HESI practice

A nursing instructor provides teaching about the ethical principle of nonmaleficence to a group of nursing students. What is appropriate for the nurse to include in the education? 1 Treat all clients equitably and fairly. Correct2 Act in ways to prevent harm to clients. 3 Tell the client the truth about their health. 4 Help the clients to make informed choices.

Nonmaleficence means to act in ways that prevent client harm or even the risk of harm. Telling the truth to clients about their health refers to veracity. Helping clients make informed choices promotes autonomy. Justice involves treating all clients equitably and fairly.

An older adult who is in acute care has a risk of skin breakdown. Which interventions are beneficial to the client? Select all that apply. Correct1 Providing meticulous skin care Correct2 Reducing shear forces and friction Incorrect3 Providing beverages and snacks frequently 4 Using a support surface base all the time Correct5 Avoiding pressure with proper positioning

Providing an older adult with meticulous skin care may reduce the risk of skin breakdown. Reducing shear forces and friction prevents the development of pressure ulcers. Pressure can be avoided with proper positioning. Beverages and snacks are frequently provided to clients who are hospitalized due to dehydration. A supportive surface base is used based on risk factors.

What is the purpose of the failure mode effective analysis? Correct1 To prevent medical errors in a hospital 2 To analyze the cause of sentinel events in a hospital 3 To analyze the efficacy of the care provided in the hospital 4 To evaluate the cause of client dissatisfaction with regard to care

The failure mode effective analysis is a tool that is designed to prevent medical errors and system failures within a health care system. It analyzes the potential failure modes, analyzes the causes of system failures, finds solutions to the problem, and evaluates the effectiveness of those solutions. The root cause analysis tool is used to analyze the cause of sentinel errors in a hospital. The efficacy of the care provided and analysis of client satisfaction are not the components of client dissatisfaction.

The nurse is transferring a client from the bed to the chair. Which action should the nurse take during the transfer? 1 Place the client in a semi-Fowler position. 2 Stand behind the client during the transfer. 3 Turn the chair so it faces away from the bed. Correct4 Instruct the client to dangle the legs.

The nurse should place the client in high-Fowler position, or 80 to 90 degrees, and then assist the client to the side of the bed. Next, the nurse helps the client sit on the edge of the bed and then instructs the client to dangle the legs. The nurse then faces the client and places the chair next to and facing the head of the bed. The semi-Fowler, or 30 to 45 degrees, position is not high enough to get the client in a sitting position.

A nurse understands that value clarification is a technique useful in therapeutic communication because initially it helps clients do what? Correct1 Become aware of their personal values 2 Gain information related to their needs 3 Make correct decisions related to their health 4 Alter their value systems to make them more socially acceptable

Value clarification is a technique that reveals individuals' values so the individuals become more aware of them and their effect on others. Gaining information, making correct health decisions, and altering value systems to make them more socially acceptable are not outcomes of value clarification.

Intrinsic Factors for motivation

Age, affiliation, Anxiety, Cognitive Level, Core Beliefs, developmental level, emotional readiness, fear of failure, gender, high expectations, perceptions of health and illness, persistence, power, required effort, risk-taker, self-confidence, self-efficacy, sensory function, values

What is the recommended length of insertion of the enema tube in a child of 3 years? 1 1 to 2.5 cm Correct2 5 to 7.5 cm 3 7.5 to 10 cm 4 2.5 to 3.7 cm

For a 3-year-old child, the recommended length of insertion of the enema tube is 5 to 7.5 cm. The length of 1 to 2.5 cm is incorrect, as it is too small. Even the insertion length of the enema tube used in infants is longer than this. For infants, the length of insertion of the enema tube should be 2.5 to 3.7 cm. For adolescents and adults, this length is 7.5 to 10 cm. Topics

A client past menopause undergoes an anteroposterior colporrhaphy. What should the nurse include in the client's discharge teaching? Correct1 Eating a high-fiber diet 2 Limiting daily activities 3 Reporting signs of urine retention 4 Being alert to signs of a rectovaginal fistula

Immediately after this type of surgery, pain is associated with bearing down; the client should be instructed to increase fluid, fiber, and activity to prevent constipation. Exercise is encouraged. The anteroposterior colporrhaphy is expected to reduce incontinence; urine retention is not expected. The colporrhaphy involves only the vaginal wall; the rectum should not be involved.

Extrinsic factors for motivation

accessibility of facilities, community systems, cultural values, family, human resources, nature of the task, physical resources, readiness of the healthcare team

A client is admitted for a rhinoplasty. To monitor for hemorrhage after the surgery, the nurse should assess specifically for the presence of which response? 1 Facial edema Correct2 Excessive swallowing 3 Pressure around the eyes 4 Serosanguineous drainage on the dressing

Internal bleeding after nasal surgery may flow by gravity to the posterior oropharynx, where it is swallowed. Facial edema is expected after the trauma of surgery. The edema that results from the trauma of surgery may be perceived as pressure around the eye; although it is expected, it is not a priority. Pink-tinged drainage on the nasal packing and nasal drip dressing is expected for 24 to 48 hours after surgery.

The nurse is assessing four clients with musculoskeletal injuries. Which client is advised to have thermotherapy? 1 Client A 2 Client B Correct3 Client C 4 Client D

Muscle spasms are caused by involuntary muscle contractions after fractures. Thermotherapy reduces muscle spasm. Therefore client C with muscle spasms is instructed to undergo this treatment. Client A with a foot drop is advised to keep the foot in a neutral position. Client B with contractures is advised to change positions frequently. Client D with muscle atrophy is advised to practice an isometric muscle-strengthening exercise regimen.

What principle of teaching specific to an older adult should the nurse consider when providing instruction to such a client recently diagnosed with diabetes mellitus? 1 Knowledge reduces general anxiety. 2 Capacity to learn decreases with age. Correct3 Continued reinforcement is advantageous. Incorrect4 Readiness of the learner precedes instruction.

Neurologic aging causes forgetfulness and a slower response time; repetition increases learning. Continued reinforcement is an example of repetition. The facts that knowledge reduces general anxiety and that the readiness of the learner precedes instruction reflect principles that are applicable to learning regardless of the client's age. Capacity to learn decreases with age.

Which information should be included in the teaching plan for the mother of a newborn with exstrophy of the bladder? 1 Maintaining sterility of the exposed bladder 2 Measuring output from the exposed bladder Correct3 Protecting the skin surrounding the exposed bladder 4 Applying a pressure dressing to the exposed bladder

Constant drainage of urine on the skin promotes excoriation and infection, so the skin must be protected. Sterility is impossible to maintain because of the leakage of urine. Output will be difficult to measure because of the constant leakage of urine. A pressure dressing is contraindicated, because it will traumatize the exposed bladder.

How can nurses exhibit the concept of open-mindedness as a part of critical thinking behavior in their teams? Select all that apply. 1 By being organized and focused 2 By working with cognitive maturity 3 By seeking the true meaning of any situation Correct4 By respecting the right of others to have different opinions Correct5 By becoming sensitive to the possibility of their own prejudices

Critical thinking behavior implies the nurse should respect the rights of others to have a different opinion. The nurse should exhibit the concept of open-mindedness by showing sensitivity to the possibility of his or her own prejudices. Being organized and focused reflects systematicity. Maturity requires the nurse to work with cognitive maturity. According to truth seeking, the nurse should seek the true meaning of a situation.Test-Taking Tip: Be alert for details about what you are being asked to do. In this Question Type, you are asked to select all options that apply to a given situation or client. All options likely relate to the situation, but only some of the options may relate directly to the situation.

After determining that the nurses on the psychiatric unit are uncomfortable caring for clients who are from different cultures than their own, the nurse manager establishes a unit goal that by the next annual review the unit will have achieved what? 1 Increased cultural sensitivity 2 Decreased cultural imposition 3 Decreased cultural dissonance Correct4 Increased cultural competence

Cultural competence encompasses sensitivity as well as knowledge, desire, and skill in caring for those who are different from one's self. The nurses are already somewhat sensitive to those from different cultures and now must move forward in their ability to care for these clients. The nurses are not imposing their culture on the clients; they are avoiding them. There is no clashing of cultures in this situation.

Which organization has a publication that includes the objective, "Aiming to develop a system to clients who are lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ)?" Correct1 U.S. Department of Health and Human Services (USDHHS) 2 The Centers for Disease Control and Prevention (CDC) 3 The Joint Commission (TJC) 4 The World Professional Association for Transgender Health (WPATH)

Developing a system to identify clients who are LGBTQ is a goal stated in the USDHHS's Healthy People 2020. The CDC's publications have goals that differ from this one. The TJC field guide lists the recommendations for health care agencies in designing a safe environment for LGBT client care. WPATH summarizes core principles that nurses and other health care providers should follow when caring for transgender clients.

An older client is apprehensive about being hospitalized. The nurse realizes that one of the stresses of hospitalization is the unfamiliarity of the environment and activity. How can the nurse best limit the client's stress? 1 Use the client's first name. 2 Visit with the client frequently. Correct3 Explain what the client can expect. 4 Listen to what the client has to say.

Explaining procedures and routines should decrease the client's anxiety about the unknown. The nurse should not confuse roles of professional and friend; the client should be called by an appropriate title (Mr., Miss, Ms., Mrs., etc.) unless the client requests otherwise. The nurse should not confuse the role of professional with that of being a friend; "visiting" has a social connotation. Although listening to the client is therapeutic, this does not change the fact that the hospital environment is strange to the client and the client needs information.Test-Taking Tip: Avoid spending excessive time on any one question. Most questions can be answered in 1 to 2 minutes.

Which bacterial skin infections are caused by group A β-hemolytic streptococci? Select all that apply. 1 Furuncle Incorrect2 Cellulitis Correct3 Impetigo 4 Folliculitis Correct5 Erysipelas

Impetigo is caused by group A β-hemolytic streptococci, staphylococci, or a combination of both. Erysipelas is caused by group A β-hemolytic streptococci. Furuncle is a deep infection with staphylococci. Staphylococcus aureus and streptococci are the usual causative agents of cellulitis. Usually staphylococci are responsible for folliculitis. Topics

Arrange the stages of Sigmund Freud's psychoanalytical model of personality development in its correct order. Correct1.Oral Correct2.Anal Correct3.Phallic or Oedipal Correct4.Latency Correct5.Genital The first stage of Freud's theory is the oral stage starting from birth to 12 to 18 months. The anal stage is the second stage which starts from 12 to 18 months to 3 years of age. Children between the ages of 3 to 6 years are considered to be in the phallic or Oedipal stage. The latency stage lasts from 6 years to 12 years. The genital stage is the sixth stage; it starts from puberty and continues to adulthood.

The first stage of Freud's theory is the oral stage starting from birth to 12 to 18 months. The anal stage is the second stage which starts from 12 to 18 months to 3 years of age. Children between the ages of 3 to 6 years are considered to be in the phallic or Oedipal stage. The latency stage lasts from 6 years to 12 years. The genital stage is the sixth stage; it starts from puberty and continues to adulthood.

A client with catatonic schizophrenia who is in a vegetative state is admitted to the psychiatric hospital. The nurse identifies short- and long-term outcomes in the client's clinical pathway. What is the priority short-term outcome of care that the client should be able to attain? 1 Talking with peers 2 Performing activities of daily living 3 Completing unit activities and assignments Correct4 Ingesting adequate fluid and food with assistance

A client in a vegetative state may not eat or drink without assistance; fluids and foods are basic physiologic needs that are necessary to prevent malnutrition and starvation; therefore the intake of adequate fluid and food is a priority short-term goal. The client is in total withdrawal; talking with peers, performing activities of daily living, and completing activities and assignments are not priority outcomes at this time.Test-Taking Tip: Answer every question. A question without an answer is always a wrong answer, so go ahead and guess.

A nurse is taking blood pressures at a health fair. Which finding should cause the nurse to advise the client to have the blood pressure checked by a primary healthcare provider? 1 A loud Korotkoff sound 2 An irregular pulse of 92 beats per minute Correct3 A diastolic blood pressure that remains greater than 90 mm Hg 4 A throbbing headache over the left eye when arising in the morning

A sustained diastolic pressure exceeding 90 mm Hg reflects pathology and could indicate hypertension. A loud Korotkoff sound is unrelated to hypertension. An irregular pulse of 92 beats per minute reflects the heart rate and rhythm, not the pressure within the arteries. Initially hypertension usually is asymptomatic; although headaches can be associated with hypertension, there are other causes of headaches.

A nurse provides a list of suggested food choices to a client who has peptic ulcer disease. Which foods should be included on the list? 1 Orange juice, fried eggs, and sausage 2 Tomato juice, raisin bran cereal, and tea Correct3 Applesauce, cream of wheat, and apple juice 4 Sliced oranges, pancakes with syrup, and coffee

Applesauce, cream of wheat, and apple juice are bland foods that do not irritate the gastric mucosa. Orange juice, fried eggs, sausage, tomato juice, raisin bran cereal, tea, sliced oranges, and coffee are not bland; they may be irritating to the mucosal lining. Caffeine should be avoided.

Which individual would be an appropriate member of a critical incident stress debriefing (CISD) team for a group of staff nurses? Select all that apply. Correct1 Staff nurse 2 Organization chaplain 3 Organization media representative Correct4 Physician trained in critical debriefing Correct5 Advanced practice mental health nurse

The critical incident stress debriefing (CISD) team includes a peer member of the group being debriefed. For this group, the CISD team would include a staff nurse. The team may include a physician trained in critical debriefing. The team leader would be someone with a background in mental or behavioral health. This role would be appropriate for the advanced practice mental health nurse. The chaplain and the media representative are not identified as being appropriate for the CISD team.Test-Taking Tip: Be alert for details about what you are being asked to do. In this Question Type, you are asked to select all options that apply to a given situation or client. All options likely relate to the situation, but only some of the options may relate directly to the situation.

Which clinical manifestation can a client experience during a fat embolism syndrome (FES)? 1 Nausea Correct2 Dyspnea 3 Orthopnea 4 Paresthesia

FES is clinically manifested by dyspnea because of low levels of arterial oxygen. Nausea and orthopnea are not seen in FES. However, tachypnea, headache, and lethargy are seen in clients with FES. Paresthesia occurs with compartment syndrome.

Which sleep disorders are examples of dyssomnias? Select all that apply. Correct1 Insomnia 2 Nightmares 3 Sleep terrors Correct4 Restless leg syndrome Correct5 Obstructive sleep apnea

Insomnia, restless leg syndrome, and obstructive sleep apnea are examples of dyssomnias. Nightmares and sleep terrors are examples of parasomnias.

A client who is obese and has a history of alcohol abuse is admitted to the hospital with the diagnosis of acute pancreatitis. Which is the initial priority expected client outcome in response to therapy at this time? Correct1 Report decreased pain 2 Insert nasogastric (NG) tube quickly 3 Join Alcoholics Anonymous 4 Lose four pounds (1.8 kilograms) a week

Pain relief is the priority. Severe pain is associated with acute pancreatitis caused by inflammation of the pancreas, peritoneal irritation, and biliary tract obstruction. Although inserting the NG tube quickly is appropriate, it is not priority, and some clients do not need an NG tube; the NG tube is inserted to allow the pancreas to rest, decreasing pain. Losing weight and joining Alcoholics Anonymous are later goals.

What are some principles for promoting older adult learning?

-make sure they're ready to learn, watch for cues-is the pt physically well enough? are they in pain?-sit facing so they can see lips and expressions-speak slowly in a normal tone of voice-present one idea or concept at a time-emphasize concrete rather than abstract material-give them time to respond as they may process slower-keep env distractions to a minimum, good lighting and a comfortable setting-defer teaching if they become distracted or can't concentrate-invite a family member to join-use audio, visual and tactile aids to enhance learning and memory-ask for feedback to ensure understanding-use past experience to connect new learning

What are the signs and symptoms observed in the human body with a decrease in body temperature? Select all that apply. Correct1 Shivering 2 Profuse sweating 3 Flushed appearance 4 Dilation of blood vessels Correct5 Contraction of blood vessels

A client who has decreased body temperature may experience shivering due to contraction of the blood vessels in the body. The client who has decreased body temperature may not experience profuse sweating, flushed appearance, and dilated blood vessels. These signs and symptoms appear with an increase in body temperature.

According to Benner et al., an expert nurse passes through five levels of proficiency when acquiring and developing generalized or specialized nursing skills. Arrange the order of level of proficiency from lowest to highest. Correct1.Novice Correct2.Advanced beginner Correct3.Competent Correct4.Proficient Correct5.Expert

A novice is a beginning nursing student who doesn't have any previous level of experience. An advanced beginner is a nurse who has had some level of experience. A nurse is said to be competent if she or he has been in the same clinical position for two to three years. A nurse is said to be proficient after three years of experience in the same clinical position. An expert is a nurse with diverse experience and who has an intuitive grasp of an existing or potential clinical problem.

A young mother of three children, all born 1 year apart, has been hospitalized after trying to hang herself. The client is being treated with milieu therapy. The nurse understands that this therapeutic modality consists of what? 1 Providing individual and family therapy 2 Using positive reinforcement to reduce guilt 3 Uncovering unconscious conflicts and fantasies Correct4 Providing a supportive environment to benefit the client

Any aspect of the treatment environment can be used to benefit the client in milieu therapy. Individual and family therapy are separate treatment modalities, not part of milieu therapy. Using positive reinforcement to reduce guilt is part of behavioral modification, not milieu therapy. Uncovering unconscious conflicts and fantasies is part of psychoanalytical, not milieu, therapy.

Which ethnic group has a greater incidence of osteoporosis due to musculoskeletal differences? 1 Irish Americans 2 African Americans Correct3 Chinese Americans 4 Egyptian Americans

Chinese Americans have an increased incidence of osteoporosis because they have shorter and smaller bones with lower bone density. Irish Americans have taller and broader bones than other Euro-Americans. African Americans have a decreased incidence of osteoporosis. Egyptian Americans are shorter in stature than Euro-Americans and African Americans.

A client is admitted with multiple trauma after a bus crash. The nurse finds that the stability of the client's vital function is threatened. Under which emergency severity index (ESI) level should the nurse triage this client's condition? 1 ESI-1 Correct2 ESI-2 3 ESI-3 4 ESI-4

Clients with multiple traumas or chest pain resulting from ischemia should be categorized under ESI-2, which indicates that the client's stability is threatened and he or she should be seen within 10 min. Level ESI-1 is for clients who have severe respiratory distress and cardiac arrest. Level ESI-3 is for clients who are stable with an unlikely threat to life, such as those with abdominal pain or a hip fracture. ESI-4 level is considered for clients with simple lacerations and cystitis.

Which statement describes the latency stage of Freud's psychoanalytic model of personality development? 1 During this stage, genital organs are the focus of pleasure. Correct2 During this stage, sexual urges are repressed and channeled into productive activities. 3 During this stage, an infant begins to think that his or her parent is separate from the self. 4 During this stage, sexual urges reawaken and are directed to an individual outside the family circle.

During the latency stage, Freud believed that sexual urges from the earlier Oedipal stage are repressed and channeled into productive activities that are socially acceptable. During the phallic stage, the genital organs are the focus of pleasure. During the oral stage, infants begin to think that the parent is something separate from the self. During the genital stage, sexual urges reawaken and are directed to an individual outside the family circle.Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer.

The nurse concludes that a client with type 1 diabetes is experiencing hypoglycemia. Which responses support this conclusion? Select all that apply. 1 Vomiting Correct2 Headache Correct3 Tachycardia Correct4 Cool, clammy skin 5 Increased respirations

Headache is a neuroglycopenic response directly related to brain glucose deprivation. Tachycardia occurs with hypoglycemia because of a neurogenic adrenergic response; it is a sympathetic nervous system response precipitated by a low blood glucose level. Cool, clammy skin is a neurogenic cholinergic response; it is a sympathetic nervous system response precipitated by a low serum glucose level. Vomiting occurs with hyperglycemia because of the effects of metabolic acidosis. Increased respirations are a sign of hyperglycemia and are related to metabolic acidosis; this is a compensatory response in an attempt to blow off carbon dioxide and increase the pH level.

The preschool-age client is learning sociocultural mores. What should this imply to the nurse regarding this client? Correct1 The child is developing a conscience. 2 The child is learning about gender roles. 3 The child is developing a sense of security. 4 The child is learning about the political process.

Learning the sociocultural mores of the family implies that the child is developing a conscience. This does not imply that the child is learning gender roles, developing a sense of security, or learning about the political process.

The nurse is caring for a client with wound dressings to the burns on 55% of the body. The dressing changes are very painful, and the client rates them 7/10 on the pain scale. The client has morphine 2 mg to be administered by mouth every 2 hours as needed. When planning the client's care, when does the nurse decide to administer the medication? 1 15 minutes before the dressing change Correct2 60 minutes before the dressing change 3 Along with a stool softener each time it is administered 4 Only if the client rates pain between 8 and 10 on the pain scale

Oral morphine takes 30 to 90 minutes to reach peak effect and can be administered at least 60 minutes before the dressing change. Although pain medications can cause constipation, the nurse would not administer a stool softener each time the morphine is administered. If the client is experiencing pain and rates it anywhere on the pain scale, the client can receive pain medication if it is within the timeframe. It is important to premedicate a client before a painful procedure.

Which principles are appropriate for promoting older adult learning? Select all that apply. 1 Emphasize abstract material Correct2 Use past experiences while teaching 3 Teach by presenting multiple examples at a time Correct4 Keep the environmental distractions to a minimum Correct5 Use audio, visual, and tactile cues to enhance learning

The nurse should use past experiences while teaching an older client, keep environmental distractions to a minimal and use audio, visual, and tactile cues to enhance learning. This helps the client to remember all the information. The nurse should emphasize concrete material. The nurse should teach clients by using one example at a time.Test-Taking Tip: You have at least a 25 percent chance of selecting the correct response in multiple-choice items. If you are uncertain about a question, eliminate the choices that you believe are wrong and then call on your knowledge, skills, and abilities to choose from the remaining responses.

A nurse instructs a 70-year-old client to dress warmly in cold weather. Which physical changes seen in the client necessitate this instruction? Select all that apply. 1 Reduced sebum production 2 Degeneration of elastic fibers 3 Decreased dermal blood flow Correct4 Thinning of the subcutaneous layer Correct5 Decreased vasomotor responsiveness

Thinning of the subcutaneous layer and decreased vasomotor responsiveness will increase the risk of hypothermia. To prevent hypothermia, the nurse instructs the client to wear warm clothing. Reduced sebum production can increase the size of pores, producing comedones. Degeneration of elastin will decrease the skin turgor of the client but does not produce hypothermia. Decreased dermal blood flow will cause risk of dry skin, which does not require the intervention of warm clothing.Test-Taking Tip: Be alert for details about what you are being asked to do. In this Question Type, you are asked to select all options that apply to a given situation or client. All options likely relate to the situation, but only some of the options may relate directly to the situation.

What should the nurse teach the parents about preventing sudden infant death syndrome (SIDS)? Select all that apply. Correct1 Refrain from smoking around the infant. Correct2 Refrain from co-sleeping or bed-sharing. Incorrect3 Position the infant on the side while sleeping. 4 Use soft pillows to support the infant while sleeping. Correct5 Refrain from placing stuffed toys on the infant's bed.

The nurse should instruct the parents to avoid exposing the infant to cigarette smoke because the chemicals place the infant at a greater risk for sudden infant death syndrome (SIDS). Co-sleeping or bed-sharing is also associated with SIDS. The nurse should ask the parents to refrain from placing stuffed toys on the infant's bed as a precautionary measure against SIDS. The infant should be positioned on his or her back to reduce the incidence of SIDS. Parents should not use soft mattresses or pillows in the infant's crib to reduce the risk for SIDS.Test-Taking Tip: Be alert for details about what you are being asked to do. In this Question Type, you are asked to select all options that apply to a given situation or client. All options likely relate to the situation, but only some of the options may relate directly to the situation.

A client reports mild tenderness and swelling near the ankle while running. Which nursing instruction would best benefit the client? 1 "Do vigorous endurance exercises." 2 "Complete your activity with a balancing exercise." 3 "Perform strengthening exercises in between your activity." Correct4 "Do warm-up muscle exercises before performing an activity."

A client with mild tenderness and swelling at the ankle area has a first-degree (mild) sprain. Warming up muscles followed by stretching exercises before performing any vigorous activity may reduce the risk of sprains and strains. The sprain may be reduced when endurance exercises start at a low level of effort and progress gradually to a moderate level. Balancing exercises, which may overlap with some strengthening exercises, help to prevent falling but is not as important in a strain as is proper warm-up. Strengthening exercises must be done prior to an activity to build muscle strength and bone density.

A mother brings her 9-month-old infant to the clinic. The nurse is familiar with the mother's culture and knows that belly binding to prevent extrusion of the umbilicus is a common practice. The nurse accepts the mother's cultural beliefs but is concerned for the infant's safety. What variation of belly binding does the nurse discourage? Correct1 Coin in the umbilicus 2 Tight diaper over the umbilicus 3 Binder that encircles the umbilicus 4 Adhesive tape across the umbilicus

A coin may be dislodged, allowing the infant to put it in his or her the mouth, resulting in a safety issue. A diaper fastened tightly around the waist, a binder, or adhesive tape over the umbilicus will not endanger the infant. Cultural beliefs that do not place the infant at risk should not be discouraged.

A nurse is caring for a client with heart failure. The healthcare provider prescribes a 2-gram sodium diet. What should the nurse include when explaining how a low-salt diet helps achieve a therapeutic outcome? Correct1 Allows excess tissue fluid to be excreted 2 Helps to control the volume of food intake and thus weight 3 Aids the weakened heart muscle to contract and improves cardiac output 4 Assists in reducing potassium accumulation that occurs when sodium intake is high

A decreased concentration of extracellular sodium causes a decrease in the release of antidiuretic hormone (ADH); this leads to increased excretion of urine. Sodium restriction does not control the volume of food intake; weight is controlled by a low-calorie diet and exercise (if permitted). The resulting elimination of excess fluid reduces the workload of the heart but does not improve contractility. Potassium is retained inefficiently by the body; an adequate intake of potassium is needed.Test-Taking Tip: Answer every question. A question without an answer is always a wrong answer, so go ahead and guess.

A family has undergone the emotional transition of accepting a new generation of members into the family system. Which changes in the family's status are required to proceed developmentally? Select all that apply. Correct1 Taking on parental roles 2 Adjusting to a reduction in family size 3 Development of intimate peer relationships Correct4 Adjusting the marital system to make space for children Incorrect5 Realigning relationships to in-laws and grandchildren

A family with more young children undergoes an emotional transition of accepting a new generation of members. These changes include taking on parental roles and adjusting the marital system to make space for children to proceed developmentally. Adjusting to a reduction in family size is required for the family life-cycle stage of children leaving the family home. The development of intimate peer relationships is required for an unattached young adult. Realigning relationships to in-laws and grandchildren is required for the family life-cycle stage of children leaving the home to start their own lives.Test-Taking Tip: Be alert for details about what you are being asked to do. In this Question Type, you are asked to select all options that apply to a given situation or client. All options likely relate to the situation, but only some of the options may relate directly to the situation.

When caring for a client with varicella and disseminated herpes zoster, the nurse should implement which types of precautions? Select all that apply. Correct1 Airborne Correct2 Contact 3 Droplet 4 Hazardous wastes Correct5 Standard

Airborne precautions are used for clients known or suspected to have infections transmitted by the airborne transmission route. Contact precautions are used for clients with known or suspected infections transmitted by direct contact or contact with items in the environment. Varicella can be transmitted by airborne and contact routes. Droplet precautions are used for clients known or suspected to have infections transmitted by the droplet route. These infections are caused by organisms in droplets that may travel 3 feet but are not suspended for long periods. Nurses should treat all body excretions, secretions, and moist membranes/tissues, excluding perspiration, as potentially infectious and thus as hazardous wastes. Contact and airborne precautions must be used. Standard precautions are used with every client.

Which intervention should the nurse implement to help prevent atelectasis in a client with fractured ribs as a result of chest trauma? 1 Apply a thoracic binder for support. Correct2 Encourage coughing and deep breathing. 3 Defer pain medication the first day after injury. 4 Position the client face-down on a soft mattress.

Atelectasis with impaired gas exchange is a major complication when clients use shallow breathing to avoid pain; coughing and deep breathing help mobilize secretions. Applying a thoracic binder for support may impede deep breathing and coughing, which help prevent atelectasis. Analgesics are essential to diminish pain caused by breathing and to help motivate the client to cough and deep breathe. The prone position may diminish breathing for both lungs and is contraindicated.

The nurse is caring for a client who has an implanted port and is receiving intravenous fluids. To decrease the risk of infection, the nurse should change the noncoring needle how often? 1 Every 3 days 2 Every 5 days Correct3 Every 7 days 4 Every 9 days

Best practice guidelines indicate that noncoring needles be changed at least every 7 days to decrease risk of infection. Changing a noncoring needle every 3 to 5 days is too frequent and increases the risk for infection as well as client discomfort. Changing a noncoring needle every 9 days increases the risk of infection due to the prolonged length of time the needle is in place.

Which clients should be considered for assessing the carotid pulse? Select all that apply. Correct1 Client with cardiac arrest 2 Client indicated for Allen test Correct3 Client under physiologic shock 4 Client with impaired circulation to foot 5 Client with impaired circulation to hand

Carotid pulse is indicated in clients with physiologic shock or cardiac arrest when other sites are not palpable in the client. Assessment of the ulnar pulse is indicated in clients requiring an Allen test. Assessment of posterior tibial pulse and dorsalis pedis pulse is indicated in clients with impaired circulation to the feet. Assessment of the radial and ulnar pulse is indicated in clients with impaired circulation to the hands.Test-Taking Tip: Be alert for details about what you are being asked to do. In this Question Type, you are asked to select all options that apply to a given situation or client. All options likely relate to the situation, but only some of the options may relate directly to the situation.

A nurse is assessing a school-aged child who has been admitted to the pediatric unit with a diagnosis of acute glomerulonephritis. What clinical finding does the nurse expect? 1 Polyuria 2 Dehydration Correct3 Periorbital edema 4 Decreased blood pressure

Decreased filtration of plasma in the glomeruli results in an excess accumulation of fluid and sodium, producing edema that is first evident around the eyes. Oliguria, not polyuria, occurs. There is an excess, not a deficient amount, of body fluid. Hypertension, not hypotension, occurs.Test-Taking Tip: Calm yourself by closing your eyes, putting down your pencil (or computer mouse), and relaxing. Deep-breathe for a few minutes (or as needed, if you feel especially tense) to relax your body and to relieve tension.

A client who has reached the stage of acceptance in the grieving process appears peaceful but demonstrates a lack of involvement with the environment. How should the nurse address this behavior? 1 Ignore the client's behavior when possible. Correct2 Accept the behavior the client is exhibiting. 3 Explore the reality of the situation with the client. 4 Encourage participation within the client's environment.

Detachment is a coping mechanism that the client needs, especially when faced with the inevitability of death; the nurse should accept this behavior. Ignoring the behavior does not convey a willingness to listen and denies the client's feelings. The client is in acceptance—it is unnecessary to point out the reality of the situation. It is counterproductive to encourage the client to become involved with the environment.

During a routine checkup a client reports concerns over weight gain despite trying juice cleanses and other trend diets. The nurse records the client's weight and BMI at a healthy range, but the client states, "I wish I were as thin as my co-workers." The client is at risk for what culturally-bound condition? 1 Neurasthenia Correct2 Anorexia nervosa 3 Shenjing shuairuo 4 Ataque de nervios

During a routine checkup a client reports concerns over weight gain despite trying juice cleanses and other trend diets. The nurse records the client's weight and BMI at a healthy range, but the client states, "I wish I were as thin as my co-workers." The client is at risk for what culturally-bound condition? 1 Neurasthenia Correct2 Anorexia nervosa 3 Shenjing shuairuo 4 Ataque de nervios

Health promotion efforts within the healthcare system should include efforts related to secondary prevention. Which activities reflect secondary prevention interventions in relation to health promotion? Select all that apply. Correct1 Encouraging regular dental checkups Incorrect2 Facilitating smoking cessation programs Incorrect3 Administering influenza vaccines to older adults Correct4 Teaching the procedure for breast self-examination 5 Referring clients with a chronic illness to a support group

Encouraging regular dental checkups is a secondary prevention activity because it emphasizes early detection of health problems, such as dental caries and gingivitis. Teaching the procedure for breast self-examination is a secondary prevention activity because it emphasizes early detection of problems of the breast, such as cancer. Facilitating smoking cessation programs is a primary prevention activity because it emphasizes health protection against heart and respiratory diseases. Administering influenza vaccines to older adults is a primary prevention activity because it emphasizes health protection against influenza. Referring clients with a chronic illness to a support group is a tertiary prevention activity because it emphasizes care that is provided after illness already exists.

A client who has an above-the-knee amputation (AKA) reports phantom limb sensations. What should the nurse do? Incorrect1 Reassure the client that these sensations will pass. 2 Explain the psychological component involved to the client. 3 Encourage the client to get involved in diversional activities. Correct4 Describe the neurologic mechanisms in language that the client understands.

Explanation of the underlying mechanism usually helps calm anxiety about a phantom pain experience. Reassuring the client that these sensations will pass is false reassurance, because phantom limb sensations may not disappear. Explaining the psychological component involved to the client reinforces the idea that there is something psychologically wrong with the client. Encouraging the client to get involved in diversional activities may distract the client but does not foster awareness of the cause.Test-Taking Tip: Look for options that are similar in nature. If all are correct, either the question is poor or all options are incorrect, the latter of which is more likely. Example: If the answer you are seeking is directed to a specific treatment and all but one option deal with signs and symptoms, you would be correct in choosing the treatment-specific option.

Which internal variable influences health beliefs and practices? 1 Family practices Incorrect2 Cultural background 3 Socioeconomic factors Correct4 Intellectual background

Intellectual background is an internal factor that affects the client's health beliefs and practices. A client's knowledge, educational background, and past experiences influence how a client thinks about health. Family practices, cultural background, and socioeconomic factors are among the external factors that influence health beliefs and practices.

The primary health care provider prescribes contact precautions for a client with hepatitis A. What nursing interventions are required for contact precautions? 1 Private room with the door closed Incorrect2 Gown, mask, and gloves for all persons entering the room Correct3 Gown and gloves when handling articles contaminated by urine or feces 4 Gowns and gloves only when handling the client's soiled linen, dishes, or utensils

Hepatitis A is transmitted via the fecal-oral route; contact precautions must be used when there are articles that have potential fecal or urine contamination. Neither a private room nor a closed door is required; these are necessary only for respiratory (airborne) precautions. Hepatitis A is not transmitted via the airborne route and therefore a mask is not necessary; a gown and gloves are required only when handling articles that may be contaminated. Wearing gowns and gloves only when handling the client's soiled linen, dishes, or utensils is too limited; a gown and gloves also should be worn when handling other fecally contaminated articles, such as a bedpan or rectal thermometer.

The nurse receives an order to prepare a solution for administering a cleansing enema for a 15-year-old client. What is the volume of solution that the nurse should prepare? 1 150 to 250 mL 2 250 to 350 mL 3 300 to 500 mL Correct4 500 to 750 mL

In adolescents, the volume of solution required is 500 to 750 mL. The nurse should prepare 150 to 250 mL of warmed solution for infants. The nurse should prepare 250 to 350 mL of warmed solution for administering a cleansing enema in a toddler. In school-age children, the volume of warmed solution is 300 to 500 mL.Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer.

A nurse notes that a client is in the precontemplation stage of wellness behavior change. What are the characteristics of this stage? Select all that apply. Correct1 The client has no intention of making any changes in the next 6 months. 2 The client will consider a change in health behavior in the next 6 months. Correct3 The client does not show interest in information related to health behavior changes. 4 The client understands that the advantages of health behavior change outweigh the disadvantages. Correct5 The client becomes defensive when confronted with information regarding his or her current health behavior.

In the precontemplation stage of health behavior change, the client has no intention of making changes within the next 6 months. As a result, the client is not interested in information related to changes. The client may become defensive when confronted with information regarding his or her current health behavior. In the contemplation stage, the client considers making changes in health behavior within the next 6 months. A client in the preparation stage understands that the advantages of health behavior change exceed the disadvantages.

Often when a family member is dying, the client and the family are at different stages of grieving. During which stage of a client's grieving is the family likely to require more emotional nursing care than the client? 1 Anger 2 Denial 3 Depression Correct4 Acceptance

In the stage of acceptance, the client frequently detaches from the environment and may become indifferent to family members. In addition, the family may take longer to accept the inevitable death than does the client. Although the family may not understand the anger, dealing with the resultant behavior may serve as a diversion. Denial often is exhibited by the client and family members at the same time. During depression, the family often is able to offer emotional support, which meets their needs.

A registered nurse is educating a nursing student on the various classifications of torts. What acts are classified as intentional torts in nursing practice? Select all that apply. Correct1 Battery Correct2 Assault 3 Negligence 4 Malpractice Correct5 False Imprisonment

Intentional torts include battery, assault, and false imprisonment. Unintentional torts include negligence and malpractice.

A client develops acute respiratory distress, and a tracheostomy is performed. Which intervention is most important for the nurse to implement when caring for this client? Correct1 Encouraging a fluid intake of 3 L daily 2 Suctioning via the tracheostomy every hour 3 Applying an occlusive dressing over the surgical site 4 Using cotton balls to cleanse the stoma with peroxide

Increased fluids help to liquefy secretions, enabling the client to clear the respiratory tract by coughing. Suctioning frequently will irritate the mucosal lining of the respiratory tract, which can result in more secretions. An occlusive dressing will block air exchange; the tracheostomy is now the client's airway. The use of cotton balls around a tracheostomy introduces the risk of aspiration of one of the cotton fibers; gauze should be used.

The nurse assessing an adult understands that the client is experiencing a midlife crisis. Which factor should the nurse attribute to this condition? 1 The client is seeking an occupational direction. Correct2 The client is examining life goals and relationships. 3 The client is directing energy towards achievements. 4 The client is sharing responsibilities in a two-career family.

Individuals between the age of 35 and 43 are vigorously examining their life goals and relationships. These individuals often experience stress or a midlife crisis during this reexamination, which may lead to changes in personal, social, and occupational areas. A young adult who is aware of his or her skills seeks to pursue a degree suitable to his or her desired occupation. A young adult between the ages of 29 to 34 directs enormous energy toward achievement and mastery of the surrounding world. A young adult must share all responsibilities in a two-career family to avoid stress.

What is the most important information the nurse and the rapid response team must keep in mind when caring for a client who just had a cardiac arrest? 1 Age of the client Correct2 How long the client was anoxic 3 Heart rate of the client before the arrest 4 Emergency medications available for the client

Irreversible brain damage will occur if a client is anoxic for more than four minutes. The age of the client does not affect the response by the arrest team. The earlier heart rate is of minimal importance; the rhythm is more significant. Although a variety of emergency medications must be available, their administration is prescribed by the healthcare provider.

A nursing student is listing the primary characteristics that establish nursing as a profession. Which statement made by the student needs correction? 1 "Nursing has a code of ethics for practice." 2 "Nursing has a theoretical body of knowledge." Correct3 "Nurses are simply required to perform specific tasks." 4 "Nurses have autonomy in decision-making and practice."

Nurses are not merely required to perform specific tasks for which they have been trained. Nursing is a profession and, therefore nurses should provide quality client-centered care in a safe, conscientious, and knowledgeable manner. The profession as a whole is required to have a code of ethics for practice. Nursing, as a profession, has a theoretical body of knowledge that helps in developing defined skills, abilities, and norms. As the members of a profession, nurses are required to have autonomy in decision-making and practice.Test-Taking Tip: Multiple-choice questions can be challenging, because students think that they will recognize the right answer when they see it or that the right answer will somehow stand out from the other choices. This is a dangerous misconception. The more carefully the question is constructed, the more each of the choices will seem like the correct response.

A client on immunosuppressive therapy is diagnosed with a peptic ulcer. Which medication might have led to this condition? Correct1 Prednisone 2 Azathioprine 3 Cyclosporine 4 Cyclophosphamide

Prednisone is a corticosteroid that suppresses inflammatory responses. A side effect of prednisone is the development of peptic ulcers. Azathioprine is an immunosuppressant that may cause anemia. Cyclosporine is an immunosuppressant that may cause nephrotoxicity and hypertension. Cyclophosphamide is an immunosuppressant that may cause hemorrhagic cystitis.

Which of these teaching methods are suitable to a preschooler? Select all that apply. Incorrect1 Fostering independent learning Correct2 Encouraging questions and offering explanations 3 Teaching psychomotor skills needed to maintain health Correct4 Using role play, imitation, and play to make learning fun 5 Allowing them to make decisions about health and health promotion

Preschoolers should be encouraged to ask questions and nurses should provide answers through simple explanations and demonstrations. The nurse should instruct parents to include role play and imitations to make learning fun for preschoolers. Independent learning should be encouraged in young and adult clients. School-aged children should be taught about psychomotor skills necessary to maintain health. An adolescent should be allowed to make decisions about his or her health and health promotion.

A nurse is discussing the diet of an 8-month-old infant with the parents. Which foods can an infant of this age on a regular diet safely be fed? Select all that apply. 1 Whole milk Correct2 Pureed pears Correct3 Pureed carrots 4 Soft-boiled eggs Correct5 Mashed sweet potatoes

Pureed pears, pureed carrots, and mashed sweet potatoes are easily digested foods that are usually introduced by 6 months of age. Breast milk or formula, not whole milk, is recommended for the first year of life. It is preferred that eggs be introduced toward the end of the first year because they may produce an allergic response.

Before discharging a 9-year-old child who is being treated for acute poststreptococcal glomerulonephritis (APSGN), what information should the nurse plan to give the parents? Incorrect1 How to obtain the vital signs daily 2 Date on which to return to prepare for renal dialysis Correct3 Instructions about which high-sodium foods to avoid 4 List of activities that will encourage the child to remain active

Sodium is usually limited to control or prevent edema or hypertension until the child is asymptomatic. The child is usually on a regular diet with sodium restrictions (e.g., salty snacks [potato chips, pretzels, tortilla chips] and hot dogs, bacon, bologna, and other processed meats). It is not necessary to check the vital signs daily, but the healthcare provider may suggest weighing the child daily. Usually recovery from APSGN is complete. The condition does not cause such severe kidney damage that dialysis is necessary. The child should not be kept active, because rest is needed until the child is asymptomatic.

While caring for a female client, the nursing student feels tenderness and a lump in the client's breast. The nursing student tells the registered nurse, "I think this client has breast cancer." Which statements of the registered nurse would be appropriate in accordance with the knowing element of Swanson's theory? Select all that apply. 1 "Try to comfort the client." Correct2 "Avoid making assumptions." Correct3 "Assess the client thoroughly." Correct4 "Check for other signs of breast cancer." 5 "Try to provide support and care to the client."

The knowing element of the caring process involves understanding an event. Avoiding assumptions, performing a thorough assessment of the client, and checking for other signs of breast cancer and are related to the knowing element of Swanson's theory of caring. The doing for element includes comforting the client. The caring process of being with involves the nurse providing emotional support.

What interventions should the nurse follow when giving health education to an elderly client? Select all that apply. Correct1 Assess the client for pain before teaching. 2 Take down notes while talking to the client. Correct3 Ensure the client is not preoccupied or anxious. Correct4 Teach one concept at a time according to the client's interest. Incorrect5 Teach a family caregiver if the client does not respond quickly.

The nurse must assess the client for pain and ensure that the client is physically well enough to learn. The nurse must begin teaching after determining that the client is not preoccupied or too anxious to comprehend the material. The nurse must postpone teaching if the client appears disinterested. The nurse should sit facing the client so that the client is able to view the nurse's expressions and lip movement. The nurse should refrain from taking down notes during the teaching because this action conveys a lack of interest. Because older adults process information more slowly than young people, the nurse should allow the client to take some time to respond to the nurse's queries.

The nurse manager asks the nurse, "How would you implement clinical decision making in a group of clients?" Which answer provided by the nurse shows effective critical thinking? Select all that apply. 1 "I will avoid involving clients as decision-makers and participants in care." Correct2 "I will discuss complex cases with other members of the healthcare team." Correct3 "I will identify the nursing diagnoses and collaborative problems of each client." Correct4 "I will consider the period it takes to care for clients whose problems have higher priority." 5 "I will decide to perform activities individually to resolve more than one client problem at a time."

The nurse should discuss complex cases with the other members of the healthcare team. It ensures a smooth transition in the care requirements. As a part of effective critical thinking, the nurse should diagnose the collaborative problems of each client. The nurse should consider the care time for the clients having problems that require high priority. Effective critical thinking requires the nurse to involve clients as decision makers or participants in care. The nurse should decide on combining activities to resolve more than one client problem at a time.Test-Taking Tip: Be alert for details about what you are being asked to do. In this Question Type, you are asked to select all options that apply to a given situation or client. All options likely relate to the situation, but only some of the options may relate directly to the situation.

What should the community nurse teach about the risk of adolescent pregnancy? Correct1 Risk for premature birth 2 Risk for having a large baby 3 Risk for chromosomal defects 4 Risk for increased weight gain Topics

The nurse should teach the community that adolescent pregnancy often leads to premature births. Adolescent pregnancy may lead to low birth weight babies due to lack of nutrition and prematurity. Older women have difficulty in becoming pregnant and they are more likely to have babies with chromosomal defects. An adolescent mother is not at risk for increased weight gain because she is more likely to be affected from lack of nutrition, and exposure to alcohol, drugs, and tobacco.Test-Taking Tip: You have at least a 25% chance of selecting the correct response in multiple-choice items. If you are uncertain about a question, eliminate the choices that you believe are wrong and then call on your knowledge, skills, and abilities to choose from the remaining responses.

When performing a neurologic assessment of a client, a nurse identifies that the client has a dilated right pupil. The nurse concludes that this suggests a problem with which cranial nerve? Correct1 Third 2 Fourth 3 Second 4 Seventh

The third cranial nerve (oculomotor) contains autonomic fibers that innervate the smooth muscle responsible for constriction of pupils. The trochlear nerve is concerned with eye movements; lesions result in diplopia, strabismus, and head tilt to the affected side. The optic nerve is concerned with vision; lesions result in visual field defects and loss of visual acuity. The facial nerve is concerned with facial expressions; lesions result in loss of taste and paralysis of the facial muscles and the eyelids (lids remain open).

A client with an inflamed sciatic nerve is to have a conventional transcutaneous electrical nerve stimulation (TENS) device applied to the painful nerve pathway. When operating the TENS unit, which nursing action is appropriate? 1 Maintain the settings programmed by the healthcare provider. 2 Turn the machine on several times a day for 10 to 20 minutes. Correct3 Adjust the dial on the unit until the client states the pain is relieved. 4 Apply the color-coded electrodes on the client where they are most comfortable.

The voltage or current is adjusted on the basis of the degree of pain relief experienced by the client. Maintaining the settings programmed by the healthcare provider may provide too little or too much stimulation to achieve the desired response. Pain suppressor TENS units must be turned on several times a day for 10 to 20 minutes, not the conventional units. The electrodes should be applied either on the painful area or immediately below or above the area.Test-Taking Tip: Many times the correct answer is the longest alternative given, but do not count on it. Item writers (those who write the questions) are also aware of this and attempt to avoid offering you such "helpful hints."

While receiving an adrenergic beta2 agonist drug for asthma, the client complains of palpitations, chest pain, and a throbbing headache. What is the most appropriate nursing action? Correct1 Withhold the drug and notify the healthcare provider. 2 Tell the client not to worry; these are expected side effects from the medicine. 3 Give instructions to breathe slowly and deeply for several minutes. 4 Explain that the effects are temporary and will subside as the body becomes accustomed to the drug.

These drugs cause increased heart contraction (positive inotropic effect) and increased heart rate (positive chronotropic effect). If toxic levels are reached, side effects occur, and the drug should be withheld until the healthcare provider is notified. Telling the client not to worry and that these are expected side effects from the medicine is false reassurance and a false statement. Controlled breathing may be helpful in allaying a client's anxiety; however, the drug may be producing adverse effects and should be withheld.Test-Taking Tip: Come to your test prep with a positive attitude about yourself, your nursing knowledge, and your test-taking abilities. A positive attitude is achieved through self-confidence gained by effective study. This means (a) answering questions (assessment), (b) organizing study time (planning), (c) reading and further study (implementation), and (d) answering questions (evaluation).

Which client needs a correction in the nursing intervention? 1 Client 1 Correct2 Client 2 3 Client 3 4 Client 4

When a child has acute pain, oral dosage forms of analgesics should be given. These medications must be given before the pain intensifies, so the nursing intervention for client 2 needs correction. In pediatrics, distraction and creative imagery during the drug administration can help to distract the child from any pain or fear, so the nursing intervention for client 1 is appropriate. In pediatrics, opioids can cause certain changes like nausea and vomiting. Administering the medications with meals can help reduce the GI upset, so the nursing intervention for client 3 is appropriate. While administering suppositories to pediatric clients, care should be taken that an adult dose is halved, split, or divided to reduce the risk of overdose, so the nursing intervention for client 4 is appropriate.

A nurse is caring for a client with pain after surgery. The nurse takes the blood pressure and pulse rate of the client and asks the client to rate the level of pain on the pain scale. Which standard of practice does the nurse perform? 1 Planning 2 Diagnosis Correct3 Assessment 4 Implementation

When a nurse collects comprehensive data relevant to the client's health or the situation, it is considered assessment. In the given scenario, the nurse is assessing the client to minimize pain. Planning refers to instances when a nurse develops a plan to attain expected outcomes. Diagnosis refers to instances when the nurse analyzes the assessment data to determine the diagnoses or issues. Implementation refers to instances when the nurse implements the identified plan.Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer.

The nurse provides back massage therapy to a client complaining of back pain. The nurse then monitors the client on an hourly basis to check if the client is feeling comfortable. Which standard of practice does the nurse perform? Correct1 Evaluation 2 Consultation 3 Coordination of care 4 Outcomes identification

When the nurse evaluates progress toward attainment of outcomes, it is referred to as evaluation. When the nurse monitors the client on an hourly basis to check if the client is feeling comfortable after giving a back massage, this is considered evaluation. Consultation is when a nurse provides consultation to influence the identified plan, enhance the abilities of others, and effect change. Coordination of care is when a nurse coordinates care delivery with other team members. Outcomes identification is when a nurse identifies expected outcomes for a plan individualized to the client or the situation.Test-Taking Tip: Read the question carefully before looking at the answers: (1) Determine what the question is really asking; look for key words; (2) Read each answer thoroughly and see if it completely covers the material asked by the question; (3) Narrow the choices by immediately eliminating answers you know are incorrect.

While performing the physical assessment of an infant, the nurse notices the infant has developed a color preference for red and yellow. What is most likely to be the age of the infant? 1 4 weeks 2 8 weeks 3 15 weeks Correct4 20 weeks

An infant develops a color preference for yellow and red between 20 to 28 weeks of age. At 4 weeks, the infant can follow a range of 90 degrees. Between 6 to 12 weeks of age, the infant develops peripheral vision to 180 degrees. Between 12 to 20 weeks of age, the infant is able to accommodate to near objects.Test-Taking Tip: Sometimes the reading of a question in the middle or toward the end of an exam may trigger your mind with the answer or provide an important clue to an earlier question.

The nurse leader is teaching the staff that the health care provider continuously strives to work effectively within the cultural context of a client. Which cultural principle is the nurse leader explaining? 1 Cultural diversity 2 Cultural sensitivity 3 Cultural imposition Correct4 Cultural competence

Cultural competence is the process in which the health care provider continuously strives to achieve the ability to effectively work within the cultural context of a client, individual, family, or community. Cultural diversity describes a vast range of cultural differences among individuals or groups. Cultural sensitivity describes the affective behaviors in individuals such as the capacity to feel, convey, and react to ideas, habits, and customs or traditions unique to a group of people. Cultural imposition is defined as the tendency of an individual or group to impose their values, beliefs, and practices on another culture for various reasons.

A new mother asks the nurse administering erythromycin ophthalmic ointment to her newborn why her baby must be subjected to this procedure. What is the best response by the nurse? 1 "It will keep your baby from going blind." 2 "This ointment will protect your baby from bright lights." 3 "There is a law that newborns must be given this medicine." Correct4 "This antibiotic helps keep babies from contracting eye infections."

Erythromycin ophthalmic ointment is used to treat gonorrhea and Chlamydia infections, which may be transmitted during birth. It is administered prophylactically. Although it will prevent the newborn from becoming blind if the infant is born with these infections, there is not enough information in the answer to help the mother understand how the ointment prevents blindness. The antibiotic ointment is not administered to protect the newborn from bright lights. Newborns are in fact required by law to receive erythromycin ophthalmic ointment, but simply stating this does not explain why it is administered.

The mother of a 6-year-old boy tells the nurse in the pediatric clinic that her son has become incontinent of stool. The nurse plans to assess the child to determine the cause of his encopresis. In what order should the nurse perform the assessments? Correct1.Bowel habits Correct2.Nutrition history Correct3.Psychosocial factors Correct4.Physical examination

First, a physical cause of the encopresis should be investigated. This includes the toilet training process and changes in bowel habits or routines. If there are no changes in bowel pattern, a nutrition history may reveal any changes in the child's eating habits that caused the encopresis. Next, the nurse should explore psychosocial factors that may have influenced the development of the encopresis. Finally, a physical examination should be performed.

In which order should the nurse explain the process of phagocytosis? Correct1.Exposure/invasion Incorrect2.Recognition Incorrect3.Attraction Incorrect4.Adherence Correct5.Cellular ingestion Correct6.Phagosome formation Correct7.Degradation

Exposure and invasion occur as the first step in response to injury or invasion. Attraction is the second step because phagocytosis can occur only when the white blood cell comes into direct contact with the target. Adherence allows the phagocytic cell to bind to the surface of the target. Recognition occurs when the phagocytic cell sticks to the target cell and "recognizes" it as non-self. Cellular ingestion is needed because phagocytic destruction occurs inside the cell. Degradation is the final step. The enzymes in the phagosome digest the engulfed target.Test-Taking Tip: In this Question Type, you are asked to prioritize (put in order) the options presented. For example, you might be asked the steps of performing an action or skill such as those involved in medication administration.

A client has a severe, unilateral throbbing headache that has lasted for 2 days. What should be the priority nursing care? 1 Administering gabapentin Correct2 Administering sumatriptan 3 Administering propranolol 4 Administering botulinum toxin A

A client with a unilateral throbbing headache which lasts from 4 to 72 hours is likely a migraine. The nurse should administer sumatriptan to reduce the symptoms of migraines, but it is most effective when taken at the onset of a migraine headache. Gabapentin is an antiseizure medication that is used in migraine prevention. Propranolol is an antihypertensive used as a prophylactic treatment. Botulinum toxin A is an effective prophylactic medication for treating chronic migraines and for migraines that do not respond to other medications.

What is the rationale for performing sponge, needle, and instrument counts in the operating room? 1 The hospital is not liable if a client is injured due to a retained sponge or instrument. 2 The nursing student is liable for client injuries due to a retained sponge or instrument. Correct3 A nurse is responsible for performing sponge and instrument counts as a part of routine surgical standards. 4 The primary healthcare provider is responsible for providing an accurate count of sponges and instruments.

A nurse should perform sponge and instrument counts in the operating room as part of routine surgical standards to help prevent injuries and lawsuits. If a client suffers from an injury due to a retained sponge or instrument, the hospital is liable if the nurse had recorded an accurate count. A nursing student is not allowed to perform vital tasks such as counting sponges and instruments in the operating room. Even though the primary healthcare provider may insert sponges and instruments in a client, the provider relies on the nurse to maintain an accurate count at the end of the procedure.

The primary healthcare provider suspects pituitary gland dysfunction in a female client. Which diagnostic test would the primary healthcare provider suggest to the client? 1 Estradiol test Correct2 Prolactin test 3 Sims-Huhner test 4 Papanicolaou (Pap) test

A prolactin test is used to detect pituitary gland dysfunction that causes amenorrhea. Therefore the primary healthcare provider would suggest that the client have a prolactin test to determine if the client does or does not have any pituitary gland dysfunction. Estradiol is tested to determine functioning of the ovaries. In men, the estradiol test is used to detect testicular tumors. The Sims-Huhner test is used to evaluate the hostility of the cervix for passage of sperm from the vagina into the uterus. The Papanicolaou (Pap) test detects malignancies, particularly cervical cancer.

A nurse should employ which technique to maintain surgical asepsis? Correct1 Change the sterile field after sterile water is spilled on it. Incorrect2 Put on sterile gloves and then open a container of sterile saline. 3 Place a sterile dressing no more than half an inch from the edge of the sterile field. 4 Clean the surgical area with a circular motion, moving from the outer edge toward the center.

A sterile field is considered contaminated when it becomes wet. Moisture can act as a wick and allow microorganisms to contaminate the sterile field. The outsides of containers and packages are not considered sterile and sterile gloves are considered contaminated when touching either of these items. Items on the sterile field should be no less than 1 inch from the outer border or edge of the sterile field; any less is not considered sterile. Surgical areas or wounds should be cleaned from the inside edges to the outside edges to prevent recontamination.

Which outcome best demonstrates a healthcare institution's commitment to providing a supportive environment for its psychiatric nursing staff? 1 Psychiatric nursing units are well staffed with qualified personnel. 2 The psychiatric units are equipped with the most modern client care equipment. Correct3 Psychiatric nurses are regularly recognized for their contributions to client healthcare. 4 The psychiatric nursing staff is represented in each client's multidisciplinary healthcare team.

A supportive nursing environment is one that fosters and supports open, honest communication among all disciplines involved in a client's care. This demonstrates respect for the professional psychiatric nurses and their influence on client healthcare. A sufficient number of qualified nursing personnel is a requirement on any nursing unit and shows a commitment to client care but not necessarily support for the unit's nursing staff. A modern, well-equipped nursing unit shows a commitment to client care but not necessarily support for the unit's nursing staff. Recognition of professional levels of nursing care is likely to have a positive effect on nursing morale but does not necessarily foster a supportive nursing environment.

A healthcare provider prescribes a standard walker (pick-up walker with rubber tips on all four legs). The nurse identifies what clinical findings that indicate the client is capable of using a standard walker? 1 Weak upper arm strength and impaired stamina 2 Weight bearing as tolerated and unilateral paralysis 3 Partial weight bearing on the affected extremity and kyphosis Correct4 Strong upper arm strength and non-weight bearing on the affected extremity

A walker with four rubber tips on the legs requires more upper body strength than a rolling walker. A client who is non-weight bearing on the affected extremity is able to use a standard walker. A rolling walker is more appropriate for a client with weak upper arm strength and impaired stamina who is less able to lift up and move a walker with four rubber tips. A client with unilateral paralysis is not a candidate for a standard walker; the client must be able to grip and lift the walker with both upper extremities and move the walker forward. A rolling walker is more appropriate for this client. A client with kyphosis is less able to lift up and move a walker with four rubber tips.

A nurse manager works on a unit where the nursing staff members are uncomfortable taking care of clients from cultures that are different from their own. How should the nurse manager address this situation? 1 Assign articles about various cultures so that they can become more knowledgeable. 2 Relocate the nurses to units where they will not have to care for clients from a variety of cultures. 3 Rotate the nurses' assignments so they have an equal opportunity to care for clients from other cultures. Correct4 Plan a workshop that offers opportunities to learn about the cultures they might encounter while at work.

A workshop provides an opportunity to discuss cultural diversity; this should include identification of one's own feelings. Also, it provides an opportunity for participants to ask questions. Although articles provide information, they do not promote a discussion about the topic. Relocation is not feasible or desirable; clients from other cultures are found in all settings. Rotating the nurses' assignments probably will increase tension on the unit.Test-Taking Tip: You have at least a 25% chance of selecting the correct response in multiple-choice items. If you are uncertain about a question, eliminate the choices that you believe are wrong and then call on your knowledge, skills, and abilities to choose from the remaining responses.

When planning discharge teaching for a young adult, the nurse should include the potential health problems common in this age group. What should the nurse include in this teaching plan? 1 Kidney dysfunction 2 Cardiovascular diseases 3 Eye problems, such as glaucoma Correct4 Accidents, including their prevention

Accidents are common during young adulthood because of immature judgment and impulsivity associated with this stage of development. Kidney dysfunction is not a problem specific to any one stage of growth. Cardiovascular disease is a common health problem in middle adulthood. Glaucoma is a common health problem in older adults.

The nurse is creating a health promotion series for a local community. Which conditions should the nurse include in the program because they are current leading causes of death in the United States? Select all that apply. Correct1 Stroke Correct2 Cancer Correct3 Diabetes 4 Accidents Incorrect5 Arthritis

According to the Centers for Disease Control and Prevention (2016), the leading causes of death in the United States (US) included stroke, cancer, diabetes, and accidents. Heart disease, chronic lower respiratory diseases, Alzheimer's disease, influenza/pneumonia, and suicide are also included on the list. Arthritis is not a current leading cause of the death in the US, although it is a chronic disease that causes great suffering for client with the condition.

A registered nurse is explaining the Quality and Safety Education for Nurses (QSEN) competencies to a nursing student. What information should the nurse provide about the competency teamwork and collaboration? 1 "A nurse should be able to use information and technology to communicate, manage knowledge, mitigate errors, and support decision-making." Incorrect2 "A nurse should be able to understand that the client is the source of control and full partner when providing compassionate and coordinated care." 3 "A nurse should be able to implement improvement methods to design and test changes in order to improve the quality and safety of the healthcare system." Correct4 "A nurse should be able to work effectively within nursing and interprofessional teams by promoting open communication and shared decision-making to provide client care."

According to the QSEN competency called teamwork and collaboration, a nurse should be able to work effectively within nursing and interprofessional teams, promoting open communication and shared decision-making to provide quality client care. According to the QSEN competency called informatics, a nurse should be able to use information and technology to communicate, manage knowledge, mitigate errors, and support decision-making. This helps to deliver optimal healthcare. As per the QSEN competency called patient-centered care, a nurse should be able to understand that the client is the source of control and full partner when the healthcare team provides compassionate and coordinated care. According to the QSEN competency called quality improvement, a nurse should be able to implement improvement methods to design and test changes in order to improve the quality and safety of the healthcare system.

While assessing the vital signs of an elderly alcoholic client with symptoms of cardiovascular collapse, the nurse notes that the client's skin is warm. What other findings does the nurse expect to observe? Select all that apply. Correct1 Body temperature of 84.2 °F Incorrect2 Body temperature of 100.6 °F Correct3 Blood pressure of 100/62 mmHg Correct4 Respiratory rate of 12 breaths/minute Incorrect5 Respiratory rate of 16 breaths/minute

Alcohol acts as a vasodilator in the body; therefore, it causes dilation of surface blood vessels and results in hypothermia due to loss of body heat. However, the skin of the alcoholic client gives a false sensation of warmth, even while the client shows symptoms of hypothermia. Therefore the nurse finds the body temperature of the client is less than 86 °F. Cardiovascular collapse can result in clients with severe hypothermia. During severe hypothermic conditions, the blood pressure of the client decreases. Hypothermia lowers the respiratory rate; therefore, the client may have a respiratory rate of 12 breaths/minute. As the client does not have hyperthermia, he or she does not have a body temperature of 100.6 °F. The normal respiratory rate for elderly clients is in the range of 12 to 18 breaths per minute. Individuals with hypothermia may not have a normal respiratory rate of 16 breaths/minute.

A nurse in the pediatric clinic receives a call from the mother of an infant who has been prescribed digoxin. The mother reports that she forgot whether she gave the morning dose of digoxin. How should the nurse respond? 1 "Give the next dose immediately." 2 "Wait 2 hours before giving the medication." Correct3 "Skip this dose and give it at the next prescribed time." 4 "Take the baby's pulse and give the medication if it's more than 90 beats/min."

An additional dose may cause overdosage, leading to toxicity; it is better to skip the dose. Giving the dose without waiting may cause an overdose, which could result in toxicity. Even waiting 2 hours may cause an overdose, leading to toxicity. Taking the pulse is not a reliable method for determining a missed dose; 90 to 110 beats/min is within the expected range for this age.

A client is admitted with a diagnosis of acute pancreatitis. The medical and nursing measures for this client are aimed toward maintaining nutrition, promoting rest, maintaining fluid and electrolytes, and decreasing anxiety. Which interventions should the nurse implement? Select all that apply. 1 Provide a low-fat diet Correct2 Administer analgesics Correct3 Teach relaxation exercises 4 Encourage walking in the hall Correct5 Monitor cardiac rate and rhythm 6 Observe for signs of hypercalcemia

Analgesics, histamine-receptor antagonists, and proton pump inhibitors may be administered to decrease gastrointestinal activity and the secretion of pancreatic enzymes. Relaxation will decrease the metabolic rate, which will decrease gastrointestinal activity, including the secretion of pancreatic enzymes. Monitoring cardiac rate and rhythm is necessary to assess for hypokalemia and fluid volume changes. The client would be kept nothing by mouth to decrease gastrointestinal activity and the secretion of pancreatic enzymes. Walking increases the metabolic rate, which will increase gastrointestinal activity, including the secretion of pancreatic enzymes. Hypocalcemia, not hypercalcemia, occurs because of calcium and fatty acids combining during fat necrosis.

Which action demonstrates the "analyticity" concept of a critical thinker? Select all that apply. Incorrect1 The nurse is organized and focused. 2 The nurse trusts one's own reasoning process. Incorrect3 The nurse accepts multiple solutions to a problem. Correct4 The nurse uses evidence-based knowledge for clinical decision-making. Correct5 The nurse anticipates possible results or consequences in a given situation.

Analyticity is one of the concepts of a critical thinker and involves the use of evidence-based knowledge for clinical decision-making. This skill may also help in anticipating possible results or consequences of a procedure or a given situation. Being organized and focused reflects systematicity. Trusting one's own reasoning process reflects self-confidence. Accepting multiple solutions to a problem reflects maturity.

A child with acute poststreptococcal glomerulonephritis requests a snack. Which is the most therapeutic selection of food the nurse can provide? 1 Peanuts 2 Pretzels 3 Bananas Correct4 Applesauce

Applesauce provides nutrition without large additional amounts of potassium and sodium. Peanuts and pretzels are high in sodium, which increases fluid retention. Bananas are high in potassium, which is contraindicated.

What does a community-based nurse do as a change agent? Select all that apply. Correct1 The nurse empowers clients and their families to creatively solve problems. Correct2 The nurse works with clients to solve problems and helps clients identify an alternative care facility. 3 The nurse helps clients gain the skills and knowledge needed to provide self-care. Correct4 The nurse empowers clients to become instrumental in creating change within a health care agency. Incorrect5 The nurse does not make decisions but rather helps clients reach decisions that are best for them.

As a change agent, the nurse empowers clients and families to creatively solve problems. As a change agent, the nurse works with clients to solve problems and helps them identify an alternative care facility. As a change agent, the nurse empowers clients to become instrumental in creating change within a health care agency. As an educator, the nurse helps clients gain the skills and knowledge needed for self-care. As a counselor, the nurse does not make decisions, but rather helps clients reach decisions that are best for them.Test-Taking Tip: Be alert for details about what you are being asked to do. In this Question Type, you are asked to select all options that apply to a given situation or client. All options likely relate to the situation, but only some of the options may relate directly to the situation.

What role is the nurse expected to have in a community-based nursing practice if there is a sudden spread of malaria? 1 Educator 2 Collaborator Correct3 Epidemiologist 4 Client advocate

As an epidemiologist, the nurse is responsible for community surveillance for risk factors such as the sudden spread of malaria. An epidemiologist nurse protects the health level of the community, develops sensitivity to changes in the health status of the community, and helps identify the cause of these changes. As an educator in a community-based setting, the nurse provides knowledge to clients and families so they can learn how to care for themselves. As a collaborator in a community-based nursing practice, the nurse collaborates with hospice staff, social workers, and pastoral care to initiate a plan to support end-of-life care for the client and support the family. As a client advocate in a community-based setting, the nurse provides necessary information for clients to make informed decisions in choosing and using services.

Which of these cultural groups is known to practice Ayurveda to prevent and treat illness? 1 East Asian 2 Hispanic Correct3 Asian Indian 4 Native American

Asian Indians are known to practice Ayurveda (a healing system comprised of a combination of dietary, herbal, and other naturalistic therapies) to prevent and treat illness. Many East Asians use yin and yang treatment to restore balance. Hispanic groups tend to use a combination of prayers, herbs, and other rituals to treat traditional illnesses. Native Americans are known to rely on a combination of prayers, chanting, and herbs to treat illnesses caused by supernatural, psychological, and physical factors.

The nurse is caring for an Asian client who had a laparoscopic cholecystectomy six hours ago. When asked whether there is pain, the client smiles and says, "No." What should the nurse do? Correct1 Monitor for nonverbal cues of pain 2 Check the pressure dressing for bleeding 3 Assist the client to ambulate around his room 4 Irrigate the client's nasogastric tube with sterile water

Asian clients tend to be stoic regarding pain and usually do not acknowledge pain; therefore, the nurse should assess these clients further. This type of surgery does not require pressure dressings. First, the client must be assessed further for pain. If there is pain, the client should ambulate after, not before, receiving pain medication. Postoperatively, nasogastric tubes are irrigated when needed, not routinely.

A registered nurse is educating a nursing student about assault. What information should the registered nurse provide? 1 "Assault refers to any action of intentional touching without consent." 2 "A procedure performed without the consent of the client is considered assault." Correct3 "Assault refers to any action that places a client in apprehension of harmful contact without consent." 4 "Threatening a client before performing a medical procedure is not considered assault."

Assault does not require actual physical contact. Any action that places the client in apprehension of a harmful contact without consent is considered to be assault. Battery refers to any action of intentional touching without consent. Medical procedures performed without the consent of the client are considered to be battery.

A physically ill client is being verbally aggressive to the nursing staff who is performing intravenous therapy on the client. What is the most appropriate initial nursing response? Correct1 Tell me why you are upset. Incorrect2 Explore the situation with the client. 3 Withdraw from contact with the client. 4 Tell the client the reason for the staff's actions

At this time the client is using this behavior as a defense mechanism. Using an open-ended question regarding the client's verbal aggression can be an effective interpersonal technique because it is nonjudgmental and allows the client to elaborate on feelings at the time. During periods of overt hostility, perceptions are altered, making it difficult for the client to evaluate the situation rationally. Withdrawal signifies nonacceptance and rejection. The staff may be the target of a broad array of emotions; by focusing on only behaviors that affect the staff, the full scope of the client's feelings are not considered.

In today's healthcare environment, the nurse is confronted with multiple stressors while attempting to meet the demands of the nurse educator role. Which condition is the most common major stressor that diminishes teaching effort effectiveness? 1 Extent of informed consumerism Correct2 Limited time to engage in teaching 3 Variety of cultural beliefs that exist 4 Deficient motivation of adult learners

Because of the variety of factors competing for the nurse's time, efficient use of the time available for teaching is essential to meet the standards of care and legal responsibilities of the nurse. The increased awareness and knowledge of health issues by consumers may provide a foundation on which the teaching plan may be built; informed consumerism should be viewed as positive, not negative. Assessing cultural beliefs is part of the initial and continuing assessment of clients; this should not cause additional stress when teaching. Generally, adults are motivated, independent learners, and the nurse teacher should be a facilitator of learning.

A client had a rubella infection (German measles) during the fourth month of pregnancy. At the time of the infant's birth, the nurse places the newborn in the isolation nursery. Which type of infection control precautions should the nurse institute? 1 Enteric 2 Contact Correct3 Droplet 4 Standard

Because the rubella virus is found in the respiratory tract and urine, isolation is necessary; rubella is spread by droplets from the respiratory tract. "Enteric precautions" is an outdated term; the techniques used with this precaution are incorporated under contact precautions, and the techniques used with contact precautions are incorporated under standard precautions. The use of standard precautions alone is unsafe; additional precautions must be implemented to protect the nurse from droplet-transmitted infection.

When the nurse arrives at 8:00 am, a client has a 1000 mL bag of D5W hanging, with 450 mL infused during the prior shift. The IV infusion is to deliver 100 mL per hour. At 11:00 am the healthcare provider changes the prescription for the intravenous solution to 1000 mL 0.9% sodium chloride to be administered at 75 mL per hour and changes the dietary order from nothing by mouth to clear liquids. From 1:00 pm to the end of the 12-hour shift at 8:00 pm, the client has 4 oz (120 mL) of apple juice, a half cup of tea, a half cup of gelatin, and 6 oz (180 mL) of water. How many milliliters should the nurse document as the client's total fluid intake for the 12-hour shift? Record your answer using a whole number. ___ mL

Between 8:00 am and 11:00 am, 100 mL per hour were infused. Between 11:00 am and 8:00 pm, 75 mL per hour were infused. A half cup is 4 oz, and each ounce is equivalent to 30 mL, so the juice, tea, and gelatin each provided 120 mL. Water intake was 180 mL. The 450 mL infused during the prior shift should not be included.Test-Taking Tip: When taking the NCLEX exam, an on-screen calculator will be available for you to determine your response, which you will then type in the provided space.

A client is to receive a transfusion of packed red blood cells (PRBCs). The nurse should prepare for the transfusion by priming the blood IV tubing with which solution? 1 Lactated Ringer solution 2 5% dextrose and water Correct3 0.9% normal saline 4 0.45% normal saline

Blood and blood products for transfusion should be infused/diluted only with 0.9% normal saline solution. Solutions other than normal saline are incompatible and may cause RBC destruction by hemolysis.Test-Taking Tip: Read every word of each question and option before responding to the item. Glossing over the questions just to get through the examination quickly can cause you to misread or misinterpret the real intent of the question.

A client who had a cerebrovascular accident (also known as a "brain attack") becomes incontinent of feces. What is the most important nursing action to support the success of a bowel training program? 1 Using medication to induce elimination Correct2 Adhering to a definite time for attempted evacuations Incorrect3 Considering previous habits associated with defecation 4 Timing of elimination to take advantage of the gastrocolic reflex

Bowel training is a program for the development of a conditioned reflex that controls regular emptying of the bowel. The key to success is adherence to a strict time for evacuation based on the client's individual schedule. The indiscriminate use of laxatives can result in dependency. Although previous habits should be considered, the brain attack affects the responses of the client by altering motility, peristalsis, and sphincter control despite adherence to previous habits. The passage of food into the stomach does stimulate peristalsis, but it is only one factor that should be considered when planning a specific time for evacuation.Test-Taking Tip: Attempt to select the answer that is most complete and includes the other answers within it. For example, a stem might read, "A child's intelligence is influenced by what?" and three options might be genetic inheritance, environmental factors, and past experiences. The fourth option might be multiple factors, which is a more inclusive choice and therefore the correct answer.

A nurse is assessing the urine of a client with a urinary tract infection. Which assessment finding is consistent with a urinary tract infection? 1 Smoky Correct2 Cloudy 3 Orange-amber 4 Yellow-brown

Cellular debris, white blood cells, bacteria, and pus can cause the urine to become cloudy. Dark, smoky urine usually suggests hematuria. Orange-amber color of urine may indicate concentrated urine; also, it can be caused by phenazopyridine or foods such as beets. Yellow-brown to dark color of urine indicates excessive bilirubin.Test-Taking Tip: Be aware that information from previously asked questions may help you respond to other examination questions.

A nurse is taking care of a client who is extremely confused and experiencing bowel incontinence. What measures can the nurse take to prevent skin breakdown in this client? 1 Instruct the client to call for help with elimination needs; answer the client's call light immediately to prevent incontinence. 2 Place a waterproof pad under the client to prevent incontinence and soiling the linens. Correct3 Check the client's buttocks at least every 2 hours; clean the client immediately after discovering incontinence. 4 Offer toileting to the client every 2 hours to prevent incontinence.

Checking the client for incontinence and cleaning immediately after each episode will prevent skin irritation by the digestive enzymes in stool. Placing a call bell within reach and instructing the client to call for help with elimination needs is not helpful, because the client is confused and unable to use the call bell. Placing a waterproof pad beneath the client helps to prevent soiling of the bed but does not keep feces away from the client's skin and therefore does not prevent skin breakdown. Toileting the client every 2 hours to prevent incontinence is not helpful, because the client is confused and unable to follow commands and has no control over elimination needs.

While a nurse is conducting an initial assessment on a client, which classic sign would alert the nurse that the client has chronic obstructive pulmonary disease (COPD)? Correct1 Barrel chest 2 Cyanosis 3 Hyperventilation 4 Lordosis

Clients with COPD often develop a barrel chest over time because of air being trapped, thus resulting in enlarged lungs and thoracic cavity. This also causes the lungs to have less flexibility. Cyanosis is a bluish discoloration, especially of the skin and mucous membranes, caused by excessive concentration of deoxyhemoglobin in the blood caused by deoxygenation. COPD sufferers can exhibit this, but barrel chest is the most obvious sign, as other respiratory/cardiovascular disorders can cause cyanosis as well. Hyperventilation is the act of breathing faster or deeper than normal, which causes excessive expulsion of circulating carbon dioxide. This causes the arterial concentration of carbon dioxide (PaCO2) to fall below normal, raising blood pH, and results in alkalosis. COPD sufferers can experience hyperventilation, but barrel chest is the classic sign of COPD. Lordosis is an unusual inward curving of the spine in the lower part of the back. It can be considered medically significant; however, it is not associated with classic signs of COPD.Test-Taking Tip: The night before the examination you may wish to review some key concepts that you believe need additional time, but then relax and get a good night's sleep. Remember to set your alarm, allowing yourself plenty of time to dress comfortably (preferably in layers, depending on the weather), have a good breakfast, and arrive at the testing site at least 15 to 30 minutes early.

The nurse is asking a client with arthritis questions in order to collect information. Which questions asked by the nurse are closed-ended questions? Select all that apply. Correct1 "Are you having pain?" 2 "Tell me how your pain has been." 3 "Describe how your husband is helping you at home." Correct4 "Do you think the medication is helping you to get pain relief?" 5 "Give me an example of a method which helps you to get pain relief at home."

Closed-ended questions limit the answers to one or two words. These queries help to identify specific problem areas and provide additional questions. When the nurse asks, "Are you having pain?" the client can reply either yes or no. Similarly when the nurse asks the client "Do you think the medication is helping you to get pain relief?" the answers can be either yes or no. Therefore these two questions are closed-ended questions. Open ended-questions are client-centered and require a complete explanation.

Which characteristics influence the intrinsic factors that determine motivation? Select all that apply. 1 Family 2 Cultural values Correct3 Cognitive level Correct4 Self-confidence Correct5 Emotional readiness

Cognitive level, self-confidence, and emotional readiness are intrinsic factors that determine motivation. Family and the cultural values are extrinsic factors that determine motivation.

A 3-year-old preschooler has been hospitalized with nephrotic syndrome. What is the best way for the nurse to evaluate fluid retention or loss? 1 Measuring the abdominal girth daily Incorrect2 Having the child urinate in a bedpan 3 Testing the child's urine for proteinuria Correct4 Weighing the child at the same time each day

Comparison of daily weights is the most accurate way to assess fluid retention or loss. Having the child urinate in a bedpan is difficult for a child of this age, and the findings will not be accurate. Measuring the abdominal girth daily is way to assess the degree of ascites; it indirectly measures fluid retention. Assessment of urine for protein gives information about the disease process, but not about the amount of fluid retention.STUDY TIP: Becoming a nursing student automatically increases stress levels because of the complexity of the information to be learned and applied and because of new constraints on time. One way to decrease stress associated with school is to become very organized so that assignment deadlines or tests do not come as sudden surprises. By following a consistent plan for studying and completing assignments, you can stay on top of requirements and thereby prevent added stress.

A school-aged child with type 1 diabetes is admitted to the pediatric unit in ketoacidosis. What sign of ketoacidosis does the nurse expect to identify when assessing the child? 1 Sweating Correct2 Hyperpnea 3 Bradycardia 4 Hypertension

Deep, rapid breathing (hyperpnea) is an attempt by the respiratory system to eliminate excess carbon dioxide; it is a compensatory mechanism associated with metabolic acidosis. Sweating is a physiological response to hypoglycemia. Tachycardia, not bradycardia, results from the hypovolemia caused by the polyuria associated with ketoacidosis. Hypotension, not hypertension, may result from the decreased vascular volume caused by the polyuria associated with ketoacidosis.Test-Taking Tip: Anxiety leading to an exam is normal. Reduce your stress by studying often, not long. Spend at least 15 minutes every day reviewing the "old" material. This action alone will greatly reduce anxiety. The more time you devote to reviewing past material, the more confident you will feel about your knowledge of the topics. Start this review process on the first day of the semester. Don't wait until the middle to end of the semester to try to cram information.

A client is admitted to a psychiatric hospital with the diagnosis of schizoid personality disorder. Which initial nursing intervention is a priority for this client? 1 Helping the client enter into group recreational activities 2 Convincing the client that the hospital staff is trying to help Correct3 Helping the client learn to trust the staff through selected experiences 4 Limiting the client's contact with others while in the hospital

Demonstrating that the staff can be trusted is a vital initial step in the therapy program. The client is not ready to enter group activities yet and will not be until trust is established. Even proof will not convince the client with a schizoid personality that feelings of distrust are false. Arranging the client's contact with others is not realistic even if it is possible; limiting contact with other clients will not enhance trust.

When planning nursing care for a 5-year-old child with acute poststreptococcal glomerulonephritis, what should the nurse emphasize that the child and family must maintain? 1 A bland diet high in protein 2 Bed rest lasting at least 4 weeks Correct3 Isolation from children with infections 4 A daily intramuscular dose of penicillin

During the acute stage, anorexia and general malaise lower the child's resistance to infection. A bland diet is not necessary, but high-protein and high-sodium foods should be avoided. Bed rest is not a necessary restriction. It is encouraged when the child is easily fatigued. Antibiotics are not necessary for all children with acute glomerulonephritis, only those with persistent streptococcal infections. The intramuscular route is not used.

Four nurse leaders are performing Gardner's tasks. Which nurse leader is implementing Gardner's task of "serving as symbol"? Correct1 A 2 B 3 C 4 D

Gardner's task of "serving as symbol" includes the representation of the nursing profession, values, and beliefs of the organization to clients, their families, and other community groups. Therefore nurse leader A implements Gardner's task of "serving as symbol." Being honest and keeping promises to clients and families in the nursing profession indicates the implementation of Gardner's task of "developing trust" by nurse leader B. Nurse leader C implements Gardner's task of "managing" by assisting clients and their families with planning, priority setting, and decision making. Nurse leader D implements Gardner's task of "managing" by ensuring that the organizational systems work on the client's behalf.Test-Taking Tip: Chart/exhibit items present a situation and ask a question. A variety of objective and subjective information is presented about the client in formats such as the medical record (e.g., laboratory test results, results of diagnostic procedures, progress notes, healthcare provider orders, medication administration record, health history), physical assessment data, and assistant/client interactions. After analyzing the information presented, the test taker answers the question. These questions usually reflect the analyzing level of cognitive thinking.

What principal components are associated with a nurse's time management skill? Select all that apply. 1 Autonomy Correct2 Goal setting Correct3 Priority setting Correct4 Interruption control 5 Right communication What principal components are associated with a nurse's time management skill? Select all that apply. 1 Autonomy Correct2 Goal setting Correct3 Priority setting Correct4 Interruption control 5 Right communication

Goal setting, priority setting, and interruption control forms the principal components of time management. Autonomy is an important component in the decision-making process. Right communication is considered one of the rights of delegation.

A nurse is teaching continuing care assistants about ways to prevent the spread of infection. It would be appropriate for the nurse to emphasize that the cycle of the infectious process must be broken, which is accomplished primarily through what? Correct1 Hand washing before and after providing client care 2 Cleaning all equipment with an approved disinfectant after use 3 Wearing personal protective equipment (PPE) when providing client care 4 Using medical and surgical aseptic techniques at all times

Hand washing before and after providing care is the single most effective means of preventing the spread of infection by breaking the cycle of infection. Although all these interventions are acceptable procedures and may assist in preventing the spread of infection, none are as effective as hand washing.

A registered nurse is educating a client with acquired immune deficiency syndrome about safe sexual practices. Which statement made by the client indicates a need for further education? 1 "I should use a dental dam during oral sex." Correct2 "I can participate in anal intercourse safely without using condoms." 3 "I should ask my partner to use a female condom while engaging in sexual activity." 4 "I should use condoms even while receiving highly active antiretroviral therapy (HAART)."

Having anal intercourse indicates the client needs more teaching because this statement is incorrect. The client should wear a condom or use other genital barriers to prevent the transmission of human immunodeficiency virus (HIV). Anal intercourse is a risky sexual practice that allows contact between the seminal fluid and the rectal mucous membranes. Anal intercourse also tears the mucous membranes, making an infection more likely. All the other statements are correct and do not indicate further education is needed. Barriers such as female condoms and dental dams are recommended while participating in sexual activity. Though the viral load may decrease with the use of HAART, the risk for transmission still exists. Therefore the client should use condoms during sexual contact

What did the nurse observe during a home visit that indicates effective teaching about avoidance therapy provided to a client with type I rapid hypersensitivity reaction? Select all that apply. 1 Pet dog sitting on the floor Correct2 Pillows covered with ultra-mesh fabric Correct3 Cloth drapes removed from all windows Correct4 Air-conditioning unit running in the home Correct5 Carpeting replaced with hard wood floors

In avoidance therapy, clients should be instructed to cover pillows with ultra-mesh fabric, remove cloth drapes, use an air-conditioning unit to remove airborne pathogens, and remove carpeting. Pets should be restricted to outdoors to decrease allergen exposure.

A multigravida of Asian descent weighs 104 lb (47.2 kg), having gained 14 pounds (6.4 kg) during the pregnancy. On her second postpartum day, the client is withdrawn and eating very little from the meals provided. Which intervention is most important for the nurse to implement? 1 Report these findings to the healthcare provider. Correct2 Encourage the family to bring in special foods preferred in their culture. 3 Order a high-protein milkshake to supplement between meals. 4 Call the dietitian to work with client to plan high calorie meals for the client to eat

In family-centered childbearing, care should be adapted to the client's cultural needs and preferences whenever possible. Discussing the problem with the healthcare provider is the nurse's responsibility but will not address the client's preferences. Ordering a high-protein milkshake as a between-meal snack may offer the client an option but is unlikely to meet the cultural preferences. Having the dietitian assist with planning meals does not address the underlying problem.STUDY TIP: Answer every question. A question without an answer is the same as a wrong answer. Go ahead and guess. You have studied for the test and you know the material well. You are not making a random guess based on no information. You are guessing based on what you have learned and your best assessment of the question.

A client is injured from falling from a hospital bed on which the side rails were not raised appropriately. The client's family files a malpractice suit against the nurse responsible for taking care of the client. Which statements regarding the lawsuit are accurate? Select all that apply. 1 The nurse is the plaintiff and the client is the defendant. 2 The plaintiff selects experts to establish the appropriateness of nursing care. Correct3 The defendant obtains all of the plaintiff's medical records in the discovery phase. Correct4 The jury uses certain standards of care to determine whether the nurse acted properly. Correct5 The plaintiff outlines what the defendant did wrong and how it resulted in injury in the pleadings phase.

In this lawsuit, the client is the plaintiff and the nurse is the defendant. The nurse selects experts to establish that appropriate care was provided to the client. In the discovery phase (which occurs before the trial), the defendant obtains all of the client's relevant medical records from before and after the treatment. The jury uses standards of care to determine whether the nurse acted appropriately or committed malpractice. In the pleadings phase, the petition is put forward in the court. The plaintiff (client) outlines what the defendant (nurse) did wrong and how his or her actions resulted in injury.

The registered nurse (RN) delegates the collection of respiratory rate data to a licensed practical nurse (LPN) for a client who is experiencing severe dehydration and whose condition is unstable. The LPN reports the data to the RN. The RN rechecks the data and finds that the report no longer reflects the client's current condition. Which characteristic of communication has interfered with the delegation process? Correct1 Information decay 2 Information salience 3 Confidence in abilities 4 Synergy between team members

Information decay can occur in a rapidly changing situation when reported information is no longer relevant to a client's condition. Information salience describes the different ways individuals from different backgrounds might assess the quality, meaning, and clarity of certain information. Trust is developed when there is confidence in the abilities and capabilities of the team members. Healthy relationships among members of the health care team promote synergy between the team members.

A client who only speaks Spanish is being cared for at a hospital in which nursing personnel only speak English. What communication technique would be appropriate for the nurse to use when discussing healthcare decisions with the client? Correct1 Contact an interpreter provided by the hospital. 2 Contact the client's family member to translate for the client. 3 Communicate with the client using Spanish phrases the nurse learned in a college course. 4 Communicate with the client with the use of a hospital-approved Spanish dictionary.

Interpreters provided by the healthcare organization should be used to communicate with clients with limited English proficiency to ensure accuracy of communicated information. In hospital settings, it is not suitable for family members to translate healthcare information, but they can assist with ongoing interactions during the client's care. The other options do not ensure accurate interpretation of language.

The professional obligation of a nurse to assume responsibility for actions is referred to as what? Correct1 Accountability 2 Individuality 3 Responsibility 4 Bioethics

Nurses have an obligation to uphold the highest standards of practice, assume full responsibility for actions, and maintain quality in the knowledge base and skill of the profession; this is referred to as accountability. Individuality and responsibility are positive characteristics of the nurse but are not necessarily professional obligations. Bioethics is a field of study concerned with the ethics and philosophical implications of certain biologic and medical procedures and treatments.

Which nursing intervention is most appropriate for a client in skeletal traction? 1 Add and remove weights as the client desires. Correct2 Assess the pin sites at least every shift and as needed. 3 Ensure that the knots in the rope are tied to the pulley. 4 Perform range of motion to joints proximal and distal to the fracture at least once a day.

Nursing care for a client in skeletal traction may include assessing pin sites every shift and as needed. The needed weight for a client in skeletal traction is prescribed by the physician, not as desired by the client. The nurse also should ensure that the knots are not tied to the pulley and move freely. The performance of range of motion is indicated for all joints except the ones proximal and distal to the fracture because this area is immobilized by the skeletal traction to promote healing and prevent further injury and pain.STUDY TIP: Regular exercise, even if only a 10-minute brisk walk each day, aids in reducing stress. Although you may have been able to enjoy regular sessions at the health club or at an exercise class several times a week, you now may have to cut down on that time without giving up a set schedule for an exercise routine. Using an exercise bicycle that has a book rack on it at home, the YMCA, or a health club can help you accomplish two goals at once. You can exercise while beginning a reading assignment or while studying notes for an exam. Listening to lecture recordings while doing floor exercises is another option. At least a couple of times a week, however, the exercise routine should be done without the mental connection to school; time for the mind to unwind is necessary, too.

The nurse manager uses operant conditioning when managing the staff by providing positive reinforcement to motivate them to repeat constructive behavior. Which leadership theory is reflected in this practice? 1 Hierarchy of needs 2 Transformational theory 3 Situational contingency theory Correct4 Organizational behavior (OB) modification

OB modification theory is applied by providing positive reinforcement to the staff to motivate them to repeat constructive behaviors in the workplace. Awareness of the hierarchy of needs can be used to understand what motivates staff; for example, the need for security will override social needs. Transformational theory does not utilize operant conditioning for motivation. Situational contingency theory is applied to consider the challenge of a situation and encourages an adaptive leadership style to complement the issue being faced.

A nurse teaches the parents of a school-aged child with celiac disease about the foods that should be eliminated from the diet. Which foods do the parents name that indicate to the nurse that the teaching has been understood? Select all that apply. 1 Milk 2 Cheese Correct3 Oatmeal 4 Rice cakes 5 Corn on the cob Correct6 Whole wheat bread

Oat grain, in addition to wheat, rye, and barley grains, contains gluten, which should be eliminated from the diet in children with celiac disease. Foods made with wheat grain, a major source of gluten, must be eliminated from the diet of a child with celiac disease. Gluten contains the gliadin fraction that causes celiac syndrome. There is no gluten in milk or other dairy products. There is no gluten in rice grain; it is a substitute for the grains that must be eliminated from a diet that should be gluten free. Corn can be eaten safely because it does not contain gluten.STUDY TIP: Record the information you find to be most difficult to remember on 3" × 5" cards and carry them with you in your pocket or purse. When you are waiting in traffic or for an appointment, just pull out the cards and review again. This "found" time may add points to your test scores that you have lost in the past.

What is a primary component of the nursing plan of care for a client with the diagnosis of anorexia nervosa? Correct1 Observing the client after meals Incorrect2 Weighing the client before meals 3 Measuring the client's fluid balance 4 Limiting the client's interaction with peers

Observing the client after meals is the only way the nurse can be certain that the client does not engage in purging. Weighing will not help the nurse assess the client's electrolyte or nutritional status. An accurate intake and output record is difficult to obtain unless the individual is closely observed throughout the day. There is no need to isolate the client from peers.

A client is recovering from full-thickness burns, and the nurse provides counseling on how to best meet nutritional needs. Which client food selections indicate to the nurse that the client understands the teaching? Correct1 Cheeseburger and a milkshake 2 Beef barley soup and orange juice 3 Bacon and tomato sandwich and tea 4 Chicken salad sandwich and soft drink

Of the selections offered, a cheeseburger and a milkshake have the highest calories and protein, which are needed for the increased basal metabolic rate associated with burns and for tissue repair. Although orange juice provides vitamin C, beef barley soup does not provide adequate protein or calories. A bacon and tomato sandwich and tea do not provide an adequate amount of calories and protein; nor do a chicken salad sandwich and a soft drink

A public health nurse routinely performs health screenings in the local senior citizen center. What concept about older adults is essential for the nurse to remember when working with these clients? 1 Reviewing the past is depressing. 2 Stimulating new situations are ideal. 3 Dependency increases as age progresses. Correct4 Staying healthy promotes a quality retirement.

Optimal health is central to optimal retirement; with good health, objectives and goals are more likely to be achieved. Reviewing the past is an essential part of the life review that older adults must engage in to eventually reach integrity. The person may be in despair when reviewing the past is depressing. Most older adults prefer familiar routines and environments and desire independence even when coping with the effects of aging and chronic illness.Test-Taking Tip: Notice how the subjects of the questions are related and, through that relationship, the answers to some of the questions may be provided within other questions of the test.

Four clients with osteomyelitis are prescribed antibiotics. Which client is at risk for Achilles tendon rupture? 1 Client A Correct2 Client B 3 Client C 4 Client D

Osteomyelitis is a severe infection of the bone, bone marrow, and surrounding soft tissue. Tendon rupture can occur with use of the fluoroquinolones. Therefore client B, prescribed ciprofloxacin, is at risk for Achilles tendon rupture. Client A, prescribed gentamicin, is at risk for visual and hearing problems. Client C, prescribed cefazolin, is at risk for severe watery diarrhea and mouth sores. Client D, prescribed tobramycin, is at risk for nephrotoxicity.Test-Taking Tip: Chart/exhibit items present a situation and ask a question. A variety of objective and subjective information is presented about the client in formats such as the medical record (e.g., laboratory test results, results of diagnostic procedures, progress notes, healthcare provider orders, medication administration record, health history), physical assessment data, and assistant/client interactions. After analyzing the information presented, the test taker answers the question. These questions usually reflect the analyzing level of cognitive thinking.In a clinical exam, you may be expected to select instruments, arrange instruments, and/or perform some other task. Acquaint yourself with the physical facility. If the required procedures are not clear to you, ask for clarification.

A nurse is caring for a 13-year-old child who has an external fixation device on the leg. What is the nurse's priority goal when providing pin care? 1 Easing pain 2 Minimizing scarring Correct3 Preventing infection 4 Preventing skin breakdown

Pin sites provide a direct avenue for organisms into the bone. Pin care will not ease pain. Some scarring will occur at the pin insertion site regardless of pin site care. Skin has a tendency to grow around the pin, rather than break down, as long as infection is prevented.

A client with a benign ovarian tumor undergoes laparoscopic surgery. What should the nurse include in the postoperative teaching? 1 "Resume usual activities after 12 hours." Correct2 "Expect shoulder pain for 12 to 24 hours." 3 "Douche with povidone-iodine twice a day." 4 "Report vaginal spotting that occurs during the first 3 days after the surgery."

Postoperative teaching should include instructing the client to expect shoulder pain, caused by the insufflated carbon dioxide, which presses on the diaphragm for 12 to 24 hours. This occurs more frequently when the client's head is elevated too soon after surgery. Usual activities should not be resumed until 2 to 3 days after surgery; the client should undertake no heavy lifting or strenuous exercise for 4 to 7 days. There is no need to douche with povidone-iodine after the surgery. Vaginal spotting may occur but is benign. Frank bleeding should be reported.STUDY TIP: Enhance your organizational skills by developing a checklist and creating ways to improve your ability to retain information, such as using index cards with essential data, which are easy to carry and review whenever you have a spare moment.

Which reactions does a nurse expect of a 4-year-old child in response to illness and hospitalization? 1 Anger, resentment over depersonalization, and loss of peer support 2 Boredom, depression over separation from family, and fear of death Correct3 Out-of-control behavior, regression to overdependency, and fear of bodily mutilation 4 Intense panic, loss of security over separation from parents, and low frustration tolerance

Preschoolers experience loss of control caused by physical restriction, loss of routines, and enforced dependency, which may make them feel out of control. Preschoolers are also likely to experience feelings of regression or overdependency and fear of bodily mutilation. Anger, resentment over depersonalization, and loss of peer support are typical feelings expressed in adolescence. Boredom, depression over separation from family, and fear of death are typical feelings expressed by school-age children. Intense panic, loss of security over separation from parents, and low frustration tolerance are feelings usually experienced by toddlers.Test-Taking Tip: Make certain that the answer you select is reasonable and obtainable under ordinary circumstances and that the action can be carried out in the given situation.

What does a nurse who is caring for a client experiencing anginal pain expect to observe about the pain? 1 Unchanged by rest 2 Precipitated by light activity 3 Described as a knifelike sharpness Correct4 Relieved by sublingual nitroglycerin

Relief by sublingual nitroglycerin is a classic reaction because it dilates coronary arteries, which increases oxygen to the myocardium, thus decreasing pain. Immediate rest frequently relieves anginal pain. Angina usually is precipitated by exertion, emotion, or a heavy meal. Angina usually is described as tightness, indigestion, or heaviness.

The nurse at the mental health clinic is counseling a client with obsessive-compulsive disorder who spends a lot of time each day engaged in handwashing and has trouble keeping appointments on time as a result. What is the most therapeutic initial intervention by the nurse? 1 Discouraging the frequent handwashing to prevent skin breakdown 2 Encouraging the client to hasten the ritual so appointments can be kept on time 3 Telling the client how angry others become when activities are delayed for handwashing Correct4 Accepting the ritualistic behavior with a matter-of-fact attitude without displaying criticism

Responding to the ritualistic behavior in a matter-of-fact way prevents reinforcing the behavior; allowing time for rituals helps prevent an increase in the anxiety level. Attempts to discourage ritualistic behavior often increase the anxiety level and intensify the performance of the ritual. Attempts to hasten ritualistic behavior will increase the level of anxiety. Disparaging the client will decrease self-esteem, will increase anxiety and guilt, and may worsen the client's symptoms.

What is the priority when the nurse is establishing a therapeutic environment for a client? Correct1 Ensuring the client's safety 2 Accepting the client's individuality 3 Promoting the client's independence 4 Explaining to the client what is being done

Safety is the priority before any other intervention is provided. Accepting the client's individuality, promoting the client's independence, and explaining to the client what is being done are all important, but less of a priority.

The nurse supervisor is assessing the care delivered by nurses working in the cardiac care unit. Which findings indicate that the nurses are providing safe health care? Select all that apply. Correct1 The nurses exhibit good decision-making skills. Correct2 The nurses act within the scope of practice of their license. 3 The nurses provide cost-effective interventions to the clients. 4 The nurses provide both curative and preventive interventions for the clients. 5 The nurses provide interventions that have reduced the duration of hospital stays of the clients.

Safety, effectiveness, and efficient care are three important attributes of health care quality. The nurses need to make good clinical decisions to ensure maximal safety of the clients. The members of the nursing team comprise registered nurses, practice nurse, and nurse assistants. Therefore the members of the team should work according to their skill sets within the scope of their practice. Providing cost-effective interventions indicates that the nurses are providing efficient care. Providing both curative and preventive interventions for the clients indicates that the nursing team is providing effective care. The care provided by the nursing team reducing the duration of hospital stays of the clients indicates that the nurses are providing efficient care.

A client with scleroderma reports having difficulty chewing and swallowing. What should the nurse recommend to safely facilitate eating? 1 Liquefy food in a blender. Correct2 Eat a mechanical soft diet. 3 Take frequent sips of water with meals. 4 Use a local anesthetic mouthwash before eating.

Scleroderma causes chronic hardening and shrinking of the connective tissues of any organ of the body, including the esophagus and face; a mechanical soft diet includes foods that limit the need to chew and are easier to swallow. Liquefied foods are difficult to swallow; esophageal peristalsis is decreased, and liquids are aspirated easily. Taking frequent sips of water with meals will not help; it is equally difficult to swallow solids and liquids, and aspiration may result. Using a local anesthetic mouthwash before eating is not necessary; oral pain is not associated with scleroderma.STUDY TIP: Laughter is a great stress reliever. Watching a short program that makes you laugh, reading something funny, or sharing humor with friends helps decrease stress.

A nurse is caring for a client with a chest tube. How will complete lung expansion be determined before removal of the chest tube? 1 Return of usual tidal volume 2 Decreased adventitious sounds Incorrect3 Absence of additional drainage Correct4 Comparison of chest radiographs

Serial chest x-rays help determine treatment effectiveness. Chest x-ray films or radiographs reveal the degree to which the lung fills the pleural cavity and also the presence or absence of mediastinal shift. Return of usual tidal volume is not specific to expansion of the affected lung. Decreased adventitious sounds are abnormal chest sounds and do not indicate the degree of lung expansion. The chest tube may have minimal drainage and the lung may still not be expanded.

A client who had the left hand amputated after a traumatic injury is being fitted for a permanent prosthesis. What should the nurse teach the client about the most important factor for successful adaptation to the permanent prosthesis? 1 Muscles in the upper arm must be developed. 2 Dexterity in the other extremity must be achieved. Correct3 Shrinkage of the residual limb must be completed. 4 Adjustment to the altered body image must be accomplished.

Shrinkage of the residual limb, resulting from reduction of subcutaneous fat and interstitial fluid, must occur for an adequate fit between the limb and the prosthesis. Although developed muscles in the upper arm and dexterity in the other extremity are desirable, it is the condition of the residual limb that is the most important factor in the fitting of a prosthesis. The prosthesis probably will facilitate an improved body image.

A client who is being treated for schizophrenia, paranoid type, arrives at the clinic demonstrating a shuffling gait and tilting the head toward one shoulder. What does the nurse conclude about these clinical manifestations? 1 Expected characteristics of this illness 2 Consistent with an acute exacerbation of the illness Correct3 Possible side effects of the antipsychotic medication 4 Life threatening and requiring immediate intervention

Shuffling gait and torticollis are symptoms of pseudoparkinsonism that are caused by antipsychotic medications, particularly the typical antipsychotics. Expected characteristics of schizophrenia, paranoid type, include delusions, hallucinations, suspiciousness, anger, hostility, and paranoia. An acute exacerbation of the illness reflects an increased intensity of the expected characteristics associated with paranoid schizophrenia, which include pressured speech, suicidal ideation, and aggressive, agitated behavior. Although these physical manifestations require intervention, they are not life threatening.STUDY TIP: Avoid planning other activities that will add stress to your life between now and the time you take the licensure examination. Enough will happen spontaneously; do not plan to add to it.

What should the nurse teach a client who is taking antihypertensives to do to minimize orthostatic hypotension? 1 Wear support hose continuously. 2 Lie down for 30 minutes after taking medication. 3 Avoid tasks that require high-energy expenditure. Correct4 Sit on the edge of the bed for 5 minutes before standing

Sitting on the edge of the bed before standing up gives the body a chance to adjust to the effects of gravity on circulation in the upright position. Support hose may help prevent orthostatic hypotension by increasing venous return. However, they must be applied before getting out of bed and should not be worn continuously. Laying down for 30 minutes after taking medication will not prevent episodes of orthostatic hypotension. Energetic tasks, once standing and acclimated, do not increase hypotension.

The nurse is counseling a client with type 1 diabetes about the client's favorite foods that are lowest in carbohydrates (CHO). Which food choice picked by the client determines that teaching was effective? Correct1 Skim milk 2 Apple juice 3 Nonfat yogurt 4 Fresh orange juice

Skim milk contains about 12 grams of CHO per cup. There are about 30 grams CHO in 1 cup of apple juice. There are about 16 grams CHO in 1 cup of nonfat yogurt. There are about 25 grams CHO in 1 cup of orange juice.

The nurse is assessing four clients in the emergency department. Which client requires least priority according to the Glasgow Coma Scale? 1 Client A 2 Client B 3 Client C Correct4 Client D

Spontaneous eye opening receives 4 points, 5 points for motor response indicates the client has localized pain and has oriented verbal response. A score of 14 indicates that client D requires the lowest priority and that treatment can be delayed for some time. Client A, who has absence of eye reflexes (1), extended motor reflex (2), and inappropriate speech (3), requires high priority. Client B who has pain opening the eyes (2) and abnormal motor response (3) and speech (3) requires an emergent treatment. Client C who has moderate eye movement (3), localized pain (5), and speaks inappropriate words (3) requires urgent treatment.

In which order should the nurse review the events that occur in stage I of the inflammatory process? Incorrect1.Increased blood flow causes swelling at the site of injury Incorrect2.Cytokine is released to produce more white blood cells Correct3.Capillary leak causes pain Incorrect4.Blood vessel changes cause redness and tissue warmth Incorrect5.Edema from plasma leaking protects further injury

Stage I is the vascular part of the inflammatory response that first involves changes in blood vessels. Blood vessel changes cause redness and warmth of the tissues. Increased blood flow to the area causes swelling at the site of injury. Capillary leakage allows blood plasma to leak into the tissues, which causes pain. Edema at the site of injury protects the area from further injury by creating a cushion of fluid. To enhance the inflammatory response, cytokines are released, which trigger the bone marrow to shorten the time needed to produce white blood cell

A hospice nurse is caring for a dying client while several family members are in the room. When the client dies, the initial nursing intervention during the shock phase of a grief reaction is focused on what? Correct1 Staying with the individuals involved 2 Directing the individuals' activities at this time 3 Mobilizing the support systems of the individuals 4 Presenting the full reality of the loss to the individuals

Staying with the individuals involved provides support until the individuals' coping mechanisms and personal support systems can be mobilized. Directing the individuals' activities at this time is not the role of the nurse. The individuals, not the nurse, must mobilize their support systems. The individuals need time before the full reality of the loss can be accepted.

A nurse hired to work in a metropolitan hospital provides services for a culturally diverse population. One of the nurses on the unit says it is the nurses' responsibility to discourage "these people" from bringing all that "alternative medicine stuff" to their family members. Which response by the recently hired nurse is most appropriate? 1 "Hospital policies should put a stop to this." 2 "Everyone should conform to the prevailing culture." Correct3 "Nontraditional approaches to health care can be beneficial." 4 "You are right because they may have a negative impact on people's health."

Studies demonstrate that some nontraditional therapies are effective. Culturally competent professionals should be knowledgeable about other cultures and beliefs. Many health care facilities are incorporating both Western and nontraditional therapies. The statement "Everyone should conform to the prevailing culture" does not value diversity. The statement "You are right because they may have a negative impact on people's health" is judgmental and prejudicial. Some cultural practices may bring comfort to the client and may be beneficial, and they may not interfere with traditional therapy. Topics

After reading that nutrition during pregnancy is important for optimal growth and development of the baby, a pregnant woman asks the nurse what foods she should be eating. The nurse begins the teaching/learning process by doing what? Correct1 Asking the client what she usually eats at each meal 2 Explaining to the client why spicy foods should be avoided 3 Instructing the client to add calories while continuing to eat a healthy diet 4 Providing the client with a list of foods for reference when planning meals

Successful dietary teaching should incorporate the client's food preferences and dietary patterns. Spicy foods are permissible if the client does not experience discomfort after eating them. Instructing the client to add calories while continuing to eat a healthy diet presupposes that the client has been eating a healthy diet. It does not provide for the additional protein requirements of pregnancy. Providing the client with a list of foods for reference when planning meals does not take into consideration the client's likes and dislikes or cultural preferences.

A nurse is educating a client about the tertiary level of prevention. What information should the nurse provide? Select all that apply. Correct1 Tertiary prevention focuses on preventing complications of illness. Correct2 Tertiary prevention helps clients achieve as high a level of functioning as possible. Correct3 Tertiary prevention aims at minimizing the effects of long-term disease or disability. 4 Tertiary prevention is applied when the client is physically and emotionally healthy. 5 Tertiary prevention activities are aimed at diagnosis and treatment instead of rehabilitation.

Tertiary prevention is also known as preventive care since it aims at preventing further disability or reduced functioning in the clients. Even though clients may have developed limitations due to illness or impairment, tertiary prevention helps in achieving as high a level of functioning as possible. Tertiary prevention makes use of interventions that prevent complications and deteriorations in order to minimize the effects of long-term disease or disability. Tertiary prevention is applied when the client has a defect or disability that is permanent and irreversible. Tertiary prevention activities focus on rehabilitative care instead of diagnosis and treatment.

What instructions should a nurse provide to adolescent boys regarding the usual procedure to be followed and normal findings observed during testicular self-examination. Select all that apply. Correct1 A firm, smooth, egg-shaped organ can be palpated. Correct2 Each testicle is examined individually after relaxing the scrotal skin. 3 A hard mass that can be palpated on anterior or lateral aspect of testicle. Correct4 The thumb and fingers of both hands can be used to apply firm and gentle pressure. Correct5 A raised swelling that can be palpated on the superior aspect of the testicle is the epididymis.

Testicular self-examination is usually performed after a warm bath when the scrotal skin is relaxed. A firm organ with smooth and egg shaped contours that can be palpated is the testicle. Each testicle is examined individually using thumb and fingers of both hands applying firm and gentle pressure. A raised swelling that can be palpated on the superior aspect of testicle is the epididymis. Testicular cancer can be suspected if a hard mass can be palpated on the anterior or lateral aspect of testicle.

Which act protects a person who is HIV positive? 1 The National Organ Transplant Act Correct2 The Americans with Disabilities Act (ADA) 3 The Patient Self-Determination Act (PSDA) 4 The Health Insurance Portability and Accountability Act of 1996 (HIPAA)

The Americans with Disabilities Act (ADA) protects a person who is HIV positive. The National Organ Transplant Act protects the donor's estate from liability for injury or damage that results from the use of the organ. The Patient Self-Determination Act (PSDA) requires healthcare associations to provide written information to clients about their rights under state law to make decisions, including the right to refuse treatment and formulate advance directives. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) protects individuals from losing their health insurance when changing jobs by providing portability.STUDY TIP: Identify your problem areas that need attention. Do not waste time on restudying information you know.

What statement by the nursing student indicates understanding of the precautions needed in the provision of care to a 7-year-old child who is HIV positive? 1 "I'll put on a mask." 2 "I'll put on an N-95 mask." 3 "I'll put on a gown and gloves." Correct4 "I'll put on gloves if I'm going to be in contact with body fluids."

The Centers for Disease Control and Prevention (Canada: Public Health Agency of Canada) recommends standard precautions for the care of individuals with HIV infection or AIDS without opportunistic infections. Droplet precautions are not necessary because HIV is not transmitted in large-particle respiratory droplets. Contact precautions are not necessary unless the HIV infection or AIDS is complicated by the presence of disease or infection, necessitating the addition of these precautions to standard precautions. Airborne precautions are unnecessary because HIV is not spread in airborne droplet nuclei; these precautions are used in addition to standard precautions if an opportunistic infection such as Mycobacterium tuberculosis is present.

Which theories are most relevant to development in adults? Select all that apply. 1 Piaget's theory 2 Erikson's theory 3 Kohlberg's theory Correct4 Stage-Crisis theory Correct5 Life Span approach

The Stage-Crisis theory and the Life Span approach are theories related to adult development. Piaget's theory is associated with children's cognitive development. Erikson's theory is associated with the psychoanalytical/psychosocial development. Kohlberg's theory is related to moral development.

he nurse is assessing the newborn in the first hour after birth. Which findings does the nurse identify as normal for the newborn? Select all that apply. 1 The newborn has a flat abdomen. Correct2 The newborn weighs 6 lbs (2,700 g). Correct3 The newborn's hands and feet appear cyanosed. 4 The newborn does not blink in the presence of light. Correct5 The circumference of the head is 33 cm (13 in).

The circumference of the head is 33 cm (13 in). The average newborn weighs between six to nine pounds (2,700 to 4,000 g). The hands and feet of the newborn are usually cyanosed during the first 24 hours after birth. The average newborn has a head circumference of 33 to 35 cm (13 to 14 inches). Newborns generally have protuberant (not flat) abdomens. Newborns exhibit a blinking reflex when light is directed toward the eye.

A client who complains of memory loss, nervousness, insomnia, and fear of leaving the house is admitted to the hospital after several days of increasing incapacitation. What nursing action is the priority in light of this client's history? 1 Evaluating the client's adjustment to the unit Correct2 Providing the client with a sense of security and safety 3 Exploring the client's memory loss and fear of going out 4 Assessing the client's perception of reasons for the hospitalization

The client is anxious and afraid of leaving home; the priority is the client's safety and security needs. Unless the client is provided with a sense of security, adjustment probably will be unsatisfactory, because the anxiety will most likely escalate. Exploring the client's memory loss and fear of going out cannot be done until anxiety is reduced. The client is experiencing memory loss and may not be able to remember what precipitated admission to the hospital; some memory loss may be a result of high anxiety and thought blocking.Test-Taking Tip: Anxiety leading to an exam is normal. Reduce your stress by studying often, not long. Spend at least 15 minutes every day reviewing the "old" material. This action alone will greatly reduce anxiety. The more time you devote to reviewing past material, the more confident you will feel about your knowledge of the topics. Start this review process on the first day of the semester. Don't wait until the middle to end of the semester to try to cram information.

What should the nurse instruct the client to do to limit triggering the pain associated with trigeminal neuralgia? 1 Drink iced liquids. 2 Avoid oral hygiene. 3 Apply warm compresses. Correct4 Chew on the unaffected side.

The client may avoid stimulating the involved trigeminal nerve and thus prevent pain by chewing on the unaffected side. Food and fluids that are too hot or too cold can precipitate pain. Although oral hygiene may initiate pain, it cannot be avoided. It can be modified to include rinsing the mouth or using a soft swab instead of a toothbrush. Warm compresses may precipitate pain.Test-Taking Tip: What happens if you find yourself in a slump over the examination? Take a time-out to refocus and reenergize! Talk to friends and family who support your efforts in achieving one of your major accomplishments in life. This effort will help you regain confidence in yourself and get you back on track toward the realization of your long-anticipated goal.

The nurse is providing care to several clients in the emergency department (ED). Which client is the priority when using the three-tiered triage system? 1 A client with a simple fracture 2 A client experiencing renal colic 3 A client with severe abdominal pain Correct4 A client with chest pain and diaphoresis

The client with chest pain and diaphoresis is classified as emergent and would require priority care. The client with renal colic and severe abdominal pain are classified as urgent. The client with a simple fracture is nonurgent.

The nurse is caring for four clients in the emergency department. In what order should the nurse prioritize client care? Correct1.Client with severe respiratory distress Correct2.Client with chest pain due to ischemia Correct3.Client with a gynecologic disorder Correct4.Client with cystitis .

The client with severe respiratory distress should be treated immediately as the condition of the client is critical and may be life-threatening. The client with chest pain due to ischemia may be treated within 10 minutes after treatment of the client with respiratory distress. One of the most common reasons for someone with a gynecologic disorder to come to the ER is for bleeding. This would take precedence over cystitis. Also the client with a gynecological disorder may require multiple diagnostic studies to determine the condition, and this can be delayed up to 1 hour. The client with cystitis may only require a simple diagnostic procedure to determine the condition and begin treatment.Test-Taking Tip: In this Question Type, you are asked to prioritize (put in order) the options presented. For example, you might be asked the steps of performing an action or skill such as those involved in medication administration

A client's arterial blood gas report indicates the pH is 7.52, PCO2 is 32 mm Hg, and HCO3 is 24 mEq/L. What does the nurse identify as a possible cause of these results? 1 Airway obstruction 2 Inadequate nutrition 3 Prolonged gastric suction Correct4 Excessive mechanical ventilation

The high pH and low carbon dioxide level are consistent with respiratory alkalosis, which can be caused by mechanical ventilation that is too aggressive. Airway obstruction causes carbon dioxide buildup, which leads to respiratory acidosis. Inadequate nutrition causes excess ketones, which can lead to metabolic acidosis. Prolonged gastric suction causes loss of hydrochloric acid, which can lead to metabolic alkalosis.

A woman fractured her left tibia and fibula one week ago and has a cast in place. She is taking acetaminophen (Tylenol) with codeine for pain and an oral contraceptive. She began experiencing left calf pain 3 days ago and began having shortness of breath and chest pain 15 minutes ago. When the shortness of breath and chest pain increase, she calls the emergency department and communicates this information to the triage nurse. What is the triage nurse's best response? Correct1 "Give me your name and address. I am sending an ambulance to your home. You need emergency care." Incorrect2 "It sounds as if your cast may be constricting the blood flow in your leg. You probably need a new cast." 3 "It sounds like you are having an allergic response to the medication. Is there someone there who can drive you to the hospital?" 4 "You are experiencing an interaction between your pain and oral contraceptive medications. You need to come to the emergency department now for care."

The client's clinical manifestations, along with the history of a recent fracture, immobilization, and use of an oral contraceptive, suggest a pulmonary embolism. An ambulance will limit the woman's use of her leg, which may prevent further emboli. The client's clinical findings are not indicative of compression syndrome. Tingling, numbness, cool skin, and lack of capillary refill are signs and symptoms of compression syndrome. The clinical manifestations do not support an allergic reaction. An allergic response may cause shortness of breath, but it does not cause calf pain. The client may be experiencing a pulmonary embolism, not an interaction between the two medications.

A toddler in the pediatric intensive care unit is on a ventilator. One of the nurses asks what should be done when condensation collects in the ventilator tubing. How should the nurse manager respond? 1 Notify the physician assistant. 2 Decrease the amount of humidity. Correct3 Empty the fluid and reconnect the tubing to the ventilator. 4 Measure the fluid and mark it on the intake and output record

The correct course of action is to empty the fluid from the tubing and reconnect it because accumulated fluid may flood the trachea. Removing condensation from the tubing does not require help from a physician assistant; the nurse or respiratory therapist, depending on hospital protocol, is responsible for this remedial action. Humidity is necessary to preserve moisture in the respiratory tract. The amount of condensation is irrelevant in terms of recording intake and output.

The nurse is teaching a client about automatic epinephrine injectors. Which statement made by the client indicates a need for additional education? Correct1 "I will keep the device in the refrigerator." 2 "I will keep the device away from light." 3 "If the cap is loose, I will obtain a replacement device." Incorrect4 "I will have at least two drug-filled devices on hand at all times."

The device should be protected from extreme temperatures. Therefore the device should not be refrigerated. The device should be protected from light. If the cap is loose or comes off accidentally, the client should obtain a replacement device. The client should have at least two drug-filled devices on hand in case more than one dose is required.

A parent of a 6-month-old infant asks the nurse which foods should be introduced first. What is the best response by the nurse? Correct1 Baby cereals 2 Soft-boiled eggs 3 Fruits and puddings 4 Meats and vegetables

The first solid food added to the infant's diet should be easily digestible; fortified cereals are easy to digest and are a rich source of iron. Eggs are one of the last foods to be added to the diet because they may cause an allergic reaction. Puddings contain eggs, which are one of the last foods to be added to the diet because they may cause allergic reactions. Meats and vegetables are more difficult to digest than cereal is.Test-Taking Tip: Answer every question. A question without an answer is always a wrong answer, so go ahead and guess.

Arrange the events of communication throughout the nursing process in chronological order. Correct1.Assessing the medical records and diagnostic tests Correct2.Intrapersonal analysis of the assessment findings Correct3.Documenting expected outcomes Correct4.Performing verbal, visual, auditory, and tactile health teaching activities Correct5.Identifying the factors affecting the outcomes

The first step of communication throughout the nursing process is assessment, which involves assessing medical records and diagnostic tests. The second step is nursing diagnosis, which involves the intrapersonal analysis of assessment findings. The third step is planning, which involves the documentation of expected outcomes. The fourth step is implementation, which involves performing verbal, visual, auditory, and tactile health teaching activities. The final step is evaluation, which involves identifying the factors affecting the outcomes.Test-Taking Tip: Try to recall the events of communication that occurs in the five phases of nursing process and arrange them in chronological order.

A nurse is teaching about near-miss events to a group of nursing students. What is appropriate for the nurse to include in the education? Select all that apply. Correct1 They do not cause actual harm to the client. 2 They may cause moderate harm to the client. Correct3 They are caused by a variation in standard care. 4 They are caused by impaired immune functioning. Correct5 Their cause can be analyzed by failure mode effective analysis.

The medical errors that cause no harm to the client are described as near-miss events. These events do not reach the client and do not cause severe complications because the interventions to avoid them or correct the damage are instituted. They are caused by a variation in standard care. The nurse can analyze the cause of these events by the failure mode effective analysis (FMEA) system while reporting them. Adverse events cause moderate harm to the client. Such events are caused by the fault of the system or health care professionals. Near miss events are not caused by impaired functioning of the immune system.

The mother of a 5-month-old boy calls the nurse in the pediatric clinic to ask why her son no longer turns his head toward her breast when she touches his cheek. How should the nurse respond? 1 "Is he able to sit unsupported?" Correct2 "Usually this reflex disappears around 4 months." 3 "Do his toes still flare out when you stroke the sole of his foot?" 4 "Please bring him to the clinic—he may have a feeding problem."

The mother is describing the rooting reflex; when touched on the cheek, the infant reflexively turns the head to that side. The rooting reflex is expected to disappear by 4 months of age. An infant can sit without support at 8 months; this is not expected of a 5-month-old infant. Stroking the sole of the foot elicits the Babinski reflex, which disappears between 8 and 12 months of age. The disappearance of the rooting reflex at 5 months of age does not require further intervention.

A client just has returned from the postanesthesia care unit after having a laparotomy. Which initial sign or symptom indicates to the nurse that peristalsis has begun to return? 1 Stool is evacuated. 2 Nausea is no longer present. Correct3 Borborygmi are auscultated. 4 Abdomen is no longer tender.

The nurse auscultates the abdomen and listens for bowel sounds (borborygmi), which signify the initial return of peristalsis. The first bowel movement occurs after peristalsis returns. Nausea and/or tenderness may be present, even though peristalsis has returned.Test-Taking Tip: If the question asks for an immediate action or response, all the answers may be correct, so base your selection on identified priorities for action.

According to Swanson's caring process, the nurse must know the client. Which factors enable the nurse to know the client better? Select all that apply. 1 Economic constraints Correct2 Continuity of care by the nursing staff 3 Fewer nurses in the healthcare facility Correct4 Collection of data about the client's clinical condition Correct5 Engagement in a caring relationship without assumptions

The nurse gets to know the client over time with continuity in care. The nurse enters into a caring process by collecting data about the client's clinical condition. The data enables the nurse to use critical thinking and clinical judgments during client care. The nurse should engage in a caring relationship with the client without any assumptions and use knowledge and experience to detect changes in the client's health condition. Economic constraints may lead to the client spending less time in the healthcare facility. This acts as a barrier in providing client-centered care. Changes in the organizational structure may result in fewer nurses caring for more clients. This results in fewer interactions with the client.

The nurse who works in a birthing unit understands that newborns may have impaired thermoregulation. Which nursing interventions may help prevent heat loss in the newborns? Select all that apply.1The nurse keeps the newborn covered in warm blankets.2The nurse keeps the newborn under the radiant warmer.3The nurse places the newborn on the mother's abdomen.4The nurse measures the newborn's temperature regularly.5The nurse encourages the mother to feed the newborn well to maintain the fluid balance.

The nurse keeps the newborn covered in warm blankets.The nurse keeps the newborn under the radiant warmer.The nurse places the newborn on the mother's abdomen.Newborns have impaired thermoregulation due to immaturity of the body systems. Therefore, the nurse performs interventions to prevent heat loss in the newborn. Covering the newborn with warm blankets helps to prevent heat loss. The nurse keeps the newborn under the radiant warmer to help maintain the body temperature. Placing the newborn on the mother's abdomen helps to promote warmth through skin-to-skin contact. Regular measurement of temperature may help in assessing any significant change; however, it may not help prevent heat loss. Ensuring that the newborn is fed well does not help to prevent heat loss.

On the second postpartum day a client mentions that her nipples are becoming sore from breastfeeding. What is the nurse's initial action in response to this information? Correct1 Assess her breastfeeding techniques to identify possible causes. 2 Provide a nipple shield to keep the infant's mouth off the nipples. 3 Instruct her to apply warm compresses 10 minutes before she begins to breastfeed. 4 Explain that she should limit breastfeeding to 5 minutes per side until the soreness subsides.

The nurse must first assess the client's breastfeeding practices; nipple soreness may occur when the newborn's mouth is not covering the entire areola; also, nipples must toughen in response to suckling. Providing a nipple shield, having the client apply warm compresses before the feeding, or limiting the time spent at breastfeeding is premature; the cause of the soreness must be determined first and will dictate the choice of intervention.

A foreign language-speaking client needs to undergo chemotherapy; a signed consent form is required. What should the nurse do to explain the terms of the consent to the client? Correct1 Seek the help of an official interpreter. 2 Seek the help of the primary healthcare provider to assist the client. 3 Seek help from the client's family friend who speaks the client's language. 4 Seek help from the client's caregiver who speaks the same language as the client.

The nurse should seek the help of an official interpreter to explain the terms of consent to the client. The nurse should not ask for the primary healthcare provider's assistance because he or she might not know the language. The nurse should not seek help from the client's family friend who speaks the language because he or she is not authorized to interpret health information. The nurse should not seek help from the client's caregiver who speaks the same language because he or she should not interpret health information.

A client who has a hemoglobin of 6 gm/dL (60 mmol/L) is refusing blood because of religious reasons. What is the most appropriate action by the nurse? 1 Call the chaplain to convince the client to receive the blood transfusion. 2 Discuss the case with coworkers. Correct3 Notify the primary healthcare provider of the client's refusal of blood products. 4 Explain to the client that they will die without the blood transfusion.

The nurse serves as an advocate for the client to uphold their wishes. Synthetic blood products are available but must be prescribed by the primary healthcare provider. Therefore the primary healthcare provider needs to be notified of the client's refusal for blood so alternatives can be considered. The chaplain's role is to offer support, not to convince the client to go against beliefs. It is a Health Insurance Portability and Accountability Act (HIPAA) (Canada: Personal Health Information Protection Act [PHIPA]) violation to discuss the case with coworkers unless they are involved in the care of the client. The nurse should not use threats or fear to coerce the client.Test-Taking Tip: Pace yourself when taking practice quizzes. Because most nursing exams have specified time limits, you should pace yourself during the practice testing period accordingly. It is helpful to estimate the time that can be spent on each item and still complete the examination in the allotted time. You can obtain this figure by dividing the testing time by the number of items on the test. For example, a 1-hour (60-minute) testing period with 50 items averages 1.2 minutes per question. The NCLEX exam is not a timed test. Both the number of questions and the time to complete the test varies according to each candidate's performance. However, if the test taker uses the maximum of 5 hours to answer the maximum of 265 questions, each question equals 1.3 minutes.

The nurse is questioning a client who reports pain. Which questions asked by the nurse are appropriate? Select all that apply. Correct1 "Where does it hurt?" Correct2 "What makes the pain worse?" Correct3 "How long have you noticed it?" 4 "Have you been treated for pain previously?" Correct5 "How severe is your pain on a scale of 0 to 10?"

The nurse should follow an orderly and systematic approach when collecting information. The nurse should ask specific questions of the client such as "Where does it hurt?", "What makes the pain worse?", "How long you have noticed it?" and "How severe is your pain on a scale of 0 to 10?" Questions such as "Have you been treated for pain previously?" should be asked after understanding the characteristics of the pain.

A nurse is educating an older adult for the purpose of promoting wellness. What instruction should the nurse give to reduce the risk of disability? Correct1 "Engage in physical activities to stay fit." 2 "Don't exhaust yourself by engaging in physical activities." 3 "Pay no heed to your financial problems if you want to stay healthy." 4 "Stay away from people so as to prevent anxiety and stress disorders."

The nurse should instruct the older adult to engage in physical activities as a means of extending the years of active independent life and reducing the risk of disability. To promote a healthy lifestyle, the nurse should encourage the older adult to engage in physical activities. The nurse should understand that the willingness of the older adult to participate in health promotion activities depends in part on socioeconomic factors; moreover, the nurse should not provide financial advice to the client. The nurse should ensure that the older adult has social support to promote health and provide access to resources.Test-Taking Tip: Multiple choice questions can be challenging, because students think that they will recognize the right answer when they see it or that the right answer will somehow stand out from the other choices. This is a dangerous misconception. The more carefully the question is constructed, the more each of the choices will seem like the correct response.

A nursing student is listing the steps to be followed when communicating with older adults with hearing problems. Which step listed by the nursing student indicates a need for additional training? 1 "Refrain from speaking extremely slowly." Correct2 "Speak clearly by exaggerating his or her lip movements." 3 "Allow the client to ask questions when necessary." 4 "Ensure that the client knows that the nurse is talking."

The nurse should not speak by exaggerating his or her lip movements when communicating with older adults with hearing problems. The nurse should speak clearly to facilitate understanding. The nurse should speak slowly but not extremely slowly. When communicating with the client, the nurse should allow the client to ask questions when necessary to facilitate better understanding. The nurse should ensure that the client knows that the nurse is speaking to facilitate good communication.

The registered nurse is teaching the student nurse about writing nursing interventions. Which intervention written by the student nurse indicates effective learning? 1 "Turn the client every 2 hours." 2 "Perform blood glucose measurements regularly." 3 "Change the client's dressing once a shift: 6 AM—2 PM—10 PM." Correct4 "Irrigate the wound with 100 mL normal saline until clear: 6 AM—2 PM—8 PM."

The nursing intervention, "Irrigate the wound with 100 mL normal saline until clear: 6 AM—2 PM—8 PM," is specific to indicate the quantity of fluid required and also the frequency of the nursing action. The intervention, "Turn client every 2 hours," does not specify the time to change the positions and the name of the positions. The intervention, "Perform blood glucose measurements," does not indicate the frequency to perform blood glucose measurements. The intervention, "Change client's dressing once a shift: 6 AM—2 PM—10 PM," does not mention details about the method to be used.

An older adult experiencing delirium suffers from a leg fracture caused by a fall. Which interventions should the nurse follow to prevent future falls? Select all that apply. Correct1 Minimizing medications Correct2 Modifying the home environment 3 Teaching clients about the safe use of the Internet Correct4 Manage foot and footwear problems 5 Providing information about the effects of using alcohol

The nursing interventions followed to prevent falls are minimizing medications, modifying the home environment and managing foot and footwear problems. Teaching clients about the safe use of Internet may be an effective intervention for preventing delirium. Providing information about the effects of using alcohol is not an intervention for older adults; this action is more beneficial for adolescents.

The nurse is evaluating whether a hospice referral is appropriate for a patient with end-stage liver failure. What is one of the two criteria necessary for admission to a hospice program?

The patient wants hospice care and agrees to terminate curative care.There are two criteria for admission to a hospice program. The first criterion is the patient must desire the services and agree in writing that only hospice care (and not curative care) can be used to treat the terminal illness. The second criterion is that the patient must be considered eligible for hospice. Two physicians must certify that the patient's prognosis is terminal with less than 6 months to live.

The nurse is assessing a client with severe burn wounds. What are the nursing interventions performed by the nurse in the order of priority? Correct1.Checking for a patent airway Correct2.Maintaining effective circulation Correct3.Performing adequate fluid replacement Correct4.Caring for the burn wound

The priority nursing intervention for a client with severe burn wounds is checking for a patent airway. The next priority is to maintain effective circulation. Then, adequate fluid replacement is established. Once a patent airway, effective circulation, and adequate fluid replacement have been established, priority is given to care of the burn wound.Test-Taking Tip: In this Question Type, you are asked to prioritize (put in order) the options presented. For example, you might be asked the steps of performing an action or skill such as those involved in medication administration.

A client is admitted to the hospital for cancer of the larynx, and a laryngectomy is scheduled. What should the nurse include in the postoperative teaching plan? Correct1 Importance of cleanliness around the site of the stoma 2 Necessity of covering the tube opening while swimming 3 Establishment of a regular schedule for suctioning the tube 4 Usage of sterile technique when caring for the tracheostomy tube

The procedure should be explained so the client understands that the tracheostomy can serve as an entrance for bacteria and that cleanliness is imperative. Clients with a laryngectomy may no longer swim because water will flood the lungs. Suctioning must be performed only as needed; a pattern is not necessary. Sterile technique is not required; medical aseptic technique is adequate and realistic.

An infant with a myelomeningocele is admitted to the pediatric intensive care unit. While the infant is awaiting surgical correction of the defect, what is the most appropriate nursing intervention? 1 Using disposable diapers Correct2 Placing the infant in the prone position 3 Performing neurologic checks above the site of the lesion 4 Washing the area below the defect with a nontoxic antiseptic

The prone position is the best position for preventing pressure on the sac. Diapers should not be applied because they may irritate or contaminate the sac. Assessment of the area below the defect is essential in determining motor and sensory function. There is no indication for the use of an antiseptic.

A 4-month-old infant is admitted directly to the pediatric unit from the primary healthcare provider's office with a diagnosis of bronchiolitis. The mother reports that the infant had a "breathing treatment" about 3 hours ago while in the primary healthcare provider's office. She says she then went home to pack some clothes first before coming to the hospital. The mother says that it has been more than 4 hours since the baby ate and requests formula and rice cereal so she can feed the baby. The admitting nurse reviews the infant's assessment findings and admission prescriptions. How should the nurse recommend that the mother feed the baby? Correct1 Withhold feedings at this time. 2 Offer Pedialyte or other clear liquid. 3 Offer up to 4 oz (120 mL) of formula. 4 Feed baby cereal followed by formula.

The respiratory rate is above 60 breaths/min, so the risk of aspiration is great. The feeding should be delayed until the respiratory rate and general condition have improved. Once the respiratory rate has slowed, the baby will benefit from clear liquids. Liquids are necessary to thin mucus, but milk is thick and may not be the best choice. Rice cereal is not necessary at this time.

A nurse is caring for a client with continuous bladder irrigation. Which action should the nurse take? 1 Monitor urinary specific gravity to determine hydration. Correct2 Subtract irrigant from output to determine urine volume. 3 Record urinary output every hour to determine kidney function. 4 Obtain a 24-hour urine specimen to determine urine concentration.

The total amount of irrigation solution instilled into the bladder is eliminated with urine and therefore must be subtracted from the total output to determine the volume of urine excreted. An accurate specific gravity cannot be obtained when irrigating solutions are instilled into the bladder. Hourly outputs are indicated only if there is concern about renal failure or oliguria. A 24-hour urine test is not accurate if the client is receiving continuous bladder irrigations.Test-Taking Tip: Multiple-choice questions can be challenging because students think that they will recognize the right answer when they see it or that the right answer will somehow stand out from the other choices. This is a dangerous misconception. The more carefully the question is constructed, the more each of the choices will seem like the correct response.

The nurse is assessing the clinical data of four clients. Which client is characterized with mixed conductive-sensorineural type of hearing loss? 1 Client A Correct2 Client B 3 Client C 4 Client D

There are four types of hearing loss: Conductive Hearing LossHearing loss caused by something that stops sounds from getting through the outer or middle ear. This type of hearing loss can often be treated with medicine or surgery. Sensorineural Hearing LossHearing loss that occurs when there is a problem in the way the inner ear or hearing nerve works. Mixed Hearing LossHearing loss that includes both a conductive and a sensorineural hearing loss. Auditory Neuropathy Spectrum DisorderHearing loss that occurs when sound enters the ear normally, but because of damage to the inner ear or the hearing nerve, sound isn't organized in a way that the brain can understand. Client B is diagnosed with a retraction in the tympanic membrane, causing obstruction to sound wave transmission. Damaged cochlear hair results in decreased sensory perception. Therefore, this client is characterized by a mixed conductive-sensorineural type of hearing loss. Client A is diagnosed with inflammation in the tympanic membrane resulting in retraction or bulging of the tympanic membrane, leading to obstruction of sound wave transmission thereby causing conductive hearing loss. The type of hearing loss diagnosed in client C is characterized as sensorineural hearing loss, as there is damage to the vestibulocochlear cranial nerve. Client D is diagnosed with fused bony ossicles, which obstructs sound wave transmission thereby causing conductive hearing loss.Test-Taking Tip: Chart/exhibit items present a situation and a variety of objective and subjective information about the client in formats such as the medical record (e.g., laboratory test results, results of diagnostic procedures, progress notes, healthcare provider orders, medication administration record, and health history), physical assessment data, and notes about client interactions. After analyzing the information presented, the test taker answers the question. These questions usually reflect the analyzing level of cognitive thinking.

A client in a mental health facility is demonstrating manic-type behavior by being demanding and hyperactive. What is the nurse's major objective? 1 Easing the client's feelings of guilt Correct2 Maintaining a supportive, structured environment 3 Pointing out reality through continued communication 4 Broadening the client's contacts with other people on the unit

These clients are acutely aware of and sensitive to the environment; they need a structured environment in which stimuli are minimized and a feeling of acceptance and support is present. Lessening the client's feelings of guilt is a vague objective; it is not measurable. Pointing out reality through continued communication is not the priority. Reality orientation is not needed as much as maintaining a safe structured environment is. The client needs minimal, not increased, stimuli.

The nurse notes that the client's cardiac rhythm strips show more P waves than QRS complexes. There is no relationship between the atria and the ventricles. How should the nurse interpret this rhythm strip? 1 First degree atrioventricular (AV) block 2 Second degree AV block Mobitz I (Wenckebach) 3 Second degree AV block Mobitz II Correct4 Third degree AV block (complete heart block)

Third degree block often is called complete heart block because no atrial impulses are conducted through the AV node to the ventricles. In complete heart block, the atria and ventricles beat independently of each other because the AV node is completely blocked to the sinus impulse and is not conducted to the ventricles. One hallmark of third degree heart block is that the P waves have no association with the QRS complexes and appear throughout the QRS waveform. In first degree AV block, a P wave precedes every QRS complex, and every P wave is followed by a QRS. Second-degree AV block type I, also called Mobitz I or Wenckebach heart block, is represented on the ECG as a progressive lengthening of the PR interval until there is a P wave without a QRS complex. Second degree AV block type II (Mobitz II) is a more critical type of heart block that requires early recognition and intervention. There is no progressive lengthening of the PR interval, which remains the same throughout with the exception of the dropped beat(s).

Which tasks should a nurse perform in order to comply with public health laws? Select all that apply. Correct1 Report cases of communicable diseases Correct2 Report incidences of domestic violence Incorrect3 Provide emergency assistance at an accident scene Incorrect4 Notify the primary healthcare provider of any client-related problems Correct5 Ensure that clients in a community have received necessary immunizations

To comply with public health laws, the nurse is required to report cases of communicable diseases. The nurse must also report cases of suspected domestic violence, child abuse, or elder abuse. The nurse should ensure that clients in a community have received all necessary immunizations. To comply with Good Samaritan laws, the nurse should provide emergency assistance consistent with his or her level of expertise at an accident scene. Notifying the primary healthcare provider of client-related problems is not an example of complying with public health laws. Topics

A health care worker is collecting data on the quality of health care provided in a health care center. The health care worker finds that too many nurses are attending to a single client. What does the health care worker conclude from this? 1 The nursing team is not providing safe care. Correct2 The nursing team is not providing efficient care. Incorrect3 The nursing team is not providing effective care. 4 The nursing team is not providing patient-centered care.

Too many nurses attending to a single client indicates that the work that can be performed by a few nurses is being performed by many nurses. This indicates that the nursing team lacks efficiency. The inability of the nursing team to avoid injuries in the client indicates that the nursing team is unable to perform safe care. The inability to address the problems of the vulnerable groups indicates that the nursing team is unable to provide effective care. The inability to address all the problems of the client while providing care indicates that the nursing team is unable to provide patient-centered care.

A client with a fractured hip is placed in traction until surgery can be performed. What should the nurse explain is the primary purpose of the traction? Correct1 Relieving muscle spasm and pain 2 Preventing contractures from developing 3 Keeping the client from turning and moving in bed 4 Maintaining the limb in a position of external rotation

Traction may be used in the treatment of a fractured hip to align the bones (reduction of fracture). If such traction is not employed, the muscles may go into spasm, shifting the bone fragments and causing pain. Traction is a temporary measure before surgery; contractures result from a shortening of the muscles by prolonged immobility. Although the affected extremity must be properly aligned, turning and moving the client can and should be done. External rotation is contraindicated and prevented by the use of positioning aids.

A nurse is helping a client determine and articulate personal values about health problems. The nurse also explains the effect of these problems on lifestyle adjustments. Which Gardner's task of leadership is the nurse leader applying? 1 Explaining Incorrect2 Managing 3 Motivating Correct4 Affirming values

Values are the connecting thoughts and inner driving forces that give purpose, direction, and precedence to life priorities. According to the Gardner's tasks of leadership, helping the client sort out and articulate personal values that are related to health problems is affirming values. It also involves explaining the effect of these problems on lifestyle adjustments. Explaining includes teaching and interpreting information to promote well-being in the client. Managing involves assisting the client with planning, priority setting, and decision making. This also includes ensuring that organizational systems work on behalf of the client. Motivating includes inspiring clients or family members to achieve their vision.

What are external barriers that can prevent a nursing professional from making morally correct actions? Select all that apply. Correct1 Inadequate staffing 2 Lack of assertiveness 3 Perception of powerlessness Correct4 Lack of organizational support Correct5 Poor relationships with colleagues

When faced with dilemmas, external and internal barriers may prevent a professional from acting in a morally correct way. This may cause moral distress. External barriers include inadequate staffing, lack of organizational support, and poor relationships with colleagues. These factors are present in the organizational environment and can lead a person to act in a particular manner. Internal barriers are factors within a person that prevent one from acting in a morally correct way. These include lack of assertiveness and perception of powerlessness.

A critically injured client was brought to the hospital following a car accident and the client should be immediately triaged for determining the nature and acuity of the injuries. Who is delegated to perform the task? 1 Nurse manager Correct2 Registered nurse 3 Licensed practical nurse 4 Primary healthcare provider

When the client arrives at the hospital after a trauma, it is the responsibility of the registered nurse to determine the nature and acuity of injuries. The nurse manager should usually be the delegator for the registered nurses and healthcare providers. Licensed practical nurses' scope of practice does not include caring for critically ill emergency clients. A primary healthcare provider should treat the client by providing required medications and diagnoses.Test-Taking Tip: Sometimes the reading of a question in the middle or toward the end of an exam may trigger your mind with the answer or provide an important clue to an earlier question.

A group of clients injured during a wildfire are admitted to an emergency unit. Which order should the nurse follow in disaster management? Incorrect1.Focusing actions on stabilizing the community Incorrect2.Designing a plan to structure the response and assess risk Correct3.Actual implementing of the disaster plan Incorrect4.Attempting to limit a disaster's impact on human health Correct5.Evaluating the response effort to prepare for the future

While dealing the clients injured during disaster, the nurse should first prepare a plan to structure the response, assess risk, and evaluate damage. Secondly, the nurse should attempt to limit a disaster's impact on human health. Then, the nurse should actually implement the disaster plan. After implementing the plan, the nurse should focus actions on stabilizing the community. Lastly, the nurse should evaluate the response effort to prepare for the future.Test-Taking Tip: In this Question Type, you are asked to prioritize (put in order) the options presented. For example, you might be asked the steps of performing an action or skill such as those involved in medication administration.

What activities would the nurse participate in while providing a primary level of preventive care? Select all that apply. Incorrect1 Providing individual and mass screening activities Correct2 Providing education about adequate housing and recreation Correct3 Providing education about attention to personality development Correct4 Providing instructions about good standard of nutrition adjusted to developmental phases of life Incorrect5 Providing hospital and community facilities for retraining and education to maximize use of remaining capacities

While providing primary level of preventive care, the nurse should educate the client about the need for adequate housing and recreation. The nurse should also provide education regarding the need to pay attention to personality development. Helping clients to maintain a good standard of nutrition adjusted to developmental phases of life is also a part of primary level preventive care. While providing secondary level of preventive care, the nurse would participate in individual and mass screening activities. While providing tertiary level of preventive care, the nurse would help ensure that clients can access hospital and community facilities for retraining and education to maximize use of remaining capacities.

A severely dehydrated infant with gastroenteritis is admitted to the pediatric unit. Nothing-by-mouth (NPO) status is prescribed. The parents ask why their baby cannot be fed. The nurse explains that it is necessary to do what? 1 Correct electrolyte imbalances Correct2 Allow the intestinal tract to rest 3 Determine the cause of the diarrhea 4 Prevent perianal irritation from the diarrhea

Withholding food reduces the need for intestinal activity, which rests the intestines and minimizes diarrhea and the loss of fluid. Although intravenous therapy will be started for rehydration and to correct electrolyte imbalances, this is not the reason for the NPO status. Stool cultures are used to determine the cause of the diarrhea. Perianal irritation is prevented with meticulous skin care, not by withholding food and fluids.Test-Taking Tip: On a test day, eat a normal meal before going to school. If the test is late in the morning, take a high-powered snack with you to eat 20 minutes before the examination. The brain works best when it has the glucose necessary for cellular function.

A nurse is planning play activities for a 6-year-old child whose energy level has improved after an acute episode of gastroenteritis. What activity should the nurse encourage? 1 Using a set of building blocks 2 Finger-painting on a large paper surface Correct3 Drawing and writing with a pencil or marker

Writing and drawing pictures provides a 6-year-old, who is of school age, with an appropriate way to express feelings. Playing with blocks is appropriate for preschoolers, who have active imaginations. Finger-painting is appropriate for preschoolers, who enjoy experimenting with different textures. Manipulating pieces of a toy is appropriate for preschoolers, who like repetition.