodine wash or an antibiotic cream. Massaging with an astringent can further damage the skin

The nurse has completed discharge teaching with new parents who will be bottle-feeding their normal term newborn. Which statement by the parents reflects the need for more teaching? a) "Our baby will require feedings through the night for several weeks or months after birth." b) "The baby should burp during and after each feeding with no projective vomiting." c) "Our baby should have 1 to 3 soft, formed stools a day." d) "We should weigh our baby daily to make sure he is gaining weight."

We should weigh our baby daily to make sure he is gaining weight." Correct Explanation: Healthy infants are weighed during their visits to their health care provider (HCP) , so it is not necessary to monitor weights at home. Infants may require 1 to 3 feedings during the night initially. By 3 months, 90% of babies sleep through the night. Projective vomiting may indicate pyloric stenosis and should not be seen in a normal newborn. Bottle-fed infants may stool 1 to 3 times daily

A nurse is assigned to a client with a cardiac disorder. The nurse should question an order to monitor the client's body temperature by which route? a) Rectal b) Tympanic c) Axillary d) Oral

When caring for a client with a cardiac disorder, the nurse should avoid using the rectal route to take temperature. Using this route could stimulate the vagus nerve, possibly leading to vasodilation and bradycardia. The other options are appropriate routes for measuring the temperature of a client with a cardiac disorder

When providing oral hygiene for an unconscious client, the nurse must perform which action? a) Place the client in a side-lying position. b) Clean the client's tongue with gloved fingers. c) Swab the client's lips, teeth, and gums with lemon glycerin. d) Place the client in semi-Fowler's position.

Place the client in a side-lying position. Correct Explanation: An unconscious client is at risk for aspiration. To decrease this risk, the nurse should place the client in a side-lying position when performing oral hygiene. Swabbing the client's lips, teeth, and gums with lemon glycerin would promote tooth decay. Cleaning an unconscious client's tongue with gloved fingers wouldn't be effective in removing oral secretions or debris. Placing the client in semi-Fowler's position would increase the risk of aspiration

A student nurse requires additional teaching if which of the following factors is identified as contributing to a client's Risk for infection? a) Proper nutrient intake b) Impairment of primary body system defenses c) Chronic disease d) Inadequate secondary defenses

Proper nutrient intake Explanation: Malnutrition, rather than proper nutrient intake, would put the client at risk for infection. Inadequate secondary defenses, impaired primary defenses, and chronic disease put the client at risk by lowering the body's ability to fight infection.

Which action is contraindicated for a client who develops a temperature of 102° F (38.9° C)? a) Monitoring his temperature every 4 hours b) Covering the client with a light blanket c) Increasing fluid intake d) Providing a low-calorie diet

Providing a low-calorie diet Correct Explanation: Because a client with a fever has an increased basal metabolism rate, he needs additional calories in his diet, not fewer calories. Monitoring the client's temperature, increasing his fluid intake, and covering him with a light blanket are therapeutic interventions for a fever

A nurse-manager works for a nonprofit health care corporation whose revenues have significantly exceeded annual expenses. The nurse-manager has been told to anticipate which action? a) Dividing revenue among stockholders as dividends b) Reducing operating expenses to help the organization pay taxes on the revenue c) Identifying revenue as profit d) Receiving a portion of the revenue to improve client services on the unit

Receiving a portion of the revenue to improve client services on the unit Correct Explanation: In a nonprofit organization, revenue exceeding expenses is tax-exempt and is usually reinvested in the organization and used to improve services. A for-profit organization calls revenue in excess of expenses a profit and divides it as a dividend among stockholders or reinvests it in the organization

The client is to receive antibiotic intravenous (IV) therapy in the home. The nurse should develop a teaching plan to ensure that the client and family can manage the IV fluid and infusion correctly and avoid complications. What should the nurse instruct the client to do? Select all that apply. a) Call the health care provider (HCP) for a temperature above 100° F (37.8° C). b) Wear sterile gloves to change the fluids. c) Report signs of redness or inflammation at the site. d) Cleanse the port with alcohol wipes. e) Place the IV bag on a table level with the client's arm.

Report signs of redness or inflammation at the site. • Cleanse the port with alcohol wipes. • Call the health care provider (HCP) for a temperature above 100° F (37.8° C). Correct Explanation: When intravenous (IV) therapy must be administered in the home setting, teaching is essential. Written instructions, as well as demonstration and return demonstration help reinforce key points. The client and/or caregiver is responsible for adhering to the established plan of care that includes the treatment plan, monitoring plan, potential for complications, expected outcome/s, potential adverse effects, and plan for communicating with the HCP. Periodic laboratory testing may be necessary to assess the effects of IV therapy and the client's progress. The client should report signs of redness or inflammation that could indicate infection, and also report an elevated temperature. Prior to changing the fluids, the caregiver should cleanse the port with alcohol wipes. It is not necessary to use sterile gloves; the IV bag should be elevated to promote gravity flow.

A nurse-manager in the office of a group of surgeons has received complaints from discharged clients about inadequate instructions for performing home care. Knowing the importance of good, timely client education, the nurse-manager should take which steps? a) Inform the nurses who work in the facility that client education should be implemented as soon as the client is admitted to either the hospital or the outpatient surgical center. b) Review and revise the way client education is conducted in the surgeons' office. c) Work with the surgeons' staff and the nursing staff in the hospital and outpatient surgical center to evaluate current client education practices and make revisions as needed. d) Because none of the clients suffered any serious damage, the nurse-manager can safely ignore their complaints.

Work with the surgeons' staff and the nursing staff in the hospital and outpatient surgical center to evaluate current client education practices and make revisions as needed. Explanation: Every nurse who provides client care should provide client education. Nurses must work together to establish the best methods of educating clients. The most appropriate response is to contact the facility's nurse-manager, not the nursing staff. Evaluating client education in only the surgeon's office doesn't consider the entire client education process and all of the staff providing it. Client education is an important nursing responsibility and every complaint deserves attention.

The nurse has just received change-of-shift report for four clients. Based on this report, the nurse should assess which client first? a) a 52-year-old with pneumonia and chronic back pain who is requesting pain medication b) a 38-year-old who is 2 days postmastectomy due to breast cancer, having difficulty coping with the diagnosis c) an 84-year-old with resolving left-sided weakness who is slightly confused and has been awake most of the night d) a 35-year-old admitted after motor vehicle accident whose urine output has totaled 30 mL over the last 2 hours

a 35-year-old admitted after motor vehicle accident whose urine output has totaled 30 mL over the last 2 hours Explanation: Urine output should be at least 500 mL in 24 hours (20 mL/h); this client's output has been just 15 mL/h for the past 2 hours requiring further assessment by the nurse. The nurse should first assess all clients and address physiological needs including pain control and safety measures; the nurse should then take time with the client having difficulty coping in order to listen and further determine her needs.

Using the Morse Fall Risk scale (see exhibit), the nurse should initiate highest fall risk precautions for which client? a) an 84-year-old client with diabetes admitted with new-onset confusion who reportedly fell at home last week, is currently on bed rest, and has normal saline infusing per saline lock b) a 48-year-old alert and oriented client with quadriplegia admitted for wound care of a stage IV pressure ulcer, receiving IV antibiotics per a peripherally inserted central catheter c) a 62-year-old client with a history of Parkinson's disease, admitted for pneumonia and receiving IV antibiotics, who has fallen at home but is able to ambulate with a cane and who during his hospitalization has gotten out of bed without calling for assistance d) a 27-year-old client with acute pancreatitis receiving morphine sulfate IV every 2 hours as needed for pain; no significant medical history, smokes two packs of cigarettes per day; may be up independently; and has steady gait

a 62-year-old client with a history of Parkinson's disease, admitted for pneumonia and receiving IV antibiotics, who has fallen at home but is able to ambulate with a cane and who during his hospitalization has gotten out of bed without calling for assistance Explanation: Using the Morse fall scale, risk factors for this client include history of falling, secondary diagnosis, ambulatory aid, IV/heparin lock, weak gait/transfer, and forgetting limitations (100 points). Client no. 1 is also high risk with a secondary diagnosis, history of falling, IV access, and confusion but is on bed rest (75 points). Client no. 2 risks include IV access and secondary diagnosis (35 points). Client no. 4 is at risk due to his IV access only (20 points)

A nurse is caring for a client who required chest tube insertion for a pneumothorax. To assess for pneumothorax resolution, the nurse can anticipate that the client will require: a) monitoring of arterial oxygen saturation (SaO2). b) arterial blood gas (ABG) studies. c) chest auscultation. d) a chest X-ray.

a chest X-ray. Explanation: Chest X-ray confirms diagnosis by revealing air or fluid in the pleural space. SaO2 values may initially decrease with a pneumothorax but typically return to normal within 24 hours. ABG studies may show hypoxemia, possibly with respiratory acidosis and hypercapnia but these are not necessarily related to a pneumothorax. Chest auscultation will determine overall lung status, but it's difficult to determine if the chest has reexpanded sufficiently

A 16-year-old primiparous client has decided to place her baby for adoption. The adoptive parents are on their way to the hospital when the mother says, "I want to see the baby one last time." The nurse should: a) tell the client that it would be best if she did not see the baby. b) allow the client to see the baby through the nursery window. c) contact the primary care provider for advice related to the client's visitation. d) allow the client to see and hold the baby for as long as she desires.

allow the client to see and hold the baby for as long as she desires. Correct Explanation: The nurse should allow the client to see and hold the baby for as long as she desires. Such activities provide memories for the mother and assist in the grieving process. There is a possibility that the client may change her mind about the adoption. If the client changes her mind about the adoption, the nurse should accept the client's decision and notify the primary care provider and social worker. Telling the client that it would be best if she did not see the baby is imposing the nurse's value system on the client. Allowing the client to see the baby through the nursery window is inappropriate because the client should be allowed to touch and hold the baby. Contacting the primary care provider for advice related to the client's visitation is not necessary.

When planning care for a group of clients, the nurse notes that which client is most susceptible to infection? a) a 6-year-old with a simple fracture of the femur b) an 18-year-old with diabetes mellitus c) an 86-year-old with burns from using a heating pad d) a 42-year-old with a recent, uncomplicated appendectomy

an 86-year-old with burns from using a heating pad Correct Explanation: The very young and the elderly are more susceptible to infection. An elderly client with a break in skin integrity, such as the 86-year-old with a burn, is at an increased risk for infection. The 6-year-old does not have a compound fracture (protruding through the skin) and is not at high risk for infection. A client with an appendectomy is at risk for infection of the surgical site but not as high a risk as the client with burns. While a client with diabetes is at risk for infection, this adolescent is not at high risk at this time.

A client presents to the OB triage unit with no prenatal care and painless bright red vaginal bleeding. Which interventions are most indicated? a) applying an external fetal monitor and completing a physical assessment b) obtaining a fundal height assessment on the client c) applying an external fetal monitor and performing a sterile vaginal examination d) obtaining fundal height and performing a sterile vaginal examination

applying an external fetal monitor and completing a physical assessment Explanation: Bright red vaginal bleeding without contractions could indicate a placenta previa. A sterile vaginal exam should never be done on a woman with a known or suspected placenta previa. Applying the external fetal monitor will allow the nurse to assess fetal status. A complete physical assessment of the client is indicated. A fundal height is used to monitor fetal growth during pregnancy but does not provide information related to vaginal bleeding.

The client is to be discharged on a low-fat, low-cholesterol, low-sodium diet. When coaching the client about the diet, the nurse should first: a) determine the client's knowledge level about cholesterol. b) ask the client to name foods that are high in fat, cholesterol, and salt. c) explain the importance of complying with the diet. d) assess the client's and family's typical food preferences.

assess the client's and family's typical food preferences. Correct Explanation: Before beginning dietary instructions and interventions, the nurse must first assess the client's and family's food preferences, such as pattern of food intake, lifestyle, food preferences, and ethnic, cultural, and financial influences. Once this information is obtained, the nurse can begin teaching based on the client's current knowledge level and then building on this knowledge base

On the first day after surgery, a client has been breathing room air. Vital signs are normal and O2 saturation is 89%. The nurse should first: a) administer oxygen by nasal cannula as prescribed at 2L per minute. b) assist the client to take several deep breaths and cough. c) lower the head of the bed. d) notify the health care provider (HCP).

assist the client to take several deep breaths and cough. Explanation: Deep breathing and coughing help to increase lung expansion and prevent the accumulation of secretions in postoperative clients. An O2 saturation of 89% is not an unexpected or emergent finding immediately following surgery. Frequent coughing and deep breathing will likely quickly remedy an O2 saturation of 89% but will also effectively help to prevent atelectasis and pneumonia in the remainder of the postoperative period. It is not necessary to notify the HCP prior to intervening with coughing/deep breathing, and it is not appropriate to position this client with the head of bed lower because this would make it more difficult for the client to expectorate secretions. Oxygen may be necessary, but the nurse should assist the client to cough and deep breath first, in an attempt to improve his oxygenation and saturation

An elderly client fractured his hip as a result of a fall at home. Because of his extensive cardiac history and chronic obstructive pulmonary disease, surgery isn't an option. The client tells the nurse he doesn't know how he's going to get better. Which response is best? a) "You're doing fine." b) "What is your biggest concern right now?" c) "Give it some time and you'll be OK." d) "You don't believe you're doing well?"

b Open-ended questions allow a client to control what he wants to discuss and help a nurse determine care needs. Telling the client that he's fine or that he just needs more time doesn't encourage him to verbalize his concerns. Reiterating the client's concerns may not encourage him to verbalize his feelings

Which outcome criterion would be most appropriate for a client with a nursing diagnosis of Ineffective airway clearance? a) Respiratory rate of 28 breaths/minute b) Continued use of oxygen when necessary c) Breath sounds clear on auscultation d) Presence of congestion on X-ray

c The expected outcome for a client with Ineffective airway clearance is for the lungs to be clear of secretions (or congestion) on auscultation. Congestion on X-ray, continued use of and need for oxygen, and a respiratory rate of 28 breaths/minute indicate that the client is still experiencing airway problems.

When planning pain control for a client with terminal gastric cancer, a nurse should consider that: a) only low doses of opioids are safe; higher doses may cause respiratory depression. b) clients with terminal cancer may develop tolerance to opioids. c) a client who can fall asleep isn't in pain. d) pain medication should be given only when a client requests it.

clients with terminal cancer may develop tolerance to opioids. Explanation: Clients with cancer may develop a tolerance to opioids, causing them to need higher doses to provide adequate pain relief. Although a nurse should always remain alert for adverse effects of opioids, clients may develop a tolerance for these effects. Therefore, it isn't likely that higher doses would cause respiratory depression. Administering pain medication around the clock maintains steady blood levels of opioids. Sleeping doesn't necessarily indicate pain relief, especially in a client who has chronic pain.

On the first day after abdominal surgery, the nurse auscultates a client's abdomen for bowel sounds; there are none. The nurse should: a) notify the health care provider (HCP). b) ask another nurse to validate the absence of bowel sounds. c) encourage the client to take more ice chips. d) document assessment findings in the client's medical record.

document assessment findings in the client's medical record. Correct Explanation: Bowel sounds are not present until the third or fourth postoperative day; the nurse should document the assessment findings. Too many ice chips may promote abdominal distention, especially if the client is not ambulating in the intermediate postoperative period

On the first day after abdominal surgery, the nurse auscultates a client's abdomen for bowel sounds; there are none. The nurse should: a) document assessment findings in the client's medical record. b) notify the health care provider (HCP). c) ask another nurse to validate the absence of bowel sounds. d) encourage the client to take more ice chips.

document assessment findings in the client's medical record. Explanation: Bowel sounds are not present until the third or fourth postoperative day; the nurse should document the assessment findings. Too many ice chips may promote abdominal distention, especially if the client is not ambulating in the intermediate postoperative period.

A nurse should encourage a client with a wound to consume foods high in vitamin C because this vitamin: a) enhances oxygen transport to tissues. b) restores the inflammatory response. c) reduces edema. d) enhances protein synthesis.

enhances protein synthesis. Explanation: The client should be encouraged to consume foods high in vitamin C because vitamin C is essential for protein synthesis, an important part of wound healing. Hemostasis is responsible for the inflammatory response and reducing edema. Hemoglobin is responsible for oxygen transport

A nurse is assessing a client for the risk of falls. The nurse should obtain: a) gait and balance information. b) the client's level of activity at home. c) the family's psychosocial history. d) the facility's restraint policy.

gait and balance information. Correct Explanation: Assessing the client's gait and balance helps determine his risk of falls. The facility's policy on restraints isn't relevant to a risk assessment for falls. Assessing the family's psychosocial history and determining the patient's home activity level are important but not as important as gait and balance in relation to the risk of falls

A client is admitted with multiple pressure ulcers. When developing the client's diet plan, the nurse should include: a) ground beef patties. b) steamed broccoli. c) ice cream. d) fresh orange slices.

ground beef patties. Explanation: Meat is an excellent source of complete protein, which this client needs to repair the tissue breakdown caused by pressure ulcers. Oranges and broccoli supply vitamin C but not protein. Ice cream supplies only some incomplete protein, making it less helpful in tissue repair.

A client has a reddened area over a bony prominence. The nurse finds an unlicensed nursing personnel (UAP) massaging this area. The nurse should: a) inform the UAP that massage is even more effective when combined with the use of lotion. b) instruct the UAP that massage is contraindicated because it decreases blood flow to the area. c) explain to the UAP that massage is effective because it improves blood flow to the area. d) reinforce the UAP's use of this intervention over the bony prominence.

instruct the UAP that massage is contraindicated because it decreases blood flow to the area. Correct Explanation: Massaging an area that is reddened due to pressure is contraindicated because it further reduces blood flow to the area. In the past, massaging reddened areas was thought to improve blood flow to the area, and some nursing personnel may still believe that massaging the area is effective in preventing pressure ulcer formation.

The nurse is preparing a 45-year-old female for a vaginal examination. The nurse should place the client in which postion? a) dorsal recumbent position b) lithotomy position c) genupectoral position d) Sims position

lithotomy position Correct Explanation: Although other positions may be used, the preferred position for a vaginal examination is the lithotomy position. This position offers the best visualization. If the client is elderly and frail, staff members may need to support the client's flexed legs while the examiner conducts the examination and obtains the Papanicolaou smear. Positioning the client in the other positions will make visualization more difficult and may not be as comfortable for the client

Which nursing intervention is most important in preventing septic shock? a) maintaining asepsis of indwelling urinary catheters b) obtaining vital signs every 4 hours for all clients c) monitoring red blood cell counts for elevation d) administering IV fluid replacement therapy as ordered

maintaining asepsis of indwelling urinary catheters Correct Explanation: Maintaining asepsis of indwelling urinary catheters is essential to prevent infection. Preventing septic shock is a major focus of nursing care because the mortality rate for septic shock is as high as 90% in some populations. Very young and elderly clients (those younger than age 2 or older than age 65) are at increased risk for septic shock. Administering IV fluid replacement therapy, obtaining vital signs every 4 hours on all clients, and monitoring red blood cell counts for elevation do not pertain to septic shock prevention.

Which indicates that performing passive range-of-motion (ROM) exercises on an unconscious client has been successful? a) preservation of muscle mass b) prevention of bone demineralization c) increase in muscle tone d) maintenance of joint mobility

maintenance of joint mobility Correct Explanation: The goal of performing passive ROM exercises is to maintain joint mobility. Active exercise is needed to preserve bone and muscle mass. Passive ROM movements do not prevent bone demineralization or have a positive effect on the client's muscle tone

The nurse assesses an older adult for signs of dehydration. Which findings would be consistent with a diagnosis of dehydration? a) orthostatic hypotension b) moist crackles c) bounding pulse d) shortness of breath

orthostatic hypotension Correct Explanation: Orthostatic hypotension or persistent hypotension is present in dehydration, as are poor skin turgor, dry oral mucous membranes, and tachycardia. If the dehydration is severe, the client may also be restless, confused, and thirsty. Most instances of crackles is indicative of excess fluid volume, not dehydration. Shortness of breath or a bounding pulse may be indicative of excess fluid, not dehydration.

An alert and oriented older adult female with metastatic lung cancer is admitted to the medical-surgical unit for treatment of heart failure. She was given 80 mg of furosemide in the emergency department. Although the client is ambulatory, the unlicensed assistive personnel (UAP) are concerned about urinary incontinence because the client is frail and in a strange environment. The nurse should instruct the UAP to assist with implementing the nursing plan of care by: a) requesting an indwelling urinary catheter to avoid incontinence b) prescribing adult diapers for the client so she will not have to worry about incontinence c) padding the bed with extra absorbent linens d) placing a commode at the bedside and instructing the client in its use

placing a commode at the bedside and instructing the client in its use Explanation: A bedside commode should be near the client for easy, safe access. Measurement of urine output is also important in a client with heart failure. Putting diapers on an alert and oriented individual would be demeaning and inappropriate. Indwelling catheters are associated with increased risk of infection and are not a solution to possible incontinence. There is no reason to think that the client would not be able to use the bedside commode

The nurse is planning the care of a hemiplegic client to prevent joint deformities of the arm and hand. Which position is appropriate? a) placing a pillow in the axilla so the arm is away from the body b) immobilizing the extremity in a sling c) inserting a pillow under the slightly flexed arm so the hand is higher than the elbow d) positioning a hand cone in the hand so the fingers are barely flexed e) keeping the arm at the side using a pillow

placing a pillow in the axilla so the arm is away from the body • inserting a pillow under the slightly flexed arm so the hand is higher than the elbow • positioning a hand cone in the hand so the fingers are barely flexed Explanation: Placing a pillow in the axilla so the arm is away from the body keeps the arm abducted and prevents skin from touching skin to avoid skin breakdown. Placing a pillow under the slightly flexed arm so the hand is higher than the elbow prevents dependent edema. Positioning a hand cone (not a rolled washcloth) in the hand prevents hand contractures. Immobilization of the extremity may cause a painful shoulder-hand syndrome. Flexion contractures of the hand, wrist, and elbow can result from immobility of the weak or paralyzed extremity. It is better to extend the arms to prevent contractures.

Several day-shift nurses complain that the night-shift nurses aren't performing the daily calibration of the capillary glucose monitoring apparatus, which is their responsibility. It would be most prudent for a nurse-manager to: a) arrange a meeting of the day-shift and night-shift nurses. b) review the capillary glucose monitoring calibration log book. c) immediately remind the night-shift nurses of the daily calibrations. d) counsel the night charge nurse about the discrepancy.

review the capillary glucose monitoring calibration log book. Explanation: When dealing with complaints, a nurse-manager should always gather data before taking action. Therefore, the nurse-manager should review the calibration documentation, then address the findings. It would be inappropriate for the nurse-manager to remind the staff of a responsibility that they may be fulfilling, arrange a meeting that could become confrontational, or counsel the charge nurse before investigating and gathering data relative to the complaint

A client who has had the jaws wired begins to vomit. The nurse should first: a) administer an antiemetic intravenously. b) insert a nasogastric (NG) tube and connect it to suction. c) use wire cutters to cut the wire. d) suction the client's airway as needed.

suction the client's airway as needed. Correct Explanation: The nurse's first action is to clear the client's airway as necessary. Inserting an NG tube or administering an antiemetic may prevent future vomiting episodes, but these procedures are not helpful when the client is actually vomiting. Cutting the wires is done only as a last resort or in case of respiratory or cardiac arrest

Which indicates that a client has achieved the goal of correctly demonstrating deep breathing for an upcoming splenectomy? The client: a) takes a deep breath in through the nose, holds it for 5 seconds, and blows out through pursed lips. b) breathes in through the mouth and out through the nose. c) breathes in through the nose and out through the mouth. d) uses diaphragmatic breathing in the lying, sitting, and standing positions.

takes a deep breath in through the nose, holds it for 5 seconds, and blows out through pursed lips. Correct Explanation: The correct technique for deep breathing postoperatively to avoid atelectasis and pneumonia is to take in a deep breath through the nose, hold it for 5 seconds, then blow it out through pursed lips. The goal is to fully expand and empty the lungs for pulmonary hygiene

The nurse is caring for a client who had an open cholecystectomy 24 hours ago. The client's vital signs have been stable over the last 24 hours, with most recent temperature 98.6° F (37° C), blood pressure (BP) 118/76 mm Hg, respiratory rate (RR) 16/min, and heart rate (HR) 78 bpm, but are now changing. Which set of vital signs indicates that the nurse should contact the health care provider (HCP)? a) temperature 100.7° F (38.2° C), BP 118/68 mm Hg, HR 84 bpm, RR 20/min b) temperature 101.8° F (38.8° C), BP 140/86 mm Hg, HR 94 bpm, RR 24/min c) temperature 97.5° F (36.4° C), BP 98/64 mm Hg, HR 98 bpm, RR 18/min d) temperature 99.5° F (37.5° C), BP 126/80 mm Hg, HR 58 bpm, RR 16/min

temperature 101.8° F (38.8° C), BP 140/86 mm Hg, HR 94 bpm, RR 24/min Correct Explanation: This client is exhibiting three of four signs of systemic inflammatory response syndrome (SIRS): temperature greater than 100.4° F (38° C) (or less than 96.8° F [36°C]), heart rate greater than 90 bpm, respiratory rate greater than 20 breaths/min. The fourth indicator is an abnormal white blood cell count (greater than 12,000 [12 × 109/L], less than 4000 [4 × 109/L] or greater than 10% [0.1 × 109/L] bands). At least two of these variables are required to define SIRS

The nurse is evaluating the effectiveness of fluid resuscitation during the emergency period of burn management. Which finding indicates that adequate fluid replacement has been achieved in the client? a) fluid intake less than urinary output b) blood pressure of 90/60 mm Hg c) an increase in body weight d) urine output greater than 35 mL/hou

urine output greater than 35 mL/hour Correct Explanation: A urine output of 30 to 50 mL/h indicates adequate fluid replacement in the client with burns. An increase in body weight may indicate fluid retention. A urine output greater than fluid intake does not represent a fluid balance. Depending on the client, blood pressure of 90/60 mm Hg could indicate the presence of a hypovolemic state; by itself, it does not indicate adequate fluid replacement.

The nurse is evaluating the effectiveness of fluid resuscitation during the emergency period of burn management. Which finding indicates that adequate fluid replacement has been achieved in the client? a) urine output greater than 35 mL/hour b) blood pressure of 90/60 mm Hg c) fluid intake less than urinary output d) an increase in body weight

urine output greater than 35 mL/hour Correct Explanation: A urine output of 30 to 50 mL/h indicates adequate fluid replacement in the client with burns. An increase in body weight may indicate fluid retention. A urine output greater than fluid intake does not represent a fluid balance. Depending on the client, blood pressure of 90/60 mm Hg could indicate the presence of a hypovolemic state; by itself, it does not indicate adequate fluid replacement.

A client with ascites and peripheral edema is at risk for impaired skin integrity. To prevent skin breakdown, the nurse should: a) massage the abdomen once a shift. b) elevate the lower extremities. c) use an alternating air pressure mattress. d) institute range-of-motion (ROM) exercise every 4 hours.

use an alternating air pressure mattress. Correct Explanation: Edematous tissue is easily traumatized and must receive meticulous care. An alternating air pressure mattress will help decrease pressure on the edematous tissue. ROM exercises are important to maintain joint function, but they do not necessarily prevent skin breakdown. When abdominal skin is stretched taut due to ascites, it must be cleaned very carefully. The abdomen should not be massaged. Elevation of the lower extremities promotes venous return and decreases swelling.

The nurse has provided an in-service presentation to ancillary staff about standard precautions on the birthing unit. The nurse determines that one of the staff members needs further instructions when the nurse makes which observation? a) placement of bloody sheets in a container designated for contaminated linens b) use of protective goggles during a cesarean birth c) disposal of used scalpel blades in a puncture-resistant container d) wearing of sterile gloves to bathe a neonate at 2 hours of age

wearing of sterile gloves to bathe a neonate at 2 hours of age Correct Explanation: One of the staff members needs further instructions when the nurse observes the staff member wearing sterile gloves to bathe a neonate at 2 hours of age. Clean gloves should be worn, not sterile gloves. Sterile gloves are more expensive than clean gloves and are not necessary when bathing a neonate.

The mother of a client who has a radium implant asks why so many nurses are involved in her daughter's care. She states, "The doctor said I can be in the room for up to 2 hours each day, but the nurses say they are restricted to 30 minutes." The nurse explains that this variation is based on the fact that nurses: a) work with radiation on an ongoing basis, while visitors have infrequent exposure to radiation. b) are at greater risk from the radiation because they are younger than the mother. c) touch the client, which increases their exposure to radiation. d) work with many clients and could carry infection to a client receiving radiation therapy, if exposure is prolonged.

work with radiation on an ongoing basis, while visitors have infrequent exposure to radiation. Explanation: The three factors related to radiation safety are time, distance, and shielding. Nurses on radiation oncology units work with radiation frequently and so must limit their contact. Nurses are physically closer to clients than are visitors, who are often asked to sit 6 feet (182.9 cm) away from the client. Touching the client does not increase the amount of radiation exposure. Aseptic technique and isolation prevent the spread of infection. Age is a risk factor for people in their reproductive years

A child has a nasogastric (NG) tube inserted by the nurse to administer a continuous feeding. Which of the following actions should the nurse take before starting the NG feeding on the child? Select all that apply. a) Prepare a 24-hour supply of formula. b) Check placement of the NG tube. c) Assess for bowel sounds. d) Verify the physician's order. e) Heat the formula in a microwave.

• Check placement of the NG tube. • Assess for bowel sounds. • Verify the physician's order. Correct Explanation: Verifying the order, checking the placement of the NG tube, and assessing bowel sounds are necessary before initiating an NG feeding. Formula should not be heated in the microwave, and no more than a 4-hour supply should be hung to prevent the growth of microorganisms

The nurse-manager of an outpatient facility isn't satisfied with discharge planning policies and procedures. Knowing other managers at similar facilities regarded as the "best" in the country, which steps should the nurse-manager take as part of a continuous quality-improvement process? a) Ask the nurse-managers at the best facilities for their policies and procedures so she can adopt them. b) Ask the staff nurses to form a task force to review and revise discharge policies and procedures. c) Ask her staff nurses to investigate discharge policies and procedures at other outpatient facilities and recommend changes. d) Contact the nurse-managers at the best facilities and compare their discharge planning policies and procedures with those of her facility.

Contact the nurse-managers at the best facilities and compare their discharge planning policies and procedures with those of her facility. Correct Explanation: Benchmarking is a good approach for the nurse-manager to take. Benchmarking is the process of comparing an organization's delivery of client care practices in one organization to those in the best health care organizations. Because the nurse-manager already has contacts at the best facilities, she's the most appropriate person to obtain the necessary information. The nurse-manager, however, shouldn't automatically change her policies and procedures to match those of the best facilities. Instead, she should evaluate the policies to determine which ones might be implemented at her facility. Then she and her staff should make appropriate recommendations for change. Asking her staff to form a task force is a good idea, but benchmarking saves time and effort and enables the nurse-manager to obtain information from excellent resources.