med surg III exam 1

The ED nurse admitting a client with a history of depression is screening the client for suicide risk. What assessment question should the nurse ask when screening the client?

"Have you ever thought about taking your own life?" Rationale: The nurse should address the client's possible plans for suicide in a direct yet empathic manner. The nurse should avoid oblique or indirect references to suicide and should not limit questions to the client's depression.

A home health nurse has completed a scheduled home visit to a client with a chronic sacral ulcer. The nurse is now evaluating and documenting the need for future visits and the frequency of those visits. What question should the nurse use when attempting to determine this need?

"Is the client's family willing to participate in care?" Rationale: Determining the willingness and ability of friends and family to provide care can help determine appropriate levels of professional home care. The time of initial diagnosis and the client's coping style are secondary. The nurse, not the client, is responsible for creating the plan of care.

A hospital audit reveals that four clients in the hospital have current orders for restraints. The nurse knows that restraints are an intervention of last resort, and that it is inappropriate to apply restraints to which of the following clients?

A client with urosepsis who is ringing the call bell incessantly to use the bedside commode Rationale: Restraints should never be applied for staff convenience. The client with urosepsis who is frequently ringing the call bell is requesting assistance to the bedside commode; this is appropriate behavior that will not result in client harm. The other described situations could plausibly result in client harm; therefore, it is more appropriate to apply restraints in these instances.

The nurse is evaluating the plan of care for a client who had a total hip replacement. Which action(s) will the nurse perform during this step of the nursing process? Select all that apply.

A. Add additional nursing diagnoses to address new problems. B. Change expected outcomes if they are not realistic. D. Determine whether priorities need to be reordered. E. Discontinue nursing interventions that are no longer needed. **all BUT C. Check that pain assessments are being performed with vital signs. Rationale: During the evaluation step of the nursing process, the nurse determines whether new actual or potential health problems have developed that need to be added to the plan of care. The nurse also checks the outcomes to determine whether they have been resolved, need modification, or whether new outcomes need to be developed. The nurse evaluates the priorities for care to see whether they need to be reordered. As the client's health conditions change, nursing interventions may also need to be added or discontinued. A chart audit to determine whether pain assessments have been completed is not part of the nursing process.

The nurse is developing nursing interventions for a nursing diagnosis related to mobility in a surgical client. Which statement is an example of a nursing intervention?

Ambulate with the client twice a day. Rationale: A nursing intervention is performed to help the client achieve expected outcomes. Nursing interventions are client-centered and always start with a verb. The intervention "ambulate the client twice a day" is client-centered and begins with a verb. Asking a nursing assistant to ambulate the client is not client-focused. "Client will walk in hall twice a day" does not start with a verb and is written in the form of an outcome rather than an intervention. The statement "client has limited mobility due to surgery" is written as a problem statement, rather than an intervention, and does not start with a verb.

The home health nurse receives a referral from the hospital for a client who needs a home visit for wound care. After obtaining the referral, what action should the nurse first take?

Call the client to obtain permission to visit. Rationale: After receiving a referral, the first step is to call the client and obtain permission to make the visit. Then the nurse should schedule the visit and verify the address. A health care provider's prescription is not necessary to schedule a visit with the client. The nurse may identify community services or the need for a home health aide after assessing the client and the home environment during the first visit with the client. This would not be delegated to a home health aide.

A client has had a total knee replacement and will need to walk with a two-wheeled walker for 6 weeks. The client is being discharged home with a referral for home health care. What assessment should the nurse prioritize during the initial nursing assessment in the home?

Characteristics of the home environment Rationale: The initial assessment includes evaluating the client, the home environment, the client's self-care abilities or the family's ability to provide care, and the client's need for additional resources. Normally an assessment is not made of assistance on the part of neighbors or the costs of the visit. Qualifications for subsidies would normally be determined beforehand.

The emergency department (ED) received news of a train derailment locally and the number of clients injured is reported between 50 and 100. The hospital has determined that it can accommodate 50 clients and still remain self-sufficient. What criteria is the hospital using to project the number of clients it can support?

Decided by the institution's ability to sustain core services for at least 96 hours ationale: The emergency preparedness planning committee must have a realistic understanding of its resources. The goal of each health care institution is to remain self-sufficient to provide and sustain core services without the support of external assistance for at least 96 hours from the inception of the incident; ideally, this self-sufficiency should last for 7 days. The institution cannot expect outside services to be available to help until after 96 hours, which is 4 days. The emergency operations plan details how the facility will respond to a mass casualty incident and may include criteria for utilizing external resources, but external assistance from the Red Cross would not be a factor in determining how many clients the facility can realistically care for immediately. External resources such as the Red Cross cannot be accessed and utilized immediately. The field incident command, not the hospital's incident command center, will provide an estimate of number of clients that will be arriving, though severity of injuries and number of clients self-reporting may not be known.

The nurse is assessing a new client and the client's home environment following a referral for community-based care. What action should the nurse prioritize during this initial visit?

Encourage the client and family to connect with appropriate community resources. Rationale: During initial and subsequent home visits, the nurse helps the client and family identify community services and encourages them to contact the appropriate agencies. This is preferable to delegating another person to make contact. When appropriate, nurses may make the initial contact. A home-health nurse would not normally encourage the client to become more involved in the community as a means of promoting health. Online forms of support can be useful, but they are not the sole form of support that most clients need.

The ED nurse is planning the care of a client who has been admitted following a sexual assault. The nurse knows that all of the nursing interventions are aimed at what goal?

Encouraging the client to gain a sense of control over his or her life Rationale: The goals of management are to provide support, to reduce the client's emotional trauma, and to gather available evidence for possible legal proceedings. All of the interventions are aimed at encouraging the client to gain a sense of control over his or her life. The client's well-being should be considered a priority over criminal proceedings. No health professional can guarantee the client's future safety and having the client verbalize the event is not a priority.

A client is brought to the ED by two police officers. The client was found unconscious on the sidewalk, the client's face and hands covered in blood. At present, the client is verbally abusive and is fighting the staff in the ED, but appears medically stable. The decision is made to place the client in restraints. What action should the nurse perform when the client is restrained?

Frequently assess the client's skin integrity. Rationale: It is important to assess skin integrity when physical restraints are used. Criminal charges are not the responsibility of the nurse and the nurse should still interact with the client. A full physical assessment, however, would likely be delayed until the client is not combative.

The nurse is admitting a client who is suspected of having heat stroke. What assessment finding would be most consistent with this diagnosis?

Hot, dry skin Rationale: Heat stroke is manifested by hot, dry skin, confusion, bizarre behavior, coma, elevated body temperature (usually 103°F/39.4°C or higher), tachypnea, hypotension, and tachycardia. A widening pulse pressure is more indicative of a heart defect or problem. Cheyne-Stokes respirations, a rare condition characterized by fast, shallow breathing followed by slow heavier breathing, followed by no breathing, are typically seen in clients with heart failure and stroke.

A client has sustained multiple injuries from a gunshot wound while hunting in cold winter weather. The client has waited several hours for rescue and is transported in a helicopter to the emergency department. The nurse recognizes what additional factors are associated with increased mortality for this client?

Hypothermia, acidosis, and coagulopathy Rationale: Major trauma can cause hypothermia, acidosis, and coagulopathy, sometimes called the "triad of death" because each of these factors is associated with increased mortality. In this case the client was exposed to cold weather for several hours. The client had a gunshot wound that caused bleeding. Coagulopathy likely occurs immediately after massive trauma and shock. As the client with trauma perfusion worsens, lactic acid rapidly accumulates in the tissues, which ultimately results in severe metabolic acidosis. Thermal changes, gravitational forces, barometric changes, and fatigue are all related to stresses of flight, but they are not directly related to an increased mortality. Comorbidities, time, and location of injury can contribute to the client's survivability but are paired with choices that do not. Venous insufficiency and hyperhidrosis (excessive sweating) are not directly linked to this event.

The hospital nurse is planning for a client's discharge. What is the initial action the nurse should take when planning discharge for a client?

Identifying the client's specific needs Rationale: The first step in the discharge planning process involves identifying the client's specific needs and developing a plan to care to meet those needs. Once the specific needs have been identified, the nurse can then make referrals to other health care professionals to meet these needs, such as the social worker, physical therapist, or dietitian.

A home health nurse is conducting a home visit to a client who receives wound care twice weekly for a diabetic foot ulcer. While performing the dressing change, the nurse realizes that the nurse has forgotten to bring the adhesive gauze specified in the wound-care regimen. What is the nurse's best action?

Improvise, if possible, using sterile gauze and adhesive tape. Rationale: Improvisation is a necessity in many home health situations. It would be logistically difficult to have the supplies delivered and leaving the wound open to air may be contraindicated. A return visit the next day does not resolve the immediate problem.

A nurse provides care on an orthopedic reconstruction unit and is admitting two new clients, both status post knee replacement. What would be the best explanation why their care plans may be different from each other?

Individual clients are seen as unique and dynamic, with individual needs. Rationale: Regardless of the setting, each client situation is viewed as unique and dynamic. Differences in insurance coverage and attitude may be relevant, but these should not fundamentally explain the differences in their nursing care. Nursing care should be planned by nurses, not by members of other disciplines.

The nurse is providing care for a client with chronic obstructive pulmonary disease (COPD). The nurse's most recent assessment reveals an SaO2 of 89%. The nurse is aware that part of critical thinking is determining the significance of data that have been gathered. What characteristic of critical thinking is used in determining the best response to this assessment finding?

Interpretation Rationale: Nurses use interpretation to determine the significance of data that are gathered. This specific process is not described as extrapolation, inference, or characterization.

The nurse, in collaboration with the client's family, is determining priorities related to the care of the client. The nurse explains that it is important to consider the urgency of specific problems when setting priorities. What should the nurse adopt as the best framework for prioritizing client problems?

Maslow hierarchy of needs Rationale: The Maslow hierarchy of needs provides a useful framework for prioritizing problems, with the first level given to meeting physical needs of the client. Availability of hospital resources, family member statements, and nursing skill do not provide a framework for prioritization of client problems, though each may be considered.

A care conference has been organized for a client with complex medical and psychosocial needs. When applying the principles of critical thinking to this client's care planning, the nurse should most exemplify what characteristic?

Openness to various viewpoints Rationale: Willingness and openness to various viewpoints are inherent in critical thinking; these allow the nurse to reflect on the current situation. An emphasis on the past, willingness to observe behaviors, and a desire to utilize the nursing scope of practice fully are not central characteristics of critical thinkers.

The community health nurse is preparing to conduct a home visit on a client without an active infection. When performing the home visit, how should the nurse best implement the principles of infection control?

Perform hand hygiene before and after giving direct client care. Rationale: Infection control is as important in the home as it is in the hospital. As in any situation, nurses should clean the hands before and after giving direct client care. Removing the wound dressings from the home is not necessary as long as they are disposed of properly. Transmission-based precautions are only necessary when the client is infected with an infectious organism. A sterile field is not necessary to provide routine care.

The nurse is planning discharge for a client receiving Medicare. The Medicare program facilitates what aspect of home health care for the client?

Providing outcome-based client care Rationale: Many home health care expenditures are financed by Medicare. Medicare uses the Outcome and Assessment Information Set (OASIS) to promote outcome-based client care. Home health nurses, despite who funds their visits, do not provide care without the oversight of a health care provider; they do not write medication orders; nor do they order the services of ancillary specialists such as physical, occupational, or speech therapists.

A nurse is involved in a program that aims to increase the use of health informatics. What is the most likely outcome of this program if it is successful?

Rapid access to client information by everyone involved in the client's care Rationale: The essence of health informatics is rapid and comprehensive access to client information. This can allow for a decentralization of care and it may or may not cause clients to become more involved in their care. Health informatics alone will not result in interprofessional collaboration

The nurse is caring for a client with cancer who is undergoing genetic testing. The nurse explains that genetic testing will affect which aspects of the client's care? Select all that apply.

Screening for genetic mutations C. Providing information on prognosis D. Choosing specific treatments Rationale: Advances in genetic testing have improved the process of screening for genetic mutations in cancer cells, diagnosing specific types of cancer, and choosing specific treatments for certain types of cancers. Genetic testing does not provide information on prognosis nor does it predict lifespan.

The nurse cites a list of skills that support critical thinking in clinical situations. The nurse should describe skills in which of the following domains? Select all that apply.

Self-regulation C. Inference E. Interpretation Rationale: Skills needed in critical thinking include interpretation, analysis, evaluation, inference, explanation, and self-regulation. Self-esteem and autonomy would not be on the list because they are not skills.

During a discussion with the client and the client's spouse, the nurse discovers that the client has a living will. How does the presence of a living will influence the client's care?

The client may nullify the living will during the hospitalization. Rationale: Because living wills are often written when the person is in good health, it is not unusual for the client to nullify the living will during illness. A living will does not make a client legally unable to refuse basic life support. The health care provider may disagree with the client's wishes but is ethically bound to carry out those wishes. A power of attorney is not synonymous with a living will.

An emergency department (ED) nurse is triaging clients according to a triage severity rating. When assigning clients to a triage level, the nurse will consider the clients' acuity as well as what other variable?

The resources that the client is likely to currently require Rationale: With the emergency severity index (ESI), clients are assigned to triage levels based on both their acuity and their anticipated resource needs. ESI is a triage algorithm. The rating is from 1 to 5 with the most urgent clients rated as a 1 and the least urgent a 5. Ability to participate, the likelihood of repeat visits, and other hospitals' ability to take clients are not explicitly considered.

A nurse is admitting a new client to the medical unit. During the initial nursing assessment, the nurse has asked many supplementary open-ended questions while gathering information about the new client. What is the nurse achieving through this approach?

Validating what the client has said Rationale: Critical thinkers validate the information presented to make sure that it is accurate (not just supposition or opinion), that it makes sense, and that it is based on fact and evidence. The nurse is not interpreting, evaluating, or assessing the information the client has given.

A client agreed to be a part of a research study involving migraine headache management. The client asks the nurse if a placebo was given for pain management or if the new drug that is undergoing clinical trials was given. After discussing the client's distress, it becomes evident to the nurse that the client did not fully understand the informed consent document that was signed at the start of the research study. What is the best response by the nurse?

"The research study is in place and there is no way to know now." Rationale: Telling the truth (veracity) is one of the basic principles of nursing culture. Three ethical dilemmas in clinical practice that can directly conflict with this principle are the use of placebos (nonactive substances used for treatment), not revealing a diagnosis to a client, and revealing a diagnosis to persons other than the client with the diagnosis. The nurse is following the guidelines of the research study, so re-educating the client about the study is the best the nurse can do. Saying "What difference does it make?" or "You signed informed consent documents" is not helpful because these statements are not supportive. While it is true that the nurse does not know what treatment the client received, this statement is also not supportive.

Which client should the nurse prioritize as needing emergent treatment, assuming no other injuries are present except the ones outlined?

A client with a blunt chest trauma with some difficulty breathing Rationale: The client with blunt chest trauma possibly has a compromised airway. Establishment and maintenance of a patent airway and adequate ventilation are prioritized over other health problems, including skeletal injuries and changes in cognition.

. The community-health nurse has received a referral for a new client who resides in a high-crime area. What is the most important request that the nurse should make of the agency to ensure safety?

A colleague to accompany the nurse on the visit Rationale: When making visits in high-crime areas, visit with another person rather than alone. A person who is waiting in the car is of little benefit. An early morning or late afternoon appointment would not necessarily guarantee safety. Similarly, assigned parking would not guarantee the nurse's safety while performing the visit.

The nurse is preparing a wellness program for seniors at a community center. Which concept of wellness should the nurse utilize when planning the program?

A person needs to be proactive in achieving wellness. Rationale: Wellness is a proactive state involving self-care activities aimed at physical, psychological, social, and spiritual well-being. Wellness exists on a continuum and is not merely the absence of sickness. Wellness is subjective and, therefore, is not the same for each person. Because wellness is the ability to adjust and adapt to varying situations, the definition of wellness can change for a person over time.

A home health nurse is admitting a new client to home care services. Which action(s) should the nurse perform during medication reconciliation? Select all that apply.

A. Check for duplicate medications. B. Assess for use of herbal remedies. D. Check that the correct dose is being administered. E. Assure the proper frequency of administration. ** all BUT C. Encourage the use of multiple pharmacies Rationale: Medication reconciliation includes reviewing all medications for duplicate medications. This can occur when there are multiple health care providers prescribing medications or several pharmacies are used. When reviewing medications, the nurse should include herbal remedies and vitamins to ensure that there are no interactions with prescribed medications. The nurse also assesses if the client is taking the correct dose at the correct time. The nurse should not encourage the use of multiple pharmacies as this increases the risk of duplicate medications and drug-drug interactions.

The nurse is providing care for a client who has a diagnosis of pneumonia due to Streptococcus pneumonia infection. What aspect of nursing care would constitute part of the planning phase of the nursing process?

Achieve SaO2 92% at all times. Rationale: The planning phase entails specifying the immediate, intermediate, and long-term goals of nursing action, such as maintaining a certain level of oxygen saturation in a client with pneumonia. Providing fluids and avoiding overexertion are parts of the implementation phase of the nursing process. Chest auscultation is an assessment.

A homeless person is admitted the ED during a blizzard, and is unable to feel the feet and lower legs. Core temperature is noted at 33.2°C (91.8°F). The client is intoxicated with alcohol at the time of admission and is visibly malnourished. What is the triage nurse's priority in the care of this client?

Addressing the client's hypothermia Rationale: The client may also have frostbite, but hypothermia takes precedence in treatment because it is systemic rather than localized. The alcohol abuse and the alteration in nutrition do not take precedence over the treatment of hypothermia because both problems are a less acute threat to the client's survival.

A client is admitted to the ED with an apparent overdose of IV heroin. After stabilizing the client's cardiopulmonary status, the nurse should prepare to perform what intervention?

Administer naloxone hydrochloride (Narcan). Rationale: Naloxone is an opioid antagonist that is given for the treatment of narcotic overdoses. There is no definitive need for a urinary catheter or for a bolus of lactated Ringer. The client's basic neurologic status should be ascertained during the rapid assessment, but a detailed examination is less important than administration of an antidote.

A recent nursing graduate is aware of the differences between nursing actions that are independent and nursing actions that are interdependent. A nurse performs an interdependent nursing intervention when performing which of the following actions?

Administering an IV bolus of normal saline to a client with hypotension Rationale: Although many nursing actions are independent, others are interdependent, such as carrying out prescribed treatments; administering medications and therapies; collaborating with other health care team members to accomplish specific, expected outcomes; and to monitor and manage potential complications. Irrigating a wound, administering pain medication, and administering IV fluids are interdependent nursing actions and require a health care provider's order. An independent nursing action occurs when the nurse assesses a client's heart rate, provides discharge education, or provides mouth care.

A client with a history of major depression is brought to the ED by the client's parents. Which of the following nursing actions is most appropriate?

Asking if the client has ever thought about taking their own life Rationale: Establishing if the client has suicidal thoughts or intents helps identify the level of depression and intervention. Physical symptoms are relevant and should be explored. Allow the client to express feelings, and conduct the interview at a comfortable pace for the client. Never leave the client alone because suicide is usually committed in solitude.

The provider has recommended an amniocentesis for an 18-year-old primiparous client. The client is at 34 weeks' gestation and does not want this procedure, but the health care provider arranges for the amniocentesis to be performed. The nurse should recognize that the provider is in violation of which ethical principle?

Autonomy Rationale: The principle of autonomy specifies that individuals have the ability to make a choice free from external constraints. The provider's actions in this case violate this principle. This action may or may not violate the principle of beneficence. Veracity centers on truth-telling, and nonmaleficence is avoiding the infliction of harm.

A home health nurse is preparing to make the initial visit to a new client's home. When planning educational interventions, what information should the nurse provide to the client and family? Select all that apply.

Available community resources to meet their needs C. The nurse's contact information D. Dates and times of scheduled home care visits Rationale: The community-based nurse is responsible for informing the client and family about the community resources available to meet their needs. During initial and subsequent home visits, the nurse helps the client and family identify these community services and encourages them to contact the appropriate agencies. The nurse also provides the client with contact information so that the client and family know how to reach the nurse with questions or a problem. The nurse also provides the client with a schedule of futures visits so the client knows when to expect visits. Following HIPAA guidelines the nurse is not able to share information on other clients. The goals for care should be developed with the client and not by the nurse alone.

A client has been brought to the ED after suffering genitourinary trauma in an assault. Initial assessment reveals that the client's bladder is distended. What is the nurse's most appropriate action?

Await orders following the urologist's assessment. Rationale: Urethral catheter insertion when a possible urethral injury is present is contraindicated; a urology consultation and further evaluation of the urethra are required. The nurse would withhold fluids, but urologic assessment is the priority.

The community-based care manager works in a medium-sized community that does not have an up-to-date discharge planning directory, so the nurse has been given the task of beginning to compile one. What will need to be included with the discharge plan? Select all that apply.

B. Collaboration of referring agency with community resources C. Eligibility requirements for services D. Lists of the most commonly used resources E. Discharge plan communication **all BUT A. Links to online health sciences journals Rationale: A discharge planning directory should include the commonly used community resources that clients need as set in the discharge plan, including eligibility requirements for those resources, and open communication within the referral systems. The discharge plan would not include links to online professional journals (which are intended for health care providers).

A client is brought to the emergency room (ER) in an unconscious state and emergency surgery is needed. No family members are present, and the client does not have identification. What action by the nurse is the priority regarding consent for treatment?

Clearly document level of consciousness (LOC) and health status on the client's chart. Rationale: When clients are unconscious and in critical condition, the condition and situation should be documented to administer treatment quickly and timely when no consent can be obtained by usual routes. According to the Emergency Medical Treatment and Active Labor Act (EMTALA), every ED with a Medicare provider agreement must perform a medical screening examination on all clients arriving with an emergency medical issue if their acute signs and symptoms could result in serious injury or death if left untreated. EDs are also required to provide treatment aimed at stabilizing each client's condition. A social worker is not asked to sign the consent. Finding the client's identity is not a priority. Obtaining a court order would take too long.

A nurse has accepted a position at a health care facility that embraces interprofessional collaboration as its model of practice. Which competency should the nurse recognize as being key to interprofessional collaboration? Select all that apply.

Client-centered care B. Evidence-based practice D. Safety E. Informatics **All BUT C. Managing care Rationale: According to the Interprofessional Collaborative Practice, the core competencies of interdisciplinary collaboration include client-centered care, evidence-based practice, safety, and informatics. Other core competencies are interdisciplinary teamwork and collaboration and quality improvement. Managing care is not a core competency of interdisciplinary collaboration. It is a function of the role of the manager.

A master's degree-prepared nurse is helping other nurses on a medical-surgical unit integrate evidence and research into their practice. Which role is this nurse performing?

Clinical nurse leader Rationale: A clinical nurse leader (CNL) is a certified nurse generalist with a master's degree in nursing who integrates evidence-based practices into client care. A case manager, who may not have a graduate degree or be a nurse, coordinates health care services to ensure cost-effectiveness, accountability, and quality care for a caseload of clients. A nurse navigator works with a given population of clients with a common diagnosis or disease to help the client and family transition through different levels of care. A critical care nurse is a staff nurse who works in an intensive care unit.

In the process of planning a client's care, the nurse has identified a nursing diagnosis of Ineffective Health Maintenance related to alcohol use. What must precede the determination of this nursing diagnosis?

Collecting and analyzing data that corroborate the diagnosis Rationale: In the diagnostic phase of the nursing process, the client's nursing problems are defined through analysis of client data. Establishing a plan comes after collecting and analyzing data; evaluating a plan is the last step of the nursing process; and assigning a positive value to each consequence is not done.

A nurse provides community-based care and acts as the case manager for a small town about 60 miles (100 km) from a major health care center. When planning care in the community, what is the most important variable in community-based nursing that the nurse should integrate into planning?

Community resources available to clients Rationale: A community-based nurse must first be knowledgeable about community resources available to clients as well as services provided by local agencies, eligibility requirements, and any possible charges for the services. The other answers are incorrect because they are not the most important factors about which a community-based nurse must be knowledgeable, even though each must be considered.

A nurse is aware that an increasing emphasis is being placed on health, health promotion, wellness, and self-care. Which of the following activities would best demonstrate the principles of health promotion?

Creation of a smoking prevention program undertaken in a middle school Rationale: Smoking prevention is a clear example of health promotion. Each of the other listed activities has the potential to be beneficial, but none is considered health promotion.

The nurse is performing initial visits to two new clients of the local home health care service. These clients live within two blocks of each other and both homes are in a high-crime area. What action best protects the nurse's personal safety?

Do not wear expensive jewelry. Rationale: Do not drive an expensive car or wear expensive jewelry when making visits in order to reduce the chance of being robbed. While all of these answers might be wise precautions to take, the other suggestions address property security rather than personal safety.

. A client admitted to the ED with severe diarrhea and vomiting is subsequently diagnosed with food poisoning. The nurse caring for this client assesses for signs and symptoms of fluid and electrolyte imbalances. For what signs and symptoms would this nurse assess? Select all that apply.

Dysrhythmias C. Hypotension E. Delirium Rationale: The client is assessed for signs and symptoms of fluid and electrolyte imbalances, including lethargy, rapid pulse rate, fever, oliguria, anuria, hypotension, and delirium. Hyperglycemia and hypothermia are not typically associated with fluid and electrolyte imbalances.

The nurse navigator is coordinating the transition from the hospital to a rehabilitation facility of a client who had a total hip replacement. Which activity would be an example of the nurse navigator role for this client?

Educating the client on the goals of rehabilitation Rationale: The role of the nurse navigator is to assist clients with transitions in different levels of care, such as from the hospital to a rehabilitation facility. It is the role of a case manager to ensure cost-effective care and to communicate with the medical insurance company. The nurse navigator does not provide direct care to clients.

A client who attempted suicide is being treated in the ED. The client is accompanied by the client's mother, father, and brother. When planning the nursing care of this family, the nurse should perform which of the following actions?

Ensure that the family receives appropriate crisis intervention services. Rationale: It is essential that family crisis intervention services are available for families of ED clients. It would be inappropriate and insensitive to explore causes of the client's suicide attempt with the family. Family participation in bedside care is often impractical in the ED setting. Psychiatry is not the normal source of psychosocial support and crisis intervention.

A home health nurse has completed a visit to a client and has immediately begun to document the visit. Accurate documentation that is correctly formatted is necessary for what reason?

Ensures that the agency is correctly reimbursed for the visit Rationale: The client's needs and the nursing care provided must be documented to ensure that the agency qualifies for payment for the visit. Documentation does not guarantee an absence of liability. Documentation is not normally provided to the client to gauge progress. Documentation is not primarily used to facilitate delegation to unlicensed caregivers.

A client with multiple trauma is brought to the emergency department (ED) by ambulance after a fall while rock climbing. What is a responsibility of the ED nurse in this client's care?

Ensuring Intravenous (IV) access Rationale: ED nursing responsibilities include ensuring airway and IV access. Nurses are not normally responsible for notifying family members. Nurses collect specimens, but are not responsible for testing . Health care providers or other team members with specialized training intubate the client.

A home health nurse is conducting an assessment of a client who may qualify for Medicare. Consequently, the nurse is utilizing the Outcome and Assessment Instrument Set (OASIS). When performing an assessment using this instrument, the nurse should assess what domain of the client's current status?

Functional status Rationale: The Omaha System of care documentation has been required for over a decade to assure that outcome-based care is provided for all care reimbursed by Medicare. This system uses sociodemographic, environment, support system, health status, and functional status domains to assess and plan care for adult clients. It does not explicitly assess spirituality, psychiatric status, or compliance with care.

A client who has been diagnosed with cholecystitis is being discharged home from the ED to be scheduled for later surgery. The client received morphine during the present ED admission and is visibly drowsy. When providing health education to the client, what would be the most appropriate nursing action?

Give verbal and written instructions to the client and a family member. Rationale: Before discharge, verbal and written instructions for continuing care are given to the client and the family or significant others. Discharge teaching is completed prior to the client leaving the ED, so phoning the client the next day is not acceptable

A client is brought to the ED by ambulance after swallowing highly acidic toilet bowl cleaner 2 hours earlier. The client is alert and oriented. What is the care team's most appropriate treatment?

Giving milk to drink Rationale: A client who has swallowed an acidic substance, such as toilet bowl cleaner, may be given milk or water to drink for dilution. Gastric lavage must be performed within 1 hour of ingestion. A psychiatric consult may be considered once the client is physically stable and it is deemed appropriate by the health care provider. Syrup of ipecac is no longer used in clinical settings.

An obtunded client is admitted to the ED after ingesting bleach. The nurse should prepare to assist with what intervention?

Helping the client drink large amounts of water Rationale: The client who has ingested a corrosive poison, such as bleach, is given water or milk to drink for dilution. Gastric lavage is not used to treat ingestion of corrosives and activated charcoal is ineffective. There is no antidote for a corrosive substance such as bleach.

A client with a fractured femur presenting to the ED exhibits cool, moist skin, increased heart rate, and falling BP. The care team should consider the possibility of what complication of the client's injuries?

Hemorrhage Rationale: The signs and symptoms the client is experiencing suggest a volume deficit from an internal bleed. That the symptoms follow an acute injury suggests hemorrhage rather than myocardial infarction or hypoglycemia. Peritonitis would be an unlikely result of a femoral fracture.

In 2 days the nurse is scheduled to discharge a client home after left hip replacement. The nurse has initiated a home health referral and met with a team of people who have been involved with this client's discharge planning. Knowing that the client lives alone, who would be appropriate people to be on the discharge planning team? Select all that apply.

Home health nurse B. Physical therapist D. Social worker Rationale: The development of a comprehensive discharge plan requires collaboration with professionals at both the referring agency and the home care agency, as well as other community agencies that provide specific resources upon discharge. The pharmacy technician does not participate in discharge planning, and there is no indication that utilizing Meals on Wheels is necessary.

A client is brought by friends to the ED after being involved in a motor vehicle accident. The client sustained blunt trauma to the abdomen. What nursing action would be most appropriate for this client?

Immobilize the client on a backboard. Rationale: When admitted for blunt trauma, clients must be immobilized until spinal injury is ruled out. Ambulation, side-lying, and upright positioning would be contraindicated until spinal injury is ruled out

The nurse is developing a plan of care for a client admitted with chronic obstructive pulmonary disease. Using the Maslow hierarchy of needs, which nursing diagnosis should the nurse give the highest priority?

Ineffective airway clearance Rationale: After nursing diagnoses have been developed, the nurse assigns priorities based on the urgency of the problem. The Maslow hierarchy of needs is one framework the nurse can utilize to prioritize needs. Using the Maslow hierarchy of needs, maintaining a patent airway would have the highest priority since it satisfies a basic physiologic need. Activity intolerance, self-esteem, and inability to toilet oneself are all important problems but would be handled after clearing the airway has been addressed and oxygenation and perfusion have been assured.

The nurse has been assigned to care for a client admitted with an opportunistic infection secondary to AIDS. The nurse informs the clinical nurse leader that the nurse refuses to care for a client with AIDS. The nurse has an obligation to this client under which of the following?

International Council of Nurses (ICN) Code of Ethics for Nurses Rationale: The ethical obligation to care for all clients is included in the Code of Ethics for Nurses. The Good Samaritan Act relates to lay people helping others in need. The NIC is a standardized classification of nursing treatment that includes independent and collaborative interventions. Nurse practice acts primarily address scope of practice.

The nurse is caring for a client whose family members are in a bitter conflict about the best course of treatment for the client. How should the nurse best address this challenging situation?

Involve the institution's ethics committee. Rationale: Challenging ethical or moral situations often benefit from the involvement of the ethics committee. Acting independently in the role of mediator likely goes beyond the nurse's skill and scope of practice. The primary health care provider likely cannot resolve this issue independently. Assertiveness on the part of the client may or may not be beneficial.

medical nurse has obtained a new client's health history and has completed the admission assessment. The nurse followed this by documenting the results and creating a care plan for the client. Which of the following is the most important rationale for documenting the client's care?

It provides continuity of care. Rationale: This record provides a means of communication among members of the health care team and facilitates coordinated planning and continuity of care. It serves as the legal and business record for a health care agency and for the professional staff members who are responsible for the client's care. Documentation is not primarily a teaching log; it does not verify staffing; and it is not intended to provide the client with information about treatments.

At the beginning of a day that will involve several home visits, the nurse has ensured that the health care agency has a copy of the nurse's daily schedule. What is the rationale for this action?

It supports safety precautions for the nurse when making a home care visit. Rationale: Whenever a nurse makes a home visit, the agency should know the nurse's schedule and the locations of the visits. The other answers are incorrect because providing the agency with a copy of the daily schedule is not for the purpose of correctly handling payment or for the ease of the nurse in changing assignments. It is also not intended for the client's ease in cancelling appointments.

A home health nurse has been working for several months with a client who is receiving rehabilitative services. The nurse is aware that maintaining the client's confidentiality is a priority. How can the nurse best protect the client's right to confidentiality?

Keep the client's medical record secured at all times. Rationale: If the nurse carries a client's medical record into a house, it must be put in a secure place to prevent it from being picked up by others or from being misplaced. This does not mean, however, that it must never be brought to the home. It is not normally necessary to limit discussions to times when the client is alone. The client has the right to decide with whom he will discuss his condition and care.

The nurse has been asked to speak to members of a self-care education program. What topic would the nurse most likely address?

Management of illness Rationale: Organized self-care education programs emphasize health promotion, disease prevention, management of illness, self-care, and judicious use of the professional health care system. Prenatal care, lobbying, and Internet activities are secondary.

The nurse is admitting a client to the medical unit after the client has been transferred from the emergency department. What is the nurse's priority action at this time?

Meeting the urgent needs of the client Rationale: Among the nurse's functions in health care delivery, identifying the client's urgent needs and working in concert with the client to address them is most important. The other nursing functions are important, but they are not the most important functions.

The nurse is caring for a client who has developed heart failure. Which intervention is a primary nursing focus in treating this collaborative problem?

Monitoring intake and output Rationale: Collaborative problems are physiologic complications that the nurse monitors to detect changes or complications. By monitoring intake and output, the nurse is monitoring the client's fluid status to detect fluid volume overload. While the nurse administers a diuretic, it is prescribed by the health care provider. Likewise, the nurse restricts the intake of fluids or inserts an indwelling urinary catheter in the client, but the interventions are prescribed by the heath care provider.

A client in the critical care unit is prescribed crystalloid intravenous fluids. The nurse anticipates administering which fluid? Select all that apply.

Normal saline B. Lactated Ringer C. Dextrose 5% in water Rationale: These crystalloid solutions in various concentrations and combinations contain electrolytes and sometimes sugars: saline; lactated Ringer; 5% dextrose in water. IV solutions with larger molecules designed to expand IV volume with increased oncotic pressures include: albumin, Hespan, or Hetastarch.

A nurse has begun creating a client's plan of care shortly after the client's admission. The nurse knows that it is important that the wording of the chosen nursing diagnoses falls within the taxonomy of nursing. Which organization is responsible for developing the taxonomy of a nursing diagnosis?

North American Nursing Diagnosis Association (NANDA) Rationale: NANDA International is the official organization responsible for developing the taxonomy of nursing diagnoses and formulating nursing diagnoses acceptable for study. The ANA, NLN, and Joint Commission are not charged with the task of developing the taxonomy of nursing diagnoses.

A nurse who has an advanced degree in primary care for a pediatric population is employed in a health clinic. In what role is this nurse functioning?

Nurse practitioner Rationale: Nurse practitioners, educated in primary care, often practice in ambulatory care settings that focus on gerontology, pediatrics, family or adult health, or women's health. Case coordinators and clinical supervisors do not necessarily require an advanced degree, and a clinical nurse specialist is not educated in primary care. Primary care is the specific focus of CNPs.

While developing the plan of care for a new client on the unit, the nurse must identify expected outcomes that are appropriate for the new client. What resource should the nurse prioritize for identifying these appropriate outcomes?

Nursing Outcomes Classification (NOC) Rationale: Resources for identifying appropriate expected outcomes include the NOC and standard outcome criteria established by health care agencies for people with specific health problems. The other options are incorrect because they do not exist.

A hospice nurse is caring for a client who is dying of lymphoma. According to the Maslow hierarchy of needs, what dimension of care should the nurse consider primary in importance when caring for a dying client?

Physiologic Rationale: Maslow ranked human needs as follows: physiologic needs; safety and security; sense of belonging and affection; esteem and self-respect; and self-actualization, which includes self-fulfillment, desire to know and understand, and aesthetic needs.

The nurse is caring for a client with alcohol withdrawal syndrome. What would be an appropriate nursing action to minimize the potential for hallucinations?

Place the client in a private, well-lit room. Rationale: The client should be placed in a quiet single room with lights on and in a calm, nonstressful environment. TV and radio stimulation should be avoided. Analgesics are not normally necessary, and would potentially contribute to hallucinations. Health education would be inappropriate while the client is experiencing acute withdrawal.

The home care nurse is assessing a client's use of crutches in the home. Which of the following actions by the client indicates that the client is using the crutches effectively?

Placing the crutches on lower step and moving the affected leg first when descending stairs Rationale: When descending stairs with crutches, the correct technique is to place the crutches on the lower step, then advance the affected leg, and move the unaffected leg last. The other techniques described are wrong and indicate that more teaching is needed on the use of crutches.

A nurse is collaborating with a team of community nurses to identify the vision and mission for community care. What is the central focus of nursing?

Promoting and maintaining the health of individuals and families Rationale: Community-based nursing practice focuses centrally on promoting and maintaining the health of individuals and families, preventing and minimizing the progression of disease, and improving quality of life. Health literacy is not a goal in itself, but rather a means to promoting health. Distributing ownership and identifying links between lifestyle and health are not the essence of community-based care.

A client with multiple injuries is brought to the emergency department by ambulance. The client has had his airway stabilized and is breathing on their own. The nurse does not see any active bleeding, but should suspect internal hemorrhage based on what finding?

Rapid pulse and decreased capillary refill Rationale: The nurse would anticipate that the pulse would increase and BP would decrease. Urine output would also decrease. An absence of bruising and the presence of diaphoresis would not suggest internal hemorrhage.

A nurse has been providing ethical care for many years and is aware of the need to maintain the ethical principle of nonmaleficence. Which of the following actions would be considered a violation of this principle?

Refusing to administer pain medication as prescribed Rationale: The duty not to inflict as well as prevent and remove harm is termed nonmaleficence. Discussing a DNR order with a terminally ill client and assisting a client with ADLs would not be considered contradictions to the nurse's duty of nonmaleficence. Some clients justifiably require more care than others.

A hospital nurse is transitioning to a home health nurse position. The nurse has that the client smokes while at home. What will the nurse need to do to work therapeutically with the client in the home setting?

Resolve to convey respect for the client's beliefs and choices. Rationale: To work successfully with clients in any setting, the nurse must be nonjudgmental and convey respect for clients' beliefs, even if they differ sharply from the nurse's. This can be difficult when a client's lifestyle involves activities that a nurse considers harmful or unacceptable, such as smoking, use of alcohol, drug abuse, or overeating. The nurse should not request another assignment because of a difference in beliefs, nor do nurses ask for the client to come to the agency to receive treatment. It is also inappropriate to convert the client's home to a hospital-like environment.

The paramedics bring a client who has suffered a sexual assault to the ED. What is important for the sexual assault nurse examiner to do when assessing a sexual assault victim?

Respect the client's privacy during assessment. Rationale: The client's privacy and sensitivity must be respected because the client will be experiencing a stress response to the assault. Pubic hair is combed or trimmed for sampling. Paper bags are used for evidence collection because plastic bags retain moisture, which promotes mold and mildew that can destroy evidence. Bathing the client before the examination would destroy or remove key evidence.

A home health nurse is making a visit to a new client who is receiving home care following a mastectomy. During the visit, the client's husband arrives home in an intoxicated state and speaks to both the nurse and the client in an abusive manner. What is the nurse's best response?

Return to the agency and notify the supervisor. Rationale: If a dangerous situation is encountered during a visit, the nurse should return to the agency and contact his or her supervisor or law enforcement officials, or both. Ignoring the husband or calling the police while in the home or attempting to remove the client from the home could further endanger the nurse and the client.

A nursing student has taught a colleague that nursing practice is not limited to hospital settings, explaining that nurses are now working in ambulatory health clinics, hospice settings, and homeless shelters and clinics. What factor has most influenced this increased diversity in practice settings for nurses?

Shift of health care delivery into the community Rationale: As health care delivery shifts into the community, more nurses are working in a variety of community-based settings. These settings include public health departments, ambulatory health clinics, long-term care facilities, hospice settings, industrial settings (as occupational nurses), homeless shelters and clinics, nursing centers, home health agencies, urgent care centers, same-day surgical centers, short-stay facilities, and clients' homes. The other answers are incorrect because our population has not shifted to a more rural base, and the use of primary care clinics has not led to an increase in practice settings or the use of rehabilitation hospitals.

The nursing instructor is preparing a group of students for their home care rotation. Which of the following types of care are the students most likely to provide?

Skilled nursing care Rationale: The role of the home health nurse is to provide skilled nursing care to clients. The home health nurse does not provide primary care to the client as this is not within the scope of practice of a nurse without an advanced practice certification. The home health aide or other assistive person may help with household chores and shopping.

There are specific legal guidelines and regulations for the documentation related to home care. When providing care for a client who is a Medicaid recipient, what is most important for the nurse to document?

The client's homebound status and the specific need for skilled nursing care Rationale: Medicare, Medicaid, and third-party payers require documentation of the client's homebound status and the need for skilled professional nursing care. The medical diagnosis and specific detailed information on the functional limitations of the client are usually part of the documentation. The other answers are incorrect because nursing documentation does not include needed supplies, tax information, or the quality of care needed.

An adult client with a history of diabetes is scheduled for a transmetatarsal amputation. When should the client's discharge planning begin?

The day that the client is admitted Rationale: Discharge planning begins with the client's admission to the hospital and must consider the possible need for follow-up home care. Discharge planning should begin prior to the other listed times.

A group of students have been challenged to prioritize ethical practice when working with a marginalized population. How should the students best understand the concept of ethics?

The formal, systematic study of moral beliefs Rationale: In essence, ethics is the formal, systematic study of moral beliefs, whereas morality is the adherence to informal personal values.

Within the public health system there has been an increased demand for medical, nursing, and social services. The nurse should recognize what phenomenon as the basis for this increased demand?

The growing number of older adults in the population Rationale: The growing number of older adults increases the demand for medical, nursing, and social services within the public health system. Income disparities, profit potential, and increased use of complementary therapies do not account for this change

Over the past several decades, nursing roles have changed and expanded in many ways. Which of the following needs has most contributed to this change?

The need to decrease the cost of health care Rationale: The role of the nurse has expanded to improve the distribution of health care services and to decrease the cost of health care. The other answers are incorrect because the expansion of roles in nursing did not occur to improve education, increase the number of nursing jobs, or increase public awareness.

A nurse has been offered a position on an obstetric unit and has learned that the unit offers therapeutic abortions, a procedure that contradicts the nurse's personal beliefs. What is the nurse's ethical obligation to these clients?

The nurse should make the choice to decline this position and pursue a different nursing role. Rationale: To avoid facing the ethical dilemma of providing care that contradicts the nurse's personal beliefs, the nurse should consider working in an area of nursing that would not pose this dilemma. The nurse should not provide care to the client because it is a conflict of personal values. The nurse should not deny care to these clients as this would be a breach in the Code of Ethics for nurses. If the client is not requesting information for alternatives to abortions, then the nurse should not be providing this information.

A medical nurse is caring for a client who is receiving palliative care following cancer metastasis. The nurse is aware of the need to uphold the ethical principle of beneficence. How can the nurse best exemplify this principle in the care of this client?

The nurse tactfully regulates the number and timing of visitors as per the client's wishes. Rationale: Beneficence is the duty to do good and the active promotion of benevolent acts. Enacting the client's wishes regarding visitors is an example of this. Each of the other nursing actions is consistent with ethical practice, but none directly exemplifies the principle of beneficence.

A community-based case manager is sending a community nurse to perform an initial home assessment of a newly referred client. To ensure safety, the case manager must make the nurse aware of which of the following?

The potential for at-risk working environments Rationale: Based on the principle of due diligence, agencies must inform employees of at-risk working environments. The case manager is not responsible for teaching or checking on the self-defense skills of the community nurse. While knowing the location of emergency services might be useful, it does not ensure the safety of the community nurse. All nurses must be aware of standard precautions for infection control when providing client care, but this knowledge does not ensure the safety of the nurse.

The public health nurse is presenting a health promotion class to a group of new mothers. How should the nurse best define health?

The state of being connected in body, mind, and spirit Rationale: The World Health Organization (WHO) defines health in the preamble to its constitution as a "state of complete physical, mental, and social well-being and not merely the absence of disease and infirmity." The concept goes beyond psychology and physiology to include social considerations. It does not depend on having an absence of disease. Fulfillment is consistent with health, but the concepts are not synonymous.

. A nurse on a medical-surgical unit has asked to represent the unit on the hospital's quality committee. When describing quality improvement programs to nursing colleagues and members of other health disciplines, what characteristic should the nurse cite?

These programs emphasize the need for evidence-based practice. Rationale: Numerous models seek to improve the quality of health care delivery. A commonality among them is a focus on the importance of evidence-based practice. Consequences, a focus on incidents, and justification for health care costs are not universal characteristics of quality improvement efforts.

An 80-year-old client is admitted with a diagnosis of community-acquired pneumonia. During admission the client states, "I have a living will." What implication of this should the nurse recognize?

This document specifies the client's wishes before hospitalization. Rationale: A living will is one type of advance directive. In most situations, living wills are limited to situations in which the client's medical condition is deemed terminal. The other answers are incorrect because living wills are not always honored in every circumstance, they are not binding for the duration of the client's life, and they are not drawn up by the client's family.

A recent nursing school graduate has chosen to pursue a community nursing position because of increasing opportunities for nurses in community settings. What change(s) in the American health care system have created an increased need for nurses to practice in community-based settings? Select all that apply.

Tighter insurance regulations D. Changes in federal legislation E. Decreasing hospital revenues Rationale: Changes in federal legislation, tighter insurance regulations, decreasing hospital revenues, and alternative health care delivery systems have also affected the ways in which health care is delivered. The United States does not have an increased rural population nor is our population younger.

A client is being treated for bites suffered during an assault. After the bites have been examined and documented by a forensic examiner, the nurse should perform what action?

Wash the bites with soap and water. Rationale: After forensic evidence has been gathered, cleansing with soap and water is necessary, followed by the administration of antibiotics and tetanus toxoid as prescribed. The client's immunization history does not directly influence the course of treatment, and hepatitis B vaccination is not indicated. Chlorhexidine bandages are not recommended.

The nurse is engaging in critical thinking while caring for a group of clients. Which situation is an example of critical thinking by the nurse?

Working with the client to find a nonpharmacologic pain relief measure Rationale: Critical thinking involves the formulation of options that are most appropriate for a situation and that are client-centered. By working with the client to find a pain relief measure for that client's specific situation, the nurse is exhibiting critical thinking. Following unit policy, administering medication according to a prescription by the health care provider, and assessing level of pain before administering a pain medication are examples of safe care but not critical thinking that is client-centered.

Nursing care is provided in an increasingly diverse variety of settings. Despite the variety in settings, some characteristics of professional nursing practice are required in any and every setting. These characteristics include:

cultural competence. Rationale: Cultural competence is necessary in any and every care setting. The other answers are incorrect because an advanced education, specialty certification, and the ability to practice independently are not consistencies between every nursing care delivery setting.

A medical-surgical nurse is aware of the scope of practice as defined in the jurisdiction where the nurse provides care. When exploring the legal basis for the scope of practice, the nurse should consult:

the nurse practice act in the nurse's jurisdiction. Rationale: Nurses have a responsibility to comply with the nurse practice act of the jurisdiction in which they practice. A nurse's scope of practice is not determined by codes of ethics, codes of conduct, or client preferences.