NURSG (eaq) PRACTICE SET

A nurse listens to the statements made by a client during assessments to individualize care provided. Which statement made by the client would the nurse consider to be an external variable influencing the client's beliefs?

"Please do not include chicken in my diet plan because my religion forbids me to consume meat."

A nurse provides discharge teaching related to intermittent urinary self-catheterization to a client with a new spinal cord injury. Which instruction is most important for the nurse to include?

"Wash your hands before performing the procedure."

A registered nurse is caring for a client who is on isolation precautions. Which tasks can be safely assigned to the nursing assistive personnel? Select all that apply.

Bringing equipment to the client's room Transporting the client to a diagnostic test

Which activity would the nurse use as an example of fine motor skills of infants aged 2 to 4 months?

Bringing objects from hand to mouth

A nurse realizes that a client has been administered a double dose of insulin by mistake and informs the primary healthcare provider. Which element of the decision-making reflects in the nurse's action?

Accountability

A nurse is reviewing the laboratory report of a client with kidney problems. When ammonia is excreted by healthy kidneys, what mechanism usually is maintained?

Acid-base balance of the body

Which nursing interventions should the nurse provide to an older client with hypertension? Select all that apply.

Advise the client to limit salt intake Teach stress management Instruct the client to quit smoking

A nurse is caring for a client with renal failure. The client wants to go back home but the family members want the client to undergo a kidney transplant. The nurse gives details about the possible threats and benefits of the surgery to the family and informs them that the client wants to stay home. What role does the nurse play here?

Advocate The nurse in the given scenario plays the role of an advocate by protecting the client's human and legal rights and by providing assistance in asserting these rights. As an educator, the nurse explains concepts and facts about health and the reason for routine care activities, demonstrates procedures, and evaluates the client's progress in learning. As a caregiver, the nurse helps clients to maintain and regain health, manages diseases and symptoms, and attains a maximal level function and independence through the healing process. As a manager, the nurse coordinates the activities of members of the nursing staff in delivering nursing care and has responsibility for personnel, policy, and budgetary issues for a specific nursing unit or agency. Test-Taking Tip: Avoid looking for an answer pattern or code. There may be times when four or five consecutive questions have the same letter or number for the correct answer

Which risks would the nurse state may be associated with adults who work on or around automobiles? Select all that apply.

Asbestosis Dermatitis

Which nursing interventions require a nurse to wear gloves? Select all that apply.

Cleaning a newborn immediately after delivery Emptying a portable wound drainage system

What important points should the nurse keep in mind when witnessing consent forms? Select all that apply.

Confirm that the client's signature is authentic. Ensure that the client has given the consent voluntarily. Refrain from asking the student nurse to witness consent forms.

The nurse receives a report on a newly admitted client who is positive for Clostridium difficile. Which category of isolation would the nurse implement for this client?

Contact precautions

A nurse is caring for a client who has developed dysphagia and is unable to swallow. The client is receiving around-the-clock opioid pain medications for cancer pain, and hospice has recently begun caring for the client. What is the best nursing intervention in preparing for the client's discharge?

Contact the client's healthcare provider to discuss use of transdermal medications for pain control.

While caring for a family, the nurse finds that the family has accepted the shifts of generational roles. Which change in the family status for proceeding developmentally would the nurse observe?

Dealing with retirement

According to Kübler-Ross, during which stage of grieving are individuals with serious health problems most likely to seek other medical opinions?

Denial

Which workers would the nurse consider to be at high risk of developing dermatitis? Select all that apply.

Dry cleaners Dye workers

What important points should the nurse keep in mind when caring for an older adult to promote health? Select all that apply.

Encourage regular physical activity and the use of stress-management strategies Consider the client's social environment and strengthen social support to promote health Assess the client for fear of falling and provide support by making environmental changes

A client becomes anxious after being scheduled for a colostomy. What is the most effective way for the nurse to help the client?

Encourage the client to express feelings.

While assessing an older adult, the nurse observes visual impairment in the client. Which technique should the nurse use to communicate?

Encourage the older adult to use assistive devices such as glasses

Which suggestion should the nurse offer to parents who are concerned about caring for their toddler?

Encourage the toddler to drink from two-handled cups.

When being interviewed for a position as a registered professional nurse, the applicant is asked to identify an example of an intentional tort. What is the appropriate response?

False imprisonment

The registered nurse is teaching the nursing student about the realms of family life. Which component does the registered nurse include while teaching about integrity processes?

Family rituals

The registered nurse is teaching a nursing student to use self-disclosure appropriately to promote a therapeutic alliance with the client. Which carative factor is involved in this situation?

Forming a human-altruistic value system

A nurse is caring for a community-dwelling older adult with dementia. What interventions should the nurse take to ensure the client's well-being? Select all that apply.

Foster human dignity and maintain the best possible functioning, protection, and safety Show the caregiver techniques to dress, feed, and toilet the older adult Protect the client's rights and provide support to maintain the physical and mental health of family members

The nurse is assessing a client with impaired hearing. Which action of the nurse is most important for establishing a good communication with the client?

Getting the client's attention before speaking

A client with limited mobility is being discharged. To prevent urinary stasis and formation of renal calculi, what should the nurse instruct the client to do?

Increase oral fluid intake to 2 to 3 L/day.

An octogenarian client tells the nurse, "Please do not give me dietary instructions post-surgery. I've had several surgeries in my lifetime and I know what to eat." Which variable influences the client's health beliefs and practices?

Intellectual background

The nurse is caring for a dying client. Which interventions should the nurse implement for the client and family? Select all that apply.

Know the client and family's strengths and weaknesses. Arrange for church or community support for the family. Help the family set up home care if required.

Which action by a home care nurse would be considered an act of euthanasia?

Knowing that a dying client is overmedicating and not acting on this information.

A client who is in a late stage of pancreatic cancer intellectually understands the terminal nature of the illness. What are behaviors that indicate the client is emotionally accepting the impending death?

Revising the client's will and planning a visit to a friend

The nurse is assisting with the end-of-life care of an older adult. Which activity is performed when the nurse views family as context?

Meet the client's comfort, hygiene and nutritional needs

In the orientation phase, a nurse and a client meet and get to know each other. Which actions should the nurse follow in this phase? Select all that apply.

Prioritizing the client's problems Clarifying the client's and nurse's roles

A client does not consent to disclose his or her medical records and information regarding his or her health status. However, a nursing student unintentionally makes the information public. According to the Health Insurance Portability and Accountability Act, which section has been violated?

Privacy

What could be the reason for cataracts in a 36-year-old client? Select all that apply.

Prolonged exposure to heat Prolonged exposure to metal powders

When providing preoperative teaching, what should the nurse focus primarily on?

Providing general information to reduce client and family anxiety

An older adult who is in acute care has a risk of skin breakdown. Which interventions are beneficial to the client? Select all that apply.

Providing meticulous skin care Reducing shear forces and friction Avoiding pressure with proper positioning

A client is undergoing radiation therapy. The nurse reassures the client and stays with the client throughout the therapy. Which caring behavior does this nursing action reflect?

Providing presence

A weak, dyspneic, terminally ill client is visited frequently by the spouse and teenage children. What should the client's plan of care include?

Teach family members how to assist with the client's basic care.

A nurse is caring for a client on bed rest. How can the nurse help prevent a pulmonary embolus?

Teach the client how to exercise the legs.

The nurse is preparing discharge instructions for a client who acquired a nosocomial Clostridium difficile infection. What should the nurse include in the instructions?

The infection causes diarrhea accompanied by flatus and abdominal discomfort.

A nurse notices that a diabetic client is consuming chocolate brought by a family member. Which nursing action should a nurse perform to adhere to the principle of autonomy?

The nurse collaborates with a dietician to obtain a special diet chart for the client.

After several weeks of caring for clients who are in the terminal stage of illness, the nurse becomes aware of feeling depressed when coming to work. What should the nurse do?

Talk with other nurses on the unit

What are the advantages of the team nursing model of providing nursing care? Select all that apply

The nursing care conferences help to solve client problems. The model provides a high level of autonomy for the team leader. The model facilitates a high level of collaboration between team members

Following a surgery on the neck, the client asks the nurse why the head of the bed is up so high. The nurse should tell the client that the high-Fowler position is preferred for what reason?

To reduce edema at the operative site

What is an example of the critical thinking attitude of independent thinking in nursing practice?

To talk with other nurses to share ideas about nursing interventions

A nurse finds that an older adult has reduced consciousness and fatigue and imagines something that is unreal. Which condition does the nurse suspect in the client?

Delirium

The nurse is teaching the parent of an infant about inspecting the crib before putting an infant to sleep. Which statement made by the parent indicates a need for further education?

"I should attach crib toys with hanging strings."

A nurse is transcribing a practitioner's orders for a group of clients. Which order should the nurse clarify with the practitioner?

Erythromycin 250 mg TIW

A nurse is preparing to change a client's dressing. What is the reason for using surgical asepsis during this procedure?

Keeps the area free of microorganisms

The nurse is having difficulty understanding a client's decision to have hospice care rather than an extensive surgical procedure. Which ethical principle does the client's behavior illustrate?

Autonomy

A nurse in a long-term health care setting will introduce a client who has a PhD to the other clients. The client tells the nurse, "I wish to be called Doctor." How should the nurse respond?

"Your wish will be respected."

A post-operative client is discharged to home. Which statement made by the nurse would be beneficial for the client's care in the home?

"I will provide you with a homecare service referral."

A nurse is teaching an older client about proper medication use. Which statement made by the client indicates the need for further education?

"I will use over-the-counter medicines along with prescribed drugs."

While assessing the motor development of an infant, a nurse asks questions to the mother about the infant's motor skills. Which statement made by the mother indicates that the infant has developed fine-motor skills?

"My child can place objects into containers."

A nurse is teaching a client about false imprisonment. What information should the nurse provide? Select all that apply.

"False imprisonment is an example of an intentional tort." "False imprisonment involves restraining a person unjustly without any legal warrant." "A falsely imprisoned client should be aware of his or her confinement."

A registered nurse is explaining Benner's five levels of proficiency that a nurse needs to go through to acquire and develop generalist or specialized nursing skills. Which statement should the registered nurse include in the teaching plan regarding the proficient stage?

"He or she should have more than 2 to 3 years of experience in the same clinical position."

A registered nurse is teaching a nursing student about the nurse's professional roles and responsibilities. When does the nurse play the role of an educator?

"A client is being discharged from the hospital setting with an implanted port. The nurse describes the routine care activities to prevent any complications."

A student nurse is listing different scenarios that comply with basic healthcare ethics. Which scenarios mentioned by the student nurse relate to the healthcare ethic of fidelity? Select all that apply.

"A nurse monitors a client after providing nonpharmacological measures to relieve anxiety due to hospitalization." "A nurse notes that the pain relief measures provided to that client have been ineffective. The nurse formulates a different plan of care." "A nurse is caring for a client who refuses to be touched by people of certain skin color. The nurse continues providing care since other colleagues refuse to attend to the client."

A nursing student is citing examples of situations that constitute invasion of privacy. Which examples are accurate? Select all that apply.

"A nurse states in a press conference that a famous singer is suffering from throat cancer." "A nurse informs a woman's husband that she has had a miscarriage without consulting with the client." "A nurse tells the parents of a 19-year-old that their child is addicted to drugs without waiting for consent."

A nurse is caring for a client who has a poor understanding of weight reduction strategies. The nurse instructs the client to follow a healthy diet regularly because crash dieting can lead to serious health issues. Which of these reactions might the nurse expect if the client is in the precontemplation stage? Select all that apply.

"As far as I know, having a thin body means that I'm healthy." "Who says that I don't eat properly? I'm just skipping my breakfast." "I don't care about following the diet plan; I just want to lose weight as soon as possible."

A registered nurse is educating a nursing student about assault. What information should the registered nurse provide?

"Assault refers to any action that places a client in apprehension of harmful contact without consent."

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?

"Engage in physical activities to stay fit."

Which question asked by the nurse is an example of open-ended questions?

"How has your health been?"

In an interview, the manager is looking for a nurse who excels in analyticity. Which statement made by the nurse would help him or her to get selected for the new project?

"I am good at using evidence-based knowledge."

A pharmacy technician arrives on the nursing unit to deliver opioids and, following hospital protocol, asks the nurse to receive the medications. The nurse is assisting a confused and unsteady client back to the client's room. How should the nurse respond to the technician?

"I can't receive them right now. Please wait a few minutes or come back."

Which statement of the nurse at the time of discharge would reflect the decision-making skill called autonomy?

"I may independently develop and implement a discharge teaching plan."

A nurse understands that the effects of different variables on client's health beliefs and practices can help healthcare providers to plan and deliver individualized care. Which statement made by the client is a socioeconomic influence on the client's health beliefs?

"I cannot afford expensive medications because I have to take care of my family."

A nurse caring for a pregnant client prioritizes nursing actions on the basis of Maslow's hierarchy of needs. Which statement of the client does the nurse consider to be a self-esteem need?

"I deserve ill treatment from my husband as I'm incapable of doing even simple things perfectly."

A nurse is caring for an older adult with dementia who has been admitted in the special ward for further treatment. Which situation should the nurse address to meet the safety and security needs of the client according to Maslow's hierarchy of needs?

"I do not want to talk to any stranger as I fear that they might take away my things."

After being medicated for anxiety, a client says to a nurse, "I guess you are too busy to stay with me." How should the nurse respond?

"I have to go now, but I will come back in 10 minutes."

A registered nurse educates a student nurse regarding the appropriate method of dealing with clients of different cultural backgrounds. Which statements by the student nurse indicate an understanding of various cultures? Select all that apply.

"I should focus on understanding the traditions, beliefs, and values of the client's culture." "I should be aware of my own cultural background and beliefs when attending to clients who belong to different cultures."

A client is being treated for influenza A (H1N1). The nurse has provided instructions to the client about how to decrease the risk of transmission to others. Which patient statement indicates a need for further instruction?

"I should obtain a pneumococcal vaccination each year."

A registered nurse is teaching the appropriate manner of acting in a professional environment to a student nurse. Which statements mentioned by the student nurse post-training are accurate? Select all that apply.

"I should provide care that is consistent with my level of expertise." "I should remember and follow the policies and procedures of the institution." "I should use restraints on a client only after obtaining a written order from a primary healthcare provider."

The registered nurse is teaching a nursing student about nursing care principles for cognitively impaired older adults. Which statement made by the nursing student indicates a need for further education?

"I should provide conditional positive support."

A registered nurse is teaching a nursing student about how to communicate with a client who is cognitively impaired. Which statements made by the nursing student indicate a need for further education? Select all that apply.

"I should use visual cues." "I should speak in a normal tone of voice." "I should face the client so that he or she can see my mouth."

A nurse notes that a client is in the habit of skipping breakfast and lunch and educates the client on the harmful effects of not getting enough nutrition. Which responses are signs that the client has reached the action stage of health behavior change? Select all that apply.

"I still tend to skip breakfast when I'm in a hurry to get to work." "I follow a proper eating schedule, but sometimes it gets in the way of my work."

A nurse instructs a client who eats a lot of candy to stop eating sweets in order to avoid high blood sugar levels. What reaction might the nurse expect if the client is in the contemplation stage?

"I understand that candy isn't good for my health, but I can't stay away from it." A client in the contemplation stage is more likely to accept information because he or she is developing a greater belief in the value of change. A client in the precontemplation stage may become defensive when confronted with information on the benefits of change. A client in the action stage may find that old habits are keeping him or her from engaging in new behaviors. A client in the maintenance stage has been able to make changes in his or her health beliefs but needs to integrate these changes into his/her lifestyle. Test-Taking Tip: Do not worry if you select the same number of answer repeatedly, because there usually is no pattern to the answers.

A nurse is caring for a client who has recently been sleeping for 12 to 14 hours on weekend nights. The nurse instructs the client to sleep for no longer than 9 hours because excessive sleeping can lead to health issues. What reaction might the nurse expect if the client is in the maintenance stage?

"I've been following a proper sleep pattern for more than a year."

A nursing student is listing the key points that need to be remembered to maintain health and wellness of the client. Which key points listed by the nursing student are accurately stated? Select all that apply.

"Internal and external variables are considered when planning care for the client." "The health belief model considers the relationship between a person's health beliefs and health behaviors." "The health promotion model highlights factors that increase individual well-being and self-actualization."

The registered nurse is teaching the student nurse about writing nursing interventions. Which intervention written by the student nurse indicates effective learning?

"Irrigate the wound with 100 mL normal saline until clear: 6 AM—2 PM—8 PM."

A nurse who is working on a medical-surgical unit receives a phone call requesting information about a client who has undergone surgery. What is the best response by the nurse?

"It is against the hospital's policy to provide you with any information."

A student nurse is listing the limitations of the total client care nursing model. Which limitation listed by the student nurse is accurately stated?

"It is not cost effective because of the high number of registered nurses required to provide care."

A student nurse lists the 10 rules of performance designed by the Institute of Medicine (IOM) that should be followed to provide appropriate care for clients. Which rules listed by the student nurse are accurate? Select all that apply.

"Knowledge is shared and information flows freely." "Care is individualized based on client needs and values." "The client is the source of control participating in shared decision making."

A registered nurse is teaching a nursing student about malpractice insurance. Which statement by the nursing student requires correction?

"Most private insurance policies for nurses are primary policies that begin covering the nurse even before all hospital insurance coverage has been exhausted."

A registered nurse is educating a nursing student about issues related to short staffing. What information should the nurse provide? Select all that apply.

"Nurses should refrain from walking out when faced with a short staffing problem." "Nurses should inform their supervisors when they are assigned to care for more clients than is reasonable." "Written protests should be submitted to nursing administrators if unreasonable assignments are given to nurses."

A nursing student is listing points that make nursing a profession and not just a job. Which points have been correctly stated? Select all that apply.

"Nursing provides a specific service." "Nursing requires a basic liberal foundation and an advanced education." "Nursing has a theoretical body of knowledge leading to defined skills, abilities, and norms."

A nursing student is listing factors that may improve the quality of life of clients in the community with chronic leg ulcers. Which factor listed by the nursing student needs correction?

"Nursing wound care specialists should inform clients that the cost of care may be expensive and that the level of pain may increase."

A home health nurse on a first visit checks the client's vital signs and obtains a blood sample for an international normalized ratio (INR). After these tasks are completed, the client asks the nurse to straighten the blankets on the bed. What is the nurse's most appropriate response?

"Of course. I want to do whatever I can for you."

A nurse is caring for a client who belongs to a different cultural community. The client is not very fluent in the language that the nurse is communicating. What would the nurse say to the client to initiate appropriate communication? Select all that apply.

"Please tell me about the healthcare practices and beliefs of your community." "Let me bring in an interpreter to help you understand the medical procedures better." "I would like to know your personal beliefs regarding healthcare traditions and practices."

A client injured in a motor vehicle accident was brought to the emergency and taken immediately for a scan. The client's family arrives later and asks about the client's health. What should the nurse tell the client's family?

"Please wait; I will update you as soon as I have any information."

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?

"Speak clearly by exaggerating his or her lip movements."

A nurse is informing a client about the benefits of rehabilitation. What information should the nurse provide? Select all that apply.

"Specialized rehabilitation services help clients and caregivers to adjust to lifestyle changes." "Rehabilitation helps prevent complications associated with illness or injury at the initial stages." "Rehabilitation helps clients attain their fullest physical, mental, social, vocational, and economic potential."

A registered nurse is teaching a nursing student about the components of the magnet model. What information should the registered nurse provide about exemplary professional practice according to the revised magnet model?

"Strong professional practice is established, and accomplishments of the practice are demonstrated."

A nursing student is listing the steps that need to be considered when preparing discharge planning for a client. Which steps listed by the nursing student are accurate? Select all that apply.

"Teach the client the safe and effective use of medications and medical equipment." "Remember that discharge planning is a centralized, coordinated, interdisciplinary process." "Develop a care plan that moves the client from the hospital to another level of healthcare."

A nursing student is listing the characteristics of the maintenance stage of health behavior change. Which points mentioned by the nursing student are accurate? Select all that apply.

"The client can sustain health behavior changes over time." "The client feels the need to integrate the changes into his or her lifestyle." "The client reaches this stage 6 months after engaging in action and continues with the changes indefinitely."

A registered nurse is teaching a nursing student about the five levels of proficiency when obtaining and developing generalist or specified nursing skills according to Benner et al (2010). Which statements indicate that a learner has reached the competent level? Select all that apply.

"The learner is able to anticipate nursing care and establish long-range goals." "The learner understands the organization and specific care required by different types of clients." "The learner has been in the same clinical position for 2 to 3 years and has experience with all types of psychomotor skills."

The registered nurse teaches a nursing student about leadership skills for prioritizing the need of the client depending on the situation. Which statement is an example of an intermediate priority need?

"The measures required to decrease postoperative complications." The nurse leader should have the ability to set the priorities of the client depending on the client's need. Intermediate priority needs includes non-emergency, non-life-threatening needs. An example of this need would be measures that are required to decrease postoperative complications. The teaching of home self-care is a low priority need. High priority needs include addressing a psychological episode of an anxiety attack and addressing a physiological episode of an obstructed airway.

A nursing student is listing the five stages of proficiency that a nurse needs to pass through according to Benner et al (2010). Which statements indicate that a nurse is in the expert stage?

"The nurse can identify the client-centered problems and health care system-related problems and the needs of the trainee nurse."

A nursing student is discussing aspects of the American Nurses Association (ANA) code of ethics. Which ANA Code of Ethics statements discussed by the nursing student are accurately stated? Select all that apply.

"The nurse coordinates with other healthcare providers to meet health needs." "The nurse takes part in the advancement of the profession by contributing to the practice and education." "The nurse's primary commitment is to the client, whether it be an individual, family, group, or community."

A student nurse requests the registered nurse explain the characteristics of the primary nursing care delivery model. What explanation should the registered nurse provide?

"There is lateral communication from nurse to nurse and caregiver to caregiver."

A cognitively impaired client's family member requests that the nurse list the benefits of using a respite care service. What information should the nurse provide about respite care services? Select all that apply.

"They are offered at home, in a day care setting, or in a health care institution that provides overnight care." "Medicare health care plans do not cover this service, and Medicaid has strict requirements for services and eligibility." "It is a service that provides short-term relief or "time off" for people providing home care to an ill, disabled, or frail older adult." Respite care service is offered at home, in day care settings, or in a health care institution that provides overnight care. Currently, Medicare does not cover respite care service and Medicaid has strict requirements for services and eligibility. Respite care services provide short-term relief or "time off" for people providing home care to an ill, disabled, or frail older adult. Assisted living includes services like laundry, assistance with meals and personal care, 24-hour oversight, and housekeeping. In assistive living, a group of residents live together, but each resident has his or her own room and shares dining and social activity areas.

A registered nurse is instructing a trainee nurse on the various advantages of the team nursing care delivery model. Which statement provided by the trainee nurse post-training indicates a need for effective learning?

"This model is inflexible but uses a variety of staffing levels and mixes."

A registered nurse is educating a student nurse regarding the role of value clarification in the resolution of ethical dilemmas. What information should the nurse provide?

"Value clarification involves tolerating differences of opinions."

A recent immigrant from mainland China is critically ill and dying. What question should the nurse ask when collecting information to meet the emotional needs of this client?

"Which family member do you prefer to receive information?"

The nurse is assessing a client using the family health system (FHS). Which question should the nurse ask to assess the interactive process of the family?

"Who are the members of your family?"

While receiving a preoperative enema, a client starts to cry and says, "I'm sorry you have to do this messy thing for me." What is the nurse's best response?

"You seem upset."

A nursing student is reviewing different statements as they fulfill Maslow's hierarchy of needs, from the highest level of needs to the lowest level of needs. In which order should the nursing student arrange the scenarios, from the highest the lowest level of needs?

1. A client says to the nurse, "I want to maintain good health as I intend to be the best soccer player on my team." 2. A client says to the nurse, "I do not have any skills that will help me be an achiever in life." 3. A client says to the nurse, "I have been feeling depressed ever since my sibling stopped speaking to me." 4. A client says to the nurse, "My father threatens to commit me to an asylum if I dare disobey him."

A nurse is evaluating different scenarios related to addressing different levels of client needs. Arrange which nursing actions are prioritized according to Maslow's hierarchy of needs.

1. Administering medications to regulate the client's body temperature of the client 2. Collaborating with the social service department to keep the client away from abusers 3. Contacting the client's family members in order to help the client mend relationships 4. Initiating therapeutic communication to boost the client's self-esteem

Some facts about a client are missing. Arrange the actions performed by the lead nurse in chronological order.

1. Talking to the client directly 2. Bringing co-workers together 3. Looking for a pattern 4. Finding a solution

After gastric surgery a client has a nasogastric tube in place. What should the nurse do when caring for this client?

A

A nurse is assessing different situations on the basis of Maslow's hierarchy of needs. Which situation will the nurse address first on priority basis?

A client has multiple fainting episodes due to lack of proper nutrition. According to Maslow's hierarchy of needs, the basic lower level needs of human beings need to be addressed first before moving on to the higher levels. A person's physiological needs should receive attention first on priority basis. If the client has fainting episodes due to lack of proper nutrition, his/her physiological needs should be addressed first. A client who feels that he/she leads a worthless life displays a lack of self-esteem. According to Maslow's hierarchy, self-esteem needs should be met after addressing physiological needs, safety and security needs, and needs related to love and belonging. A client who shows signs of impaired social interactions has a lack of love and belonging needs. According to Maslow's hierarchy, these needs should be met after addressing physiological needs and safety and security needs. Similarly, a client who is estranged from family members displays a lack of love and belonging needs.

A nurse is prioritizing client-care by using Maslow's hierarchy of needs. Which situation should the nurse address to meet the self-actualization needs of the client?

A client says, "I want to be a world class athlete."

Which client's need should be considered high priority?

A client with dysphagia who is choking while eating

A hospitalized client experiences a fall after climbing over the bed's side rails. Upon reviewing the client's medical record, the nurse discovers that restraints had been prescribed but were not in place at the time of the fall. What information should the nurse include in the follow-up incident report?

A listing of facts related to the incident as witnessed by the nurse

Which example best demonstrates humility in a critical thinker?

A nurse accepts his or her lack of knowledge regarding stem cell transplantation and seeks opportunities for learning.

Which situation is an accurate instance of false imprisonment?

A nurse applies restraints to a conscious client to feed him or her. False imprisonment refers to the unjustified restraint of a person without any legal warrant. The client is required to be conscious of his or her confinement. If the nurse applies restraints to a client solely for the purpose of feeding, this action is considered to be false imprisonment. If proper consent has been obtained to restrain an aggressive client, this action is not considered to be false imprisonment. Restraining an unconscious client is not considered to be false imprisonment because the client is unaware of his or her confinement. If the primary healthcare provider instructs the nurse to apply restraints to keep the client from self-harm, this action is not considered to be false imprisonment. Test-Taking Tip: Reread the question if the answers do not seem to make sense, because you may have missed words such as "not" or "except" in the statement.

The Quality and Safety Education for Nurses (QSEN) initiative addresses the challenge to prepare nurses with the competencies that are required to improve the quality of client care. Which scenario is representative of the teamwork and collaboration competency

A nurse discusses the development of a special diet chart with a dietician for a diabetic client.

A nurse is examining different scenarios related to defamation of character. Which scenarios are examples of slander? Select all that apply.

A nurse informs the primary healthcare provider falsely that a client shows signs of drug abuse. A nurse informs the client's caregivers that the client is aggressive, even though there is no evidence. A nurse warns a colleague that a client displays inappropriate sexual behavior when no such event happened.

Which statement accurately demonstrates an act of nursing negligence?

A nurse instructs the nursing assistive personnel to administer medication through an intravenous line.

The advanced practice registered nurse is the most independently functioning nurse. What are the specific functions of the nurse practitioner as an advanced practice registered nurse in a healthcare setting? Select all that apply.

A nurse practitioner has the knowledge and skills necessary to detect and manage self-limiting acute and chronic stable medical conditions. A nurse practitioner provides comprehensive care by directly managing the medical care of clients who are healthy or who have chronic conditions. A nurse practitioner may establish a collaborative provider-client relationship, working with a specific group of clients or with clients of all ages and healthcare needs.

A registered nurse is explaining healthcare settings and services to a nursing student. Which scenario mentioned by the registered nurse is considered secondary acute care?

A nurse prepares a client who has suffered from repeated cerebral attacks for a CT scan.

A nursing student is evaluating scenarios pertaining to the professional code of ethics from the American Nurses Association (ANA). Which scenarios are examples of the principle of advocacy? Select all that apply.

A nurse respects a client's wishes and refuses visitation by family members post-surgery. A nurse recognizes signs of child abuse and reports it according to state and facility requirements. A nurse tries to convince family members of the benefits of a life-saving surgery for the client after they refuse authorization due to personal beliefs.

A client who is receiving a screening test for tuberculosis (TB) asks the nurse what a positive reaction will mean. What should the nurse explain that a positive reaction indicates?

A previous exposure to the organism

What should a nurse understand about healthcare proxies or a durable power of attorney for healthcare?

A proxy is a legal document that designates a person or persons to make health care decisions on behalf of the client.

The family of an older adult who is aphasic reports to the nurse manager that the primary nurse failed to obtain a signed consent before inserting an indwelling catheter to measure hourly output. What should the nurse manager consider before responding?

A separate signed informed consent for routine treatments is unnecessary

When caring for a client with a fractured hip, the nurse should place pillows around the injured leg to specifically maintain what?

Abduction

When caring for a client with varicella and disseminated herpes zoster, the nurse should implement which types of precautions? Select all that apply.

Airborne Contact Standard

A 93-year-old client in a nursing home has been eating less food during mealtimes. What is the priority nursing intervention?

Allow the client a longer period of time to complete the meal.

A primary healthcare provider tells a client about the diagnosis of inoperable cancer and that the client does not have long to live. After the primary healthcare provider leaves, the client says to the nurse, "I feel fine. I probably only have the flu." The nurse determines that the client is in the denial stage of grief. What should the nurse do to help meet the client's emotional needs?

Allow the denial and be available to discuss the situation with the client.

A client has a platelet count of 49,000/mL (40 × 109/L). The nurse should instruct the client to avoid which activity?

Blowing the nose

A nurse is recalling the various levels of preventive care to promote health, wellness, and to prevent illness. Which scenario is a perfect example of primary prevention?

An infant receives rotavirus vaccination in the hospital setting.

Arrange the order of donning personal protective equipment (PPE) while caring for a client with isolation precautions.

Apply the cover gown, pull the sleeves down to the wrists, and tie the gown securely at the neck and waist Apply either a surgical mask or a respirator around the mouth and nose Apply eyewear or goggles snugly around the face and eyes Apply clean gloves within the gown Bring the glove cuffs over the edge of the gown sleeves

A client says, "None of the medications will work on me because I am away from my holy land." What course of action should the nurse take to comply with teamwork and collaboration competency according to the Quality and Safety Education for Nurses (QSEN)?

Approach the agency chaplain to discuss the spiritual needs of the client According to Quality and Safety Education for Nurses (QSEN) competency, the nurse complies with teamwork and collaboration competency to function effectively within the nursing and interprofessional teams. In the given scenario, the nurse should collaborate with the agency chaplain to discuss the client's spiritual needs. The nurse complies with the patient-centered care competency by providing care to the client with respect to his or her diversity, values, and beliefs. The nurse complies with the evidence-based practice competency by conducting thorough research on the effect of emotional distress on the client's health. The nurse complies with the quality improvement competency by using the flow chart data to provide the best possible care and monitor the outcome of care processes.

A client requests information about the prescribed medication regimen. What is the best response by the nurse?

Ask the client to state what is already known about the medication.

A client is placed on a restricted diet. What is the best communication technique for the nurse to use when beginning to teach the client about the diet?

Asking about what the client knows about the diet that was prescribed

A nursing student is listing examples of quasi-intentional torts. Which examples mentioned by the nursing student need correction? Select all that apply.

Assault Battery Malpractice

A nurse notes that a client with dementia refuses to eat. Instead of informing the primary healthcare provider, the nurse threatens to force-feed the client, and proceeds to apply restraints in order to do so. What legal charges may be brought up against the nurse? Select all that apply.

Assault Malpractice False imprisonment

A nurse is teaching a group of parents about child abuse. What definition of assault should the nurse include in the teaching plan?

Assault is a threat to do bodily harm to another person.

What interventions should the nurse follow when giving health education to an elderly client? Select all that apply.

Assess the client for pain before teaching. Ensure the client is not preoccupied or anxious. Teach one concept at a time according to the client's interest.

A nurse is caring for a client who has been admitted to a healthcare facility for the treatment of sinus disorders. The nurse discovers that the client is a cocaine addict. What task followed by the nurse is the best way to deal with the situation?

Assess the client's drug intake and ensure that the individual does not leave the healthcare facility.

A terminally ill client is furious with one of the staff nurses. The client refuses the nurse's care and insists on doing self-care. A different nurse is assigned to care for the client. What should be the newly assigned nurse's initial step in revising the client's plan of care?

Assess the client's present status and include the client in a discussion of revisions to the plan of care.

A client is transferred to an acute care nursing unit after surgery. Which action of the nurse is most important and should be performed first?

Assess the patency of airway.

Which nursing intervention is most appropriate for a client in skeletal traction?

Assess the pin sites at least every shift and as needed.

The home healthcare nurse visits an elderly couple living independently. The wife cares for the husband who has dementia. Which interventions should the nurse implement for them? Select all that apply.

Assess the wife for caregiver burden. Assess the husband for signs of physical abuse. Identify social support within the community.

A daughter of a Chinese-speaking client approaches a nurse and asks multiple questions while maintaining direct eye contact. What culturally related concept does the daughter's behavior reflect?

Assimilation

A nurse anticipates that a hospitalized client will be transferred to a nursing home. When should the nurse begin preparing the client for the transfer?

At the time of admission

The nurse should suspect that a client who had a recent myocardial infarction is experiencing denial when the client does what?

Attempts to minimize the illness

What should the nurse educator instruct a graduate nurse who is seeking employment? Select all that apply

Attend workshops and conferences Work on developing effective communication Approach institutions that provide mentoring

The way individuals cope with an unexpected hospitalization depends on many factors. However, what is the one that is most significant?

Basic personality

What steps should a nurse take when caring for a client to prevent nursing malpractice? Select all that apply.

Be alert about common sources of client injuries. Gain knowledge regarding current nursing practices. Communicate with the client regarding tests and treatment plans.

A client who is human immunodeficiency virus (HIV) positive is admitted to a surgical unit after an orthopedic procedure. The nurse should institute appropriate precautions with the awareness that HIV is highly transmissible through what means? Select all that apply.

Blood Semen

A nurse withholds a prescribed opioid medication from a client with intractable pain because the nurse fears the client will become addicted. In this situation the nurse is adhering to which ethical principle?

Beneficence

A nurse is preparing a lecture for a group of nursing students related to ethics and legal principles. Which statement would be appropriate to include?

Beneficence emphasizes the importance of preventing harm and ensuring the client's well-being.

A nurse addresses the needs of a client who is hyperventilating to prevent what complication?

Carbonic acid deficit

A nurse is discussing various scenarios involving healthcare settings and services with other team members. Which scenario mentioned by the nurse is an example of continuing care?

Caring for a client with Parkinson's disease who requires day care service

The nurse is assessing a client working in a glass factory. Which occupational hazard should the nurse assess the client for?

Cataracts

The nurse should instruct a client with an ileal conduit to empty the collection device frequently because a full urine collection bag may do what?

Cause the device to pull away from the skin. If the device becomes full and is not emptied, it may pull away from the skin and leak urine. Urine in contact with unprotected skin will irritate and cause skin breakdown. A full urine collection bag will not cause urine to back up into the kidneys, suppress the production of urine, or tear the ileal conduit.

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?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?

Check the client's buttocks at least every 2 hours; clean the client immediately after discovering incontinence.

When changing the soiled bed linens of a client with a wound that is draining seropurulent material, what personal protective equipment (PPE) is most essential for the nurse to wear?

Clean gloves

A nurse notes that a client is refusing a vital life-saving surgery due to financial constraints. The client's insurance has lapsed and the healthcare facility's policies do not allow surgeries to be performed free of cost. What should the nurse do first to deal with the situation?

Collect information relevant to the issue from multiple sources.

What problems may a nurse come across when dealing with ethical issues related to end-of-life care? Select all that apply.

Clients are unable to communicate effectively. All interventions for helping the clients seem futile. Predictions regarding health outcomes are not always accurate.

A nurse caring for a client with dementia notes that the primary healthcare provider has prescribed an experimental course of treatment. What important factor should the nurse keep in mind regarding the procurement of informed consent?

Clients with mental illness have the right to refuse treatment.

A young woman tells the nurse, "My partner prevents me from taking my medications." What should the nurse do to deal with the situation?

Conduct an interview with the client alone, when the partner is not around.

The nurse introduces him or herself and explains a procedure to be performed to clean and dress a surgical wound. Which critical thinking attitude is the nurse applying?

Confidence

A client with hypothermia is brought to the emergency department. What treatment does the nurse anticipate?

Core rewarming with warm fluids

A client with multiple fractures is admitted to the hospital. What is a nurse in the proficient stage expected to do in this situation?

Coordinate with all the appropriate members of the healthcare team when providing client care A nurse who has reached the proficient stage is able to assess an entire situation and transfer knowledge gained from multiple past experiences. Because this nurse focuses on managing care, the nurse is expected to coordinate with all the appropriate members of a healthcare team to provide proper client care. An expert-level nurse is able to look at a situation intuitively; in this case, a nurse at this level is expected to assess the client for potential complications related to multiple fractures. A nurse at the competent stage is able to understand the organization and specific care required for the type of client in question; in this case, the nurse is expected to understand that the client requires orthopedic care and should be transferred to the orthopedic unit for proper treatment. A nurse at the advanced beginner level is expected to identify the basic principles of providing orthopedic care. However, a nurse of a higher level should provide client care. Test-Taking Tip: Be alert for details. Details provided in the stem of the item, such as behavioral changes or clinical changes (or both) during a certain period, can provide a clue to the most appropriate response or, in some cases, responses.

A nurse is caring for a client who believes that surgery contaminates the soul unless proper cleansing rituals are performed. Which nursing activity adheres to the Quality and Safety Education for Nurses (QSEN) competency patient-centered care?

Coordinating with appropriate spiritual practitioners to help perform the cleansing ritual before the client's surgery Patient-centered care requires the nurse to understand that the client is the source of control when providing care. The nurse should therefore observe and respect any of the client's values, needs, and preferences when delivering health care. The nurse in the given situation complies with the client's wishes by coordinating with appropriate spiritual practitioners to help perform the cleansing ritual before the surgery. Quality improvement requires the nurse to use data for monitoring the outcomes of care processes. The nurse adheres to this competency by evaluating the effects of complying with the requests of clients regarding their psychological health. In order to adhere to the QSEN competency called safety, the nurse should minimize the risk of harm by improving his or her professional performance. The nurse improves his or her communication skills in order to reduce the risk of harming the client emotionally. Evidence-based practice requires nurses to integrate best professional practices with the client's preferences when delivering health care. The nurse complies with this competency by conducting research about the ritualistic practices of the client's community to formulate a care plan. 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.

The nurse understands that the action of an antidiuretic hormone (ADH) is to do what?

Decrease water loss in urine

Which statements accurately explain the deontology system of ethics? Select all that apply.

Deontology examines a situation for the presence of essential right or wrong. Deontology emphasizes the commitment to respect the "rightness" of autonomy. Deontology determines that actions are right or wrong based on their "right-making characteristics."

A client complains of anxiety before a diagnostic procedure. The nurse explores and collects a thorough assessment to find the reason for client's anxiety. Which critical thinking attitude is involved in this situation?

Discipline

The registered nurse instructed the nursing student to care for a client who suffers from depression. During a follow up visit, the registered nurse finds that the client's symptoms have not improved. Which activity of the nursing student would the registered nurse relate this to?

Discouraging social interaction to avoid the client's distraction from outside environment

A 2 g sodium diet is prescribed for a client with stage 2 hypertension, and the nurse teaches the client the rationale for this diet. The client reports distaste for the food. The primary nurse hears the client request that the family "bring in a ham and cheese sandwich and fries." What is the most effective nursing intervention?

Discuss the diet with the client and family.

The nurse is assessing a client with an illness. Which questions asked by the nurse indicates that he or she is gathering a client's physical and developmental health history? Select all that apply.

Do you have any marital problem? Are you able to complete your activities of daily living?

The mother of an 11-month-old infant reports that the baby has allergies. After an assessment, the primary healthcare provider also suspects anemia. Which questions would the primary healthcare provider most likely ask the mother? Select all that apply.

Do you use 2% cow's milk? Do you use whole cow's milk? Do you use alternate milk products?

The unlicensed healthcare worker assigned to the 7:00 am shift has not been coming to work until 8:00 am. Nursing care is delayed, and assignments are started late. What is the most appropriate action by the charge nurse/team leader?

Document the information before discussing it with the unlicensed healthcare worker. Documentation is the best initial response; documentation should include both the missed time and the effect on client care. Discussing the issue with a friend from another unit is not a professional or appropriate response to the problem. Reminding the unlicensed healthcare worker of the expected start time may be helpful, but will not address the issue if the problem continues. Reporting the event to the Human Resources department may be a later response to the problem. Test-Taking Tip: Being prepared reduces your stress or tension level and helps you maintain a positive attitude.

A nurse is caring for an obese client with diabetes mellitus. Which nursing actions satisfy the Quality and Safety Education for Nurses (QSEN) competency called teamwork and collaboration? Select all that apply.

Engaging the physical therapist in managing the client's condition Explaining the client's medication routine to the next shift nurse Consulting with the dietician to help manage the client's condition

While measuring the rectal temperature, the nurse inserts the thermometer probe 2.5 to 3.5 cm into the anus in the direction of the umbilicus. What would be the rationale behind this?

Ensure adequate exposure to the blood vessels

What key points should the nurse keep in mind about the legal implications of nursing practice? Select all that apply.

Ensure that the nurse knows all the laws and that these laws are applied in the nursing practice, whenever required. Ensure that the primary healthcare providers' orders are followed unless they appear to be incorrect or inappropriate. Ensure that the nurse can makes a formal protest to the nursing administrator if he or she is asked to take care of more clients than is reasonable.

What role is the nurse expected to have in a community-based nursing practice if there is a sudden spread of malaria?

Epidemiologist

The nursing student accompanies a group of registered nurses in a campaign that promotes the participation of parents to get their children immunized. After the campaign's completion, the group prepares a report that counts the number of immunizations and compares it to last year's report. Which type of research does the nursing student think that the group is doing?

Evaluation research

Two clients in the same medical facility receive differing levels of care due to the lack of financial resources of the family of one of the clients. The nurse in charge tries to resolve the ethical dilemma at hand. The nurse collects all relevant information regarding the problem from multiple sources. What should be the nurse's next course of action?

Examine own values regarding the issue at hand based on the information obtained.

A client complains to the nurse that a staff member did not respond to the client's call. The nurse politely reassures the client, and makes the client comfortable. The nurse speaks to the staff member about the incident and solves the problem. Which critical thinking attitude has the nurse demonstrated in this situation?

Fairness

A client complains to the nurse manager about a coworker. The nurse manager listens to both the patient's and the coworker's side of the story. Which critical thinking quality is shown in this situation?

Fairness

A client with a leg prosthesis and a history of syncopal episodes is being admitted to the hospital. When formulating the plan of care for this client, the nurse should include that the client is at risk for what?

Falls

Which nursing intervention is performed for a middle-aged adult in restorative and continuing care?

Focusing on problems related to sense of identity The nurse should determine the coping mechanisms of the client and family if the client is a middle-aged adult. Establishing independence, focusing on problems related to sense of identity, and reorganizing intimate relationships and family structure are interventions performed if the client is a young adult.

The nurse is caring for an infant at the healthcare facility. Which nursing intervention fosters the infant's development of trust?

Follow the parents' directions while providing care.

An 85-year-old client is alert and able to participate in care. The nurse understands that, according to Erikson, a person's adjustment to the period of senescence will depend largely on adjustment to which developmental stage?

Generativity versus stagnation

Twenty-four hours after a cesarean birth, a client elects to sign herself and her baby out of the hospital. Staff members are unable to contact her primary healthcare provider. The client arrives at the nursery and asks that her infant be given to her to take home. What is the most appropriate nursing action?

Give the infant to the client and instruct her regarding the infant's care.

A nursing student lists examples of health promotion activities that can help patients maintain or enhance their present levels of health. Which examples are accurate? Select all that apply.

Good nutrition Regular exercise

A nurse manager in charge of a unit overhears two nurses in a hall filled with visitors discussing a client on the unit who has AIDS. What should be the nurse manager's initial action?

Have a conference with the nurses and talk about the need for confidentiality.

A nurse keeps track of the immunization schedules for a childbearing family. Which type of nursing intervention is executed in this situation?

Health promotion

The nurse is providing interventions to give support services for delivery of care. According to the Nursing Intervention Classification (NIC) taxonomy, which domain does this care belong to?

Health system

A client suffering from cancer is at the last stage of life. Which actions should be performed by the nurse to support the client's family members? Select all that apply.

Helping the family to set up home care Giving the family about the information of dying process Making sure that the family knows about what to do at the time of death

A registered nurse is educating a nursing student about the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS). Which points mentioned by the nursing student post-teaching are correct? Select all that apply.

Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) is a standardized survey developed to measure client perceptions of their hospital experience. Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey is administered to a randomly selected sample of adults who were discharged from a hospital between 48 hours and 6 weeks ago Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys have 27 questions that ask clients to rate their communication with nurses and physicians, discuss other details about treatment, and share their willingness to recommend the hospital.

The client receives a prescription for tap water enemas until clear. The nurse is aware that no more than two enemas should be given at one time to prevent the occurrence of what?

Hypokalemia

Place the steps of the nursing process in its correct order.

Identify the client's health care needs by collecting subjective and objective data. Define the nursing diagnoses or collaborative problems clearly. Plan the care by determining priorities, goals, and expected outcomes of care Perform the nursing interventions competently. Evaluate the effects of the nursing interventions performed.

Which intervention does the nurse implement to develop a caring relationship with the client's family?

Identifying the client's family members and their roles

A client with chronic obstructive pulmonary disease (COPD) states, "I have had steady weight loss, and I am often too tired to eat." Which nursing diagnosis would be most appropriate for this client?

Imbalanced nutrition: less than body requirements, related to fatigue

A registered nurse advises a nursing student to value learning for learning's sake. Which concept of critical-thinking behavior is the registered nurse referring to?

Inquisitiveness

A registered nurse notices that the insertion site of a client receiving intravenous medication is swollen. The nurse takes appropriate measures to treat the area and takes a photo of the insertion site and saves it in the client's electronic health record. Which Quality and Safety Education for Nurses (QSEN) competency is the nurse following?

Informatics

The nurse is transferring a client from the bed to the chair. Which action should the nurse take during the transfer?

Instruct the client to dangle the legs.

Which nursing intervention can be classified under complex physiologic domain according to the Nursing Interventions Classification (NIC) taxonomy? Select all that apply.

Interventions to restore tissue integrity Interventions to optimize neurologic functions Interventions to provide care before, during, and immediately after surgery

Which action by the nurse is appropriate when caring for an elderly client admitted to a healthcare facility?

Invite a family member to join the conversation.

What does the nurse understand the term in-service education to mean?

It helps achieve an organization's required competencies. In-service education helps achieve an organization's required competencies. Continuing education and in-service education help the nurse gain knowledge about the latest research and practice developments. Continuing education is a one-way education program to promote and maintain current nursing skills. In-service education is focused on new technologies.

What is a living will?

It is a written document that directs treatment according to the client's wishes, in case of a terminal illness or condition.

When meeting the unique preoperative teaching needs of an older adult, the nurse plans a teaching program based on which principle about learning?

It requires continued reinforcement.

Which is an example of a nurse-initiated intervention?

Keeping edematous lower extremities elevated on pillows

Which nursing action is a part of the evaluation phase of the critical thinking process? Select all that apply.

Looking at all the situations objectively Using several criteria to determine the effectiveness of a nursing intervention

A client who underwent surgery feels pain in the lower abdomen. The nurse provides pain relief but the client is still reporting pain. Which actions of the nurse would help the client to get relief? Select all that apply.

Looking for different distraction techniques Involving the client's family in creating a new plan for pain relief

A client has seeds containing radium implanted in the pharyngeal area. What should the nurse include in the client's plan of care?

Maintain the client in an isolation room.

What is the priority nursing intervention for a client during the immediate postoperative period?

Maintaining a patent airway

Which action of the nurse would be most important to convey interest in starting a conversation with a client who has hearing loss?

Making eye contact with the client

A nurse administers medication via the central venous access device (CVAD) and forgets to monitor the client at the required intervals. The client then develops phlebitis. What charges may the nurse face for this action?

Malpractice

A nurse is helping a client who observes the traditional Jewish dietary laws to prepare a dietary menu. What considerations should the nurse make?

Meat and milk at the same meal are forbidden.

A nurse is explaining about healthcare plans to a patient. Which healthcare plan finances a large portion of care for low-income children, their parents, pregnant women, and disabled very poor adults?

Medicaid

An arterial blood gas report indicates the client's pH is 7.25, PCO2 is 35 mm Hg, and HCO3 is 20 mEq/L. Which disturbance should the nurse identify based on these results?

Metabolic Acidosis

A nurse is caring for a client who has a Hemovac portable wound suction device after abdominal surgery. What is the reason why the nurse empties the device when it is half full?

Negative pressure in the unit lessens as fluid accumulates, interfering with further drainage.

A nurse provides crutch-walking instructions to a client who has a left-leg cast. The nurse should explain that weight must be placed where?

On the hands

The registered nurse asks a client to rate his or her pain on a scale from 0 to 10, then instructs the nursing student to perform a physical assessment. Which assessments performed by the nursing student would be appropriate? Select all that apply.

Palpating for tenderness Inspecting any areas of discomfort

Which healthcare factors create barriers that prevent older adults from participating in healthcare promotion and disease prevention? Select all that apply.

Personal motivation Previous healthcare experience

A nurse preceptor is evaluating a nurse who is preparing to administer digoxin intravenously (IV) to a client. The preceptor should stop the nurse from continuing with the procedure when the preceptor observes the nurse doing what?

Piggybacking the digoxin in an existing infusion

A nurse assesses a client's serum electrolyte levels in the laboratory report. What electrolyte in intracellular fluid should the nurse consider most important?

Potassium

When monitoring fluids and electrolytes, the nurse recalls that the major cation-regulating intracellular osmolarity is what?

Potassium

What activities would the nurse state are involved in providing a secondary level of preventive care? Select all that apply.

Preventing the spread of communicable disease Providing facilities to limit disability and prevent death Providing adequate treatment to arrest the disease process

According to Kohlberg's development of moral reasoning, at which phase of life would a child develop premoral orientation?

Preschool

The healthcare provider prescribes a low-fat, 2-gram sodium diet for a client with hypertension. The nurse should explain that the purpose of restricting sodium is to do what?

Prevent reabsorption of water in the distal tubules

Which subdimension would form a part for the caring process "doing for" according to the Swanson's theory of caring? Select all that apply.

Protecting Comforting

What are the best ways for a nurse to be protected legally? Select all that apply.

Provide care within the parameters of the state or provinces standards for nursing practice. Document consistently and objectively. Clearly document a client's nonadherence to the medical regimen.

The nurse is caring for a client who had a hip replacement 2 days prior. After removing a bedpan from under the client, what is a priority nursing intervention?

Provide perineal care.

An older adult in an acute care setting is having urinary incontinence. Which interventions would help the client? Select all that apply.

Provide voiding opportunities Avoid indwelling catheterization Promote measures to prevent skin breakdown

A nurse is evaluating different situations related to addressing different levels of client needs. According to Maslow's hierarchy of needs, in which order should the nurse prioritize his or her actions?

Providing a warm bath to the client to promote a good night's sleep Encouraging the client to talk about his or her fears and feelings Assisting the client in getting out of bed to join family members for meals Praising the client for administering insulin accurately

A pregnant woman is admitted with a tentative diagnosis of placenta previa. The nurse implements prescriptions to start an intravenous (IV) infusion, administer oxygen, and draw blood for laboratory tests. The client's apprehension is increasing, and she asks the nurse what is happening. The nurse tells her not to worry, that she is going to be alright, and that everything is under control. What is the best interpretation of the nurse's statement?

Questionable, because the client has the right to know what treatment is being given and why

A client who sustained a large open wound as a result of an accident is receiving daily sterile dressing changes. To maintain sterility when changing the dressing, what should the nurse do?

Remove the sterile drape from its package by lifting it by the corners.

The nurse listens to and validates the feelings expressed by a confused older adult. Which elements does the nurse convey in this situation? Select all that apply.

Respecting Reassuring Understanding

What should the nurse teach the parents about preventing sudden infant death syndrome (SIDS)? Select all that apply.

Refrain from smoking around the infant. Refrain from co-sleeping or bed-sharing. Refrain from placing stuffed toys on the infant's bed.

A nursing student is listing the guidelines to be followed to make the referral process successful. Which step listed by the nursing student needs correction?

Refraining from giving the referral care provider information about the client in advance

The nursing team is providing care for a client. The team leader develops client care plans and coordinates care among the team members. Which member of the team acts as a team leader?

Registered nurse

A nurse is caring for a client with hemiplegia who becomes frustrated when performing skills. How can the nurse motivate the client toward independence?

Reinforce success in tasks accomplished.

The nurse finds that a client prefers Reiki to antidepressants for treating depression. Which intervention of the nurse indicates open-mindedness?

Respecting the client's preference

The nurse is assisting a client in labor. Which intervention should the nurse perform as soon as the newborn is delivered?

Remove nasopharyngeal secretions

The plan of care for the client was to lose 7 lbs (3.2 kg) by the end of the month. The client only lost 3 lbs (1.4 kg). How should the nurse respond?

Reevaluate the plan of care for appropriateness.

A nurse is caring for a client who has lost both feet in an accident. What course of action should the nurse take to adhere to the Quality and Safety Education for Nurses (QSEN) competency called evidence-based practice?

Refer to medical textbooks to understand the psychological effects of loss of limbs.

A client admitted to the hospital is diagnosed with leukemia. The client's family members inform the nurse that no blood should be transfused to the client under any circumstances because it is against their belief system. The client however, requests the nurse to carry out all necessary procedures without informing family members. What should the nurse do to comply with the principle of confidentiality according to the American Nurses Association (ANA) code of ethics?

Refrain from repeating the client's instructions to the family members.

Which nursing action is legally required?

Reporting incidents of suspected child abuse to the appropriate authorities The reporting of possible child abuse is required by law, and the nurse's identity can remain confidential. The nurse is functioning in a professional capacity and therefore can be held accountable. Although the Good Samaritan Act protects health professionals, the nurse is still responsible for acting as any reasonably prudent nurse would in a similar situation.

While a nurse is providing food to a client in traction, the client reports feeling uncomfortable from being in the same position. Which nursing intervention is priority in this situation?

Repositioning the client

While reviewing a client's prescriptions, the nurse finds that one of the prescribed drugs is redundant and notifies the primary healthcare provider. Which attitude of critical thinking does the nurse exhibit?

Risk taking If the nurse questions a healthcare provider's order by applying his or her knowledge, then this attitude is considered risk taking. If a nurse explores and learns more about a client to make appropriate judgments, then the attitude is curiosity. Thinking independently is indicated when a nurse reads nursing literature that provides multiple viewpoints on the same subject. The responsibility and authority of a nurse is shown by asking for help, reporting problems immediately, and following proper procedures. Test-Taking Tip: Identifying content and what is being asked about that content is critical to your choosing the correct response. Be alert for words in the stem of the item that are the same or similar in nature to those in one or two of the options.

A nurse is teaching a client how to use the call bell/call light system. Which level of Maslow's hierarchy of needs does this nursing action address?

Safety

What does a nurse understand about the secondary level of prevention?

Secondary prevention is focused on individuals who are in the early stage of their illnesses.

A teenager begins to cry while talking with the nurse about the problem of not being able to make friends. What is the most therapeutic nursing intervention?

Sitting quietly with the client

A nurse notes that a famous client has received an incorrect dose of medication due to the malfunction of the intravenous (IV) device, but does not inform the primary healthcare provider. Instead the nurse tells a colleague that the medication could not be given due to the client's inappropriate behavior. The nurse then updates media personnel about the client's health status. What legal charges may be brought up against the nurse? Select all that apply.

Slander Malpractice Invasion of Privacy

Which standards would the nurse explain are important for critical thinking? Select all that apply.

Specific Relevant

An elderly client states, "Disease occurs when supernatural elements enter the body." Which variable influences the client's health beliefs in this scenario?

Spiritual factors

The registered nurse is teaching the student nurse about Lawrence Kohlberg's theory of moral development. While teaching, the registered nurse states, "Children follow the parents' rule of being at home on time." Which stage of Lawrence Kohlberg's theory of moral development is the registered nurse explaining?

Stage 2

A nursing student notes information regarding restorative care. Which points noted by the nursing student are accurate? Select all that apply.

Success depends on effective and early collaboration with clients and their families. Clients and families follow treatment plans better when they are involved in restorative care. Restorative care is provided through home healthcare, rehabilitation, or extended care facilities.

Which nursing actions reflect the carative factor of 'promoting and expressing positive and negative feelings' according to the Watson's transpersonal caring? Select all that apply.

Supporting and accepting the client's feelings Showing a willingness to take risks in sharing in the relationships when connecting with clients

A nursing student is listing the different levels of the health care services pyramid. Under which type of health care services should the nursing student include subacute care?

Tertiary care

A nurse signs as a witness to informed consent provided by the client. What does the signature of the nurse imply? Select all that apply.

That the client's signature is authentic That the client has given consent voluntarily That the client appears to be competent to give consent

A nursing student is noting information about the National Database of Nursing Quality Indicators (NDNQI). Which point noted by the nursing student needs correction?

The National Database of Nursing Quality Indicators (NDNQI) reports provide a database for individual hospitals to compare their performance against nursing performance internationally. National Database of Nursing Quality Indicators (NDNQI) reports provide a database for individual hospitals to compare their performance against nursing performance nationally. The American Nurses Association (ANA) developed NDNQI with the aim of bringing about quality improvement in client care. NDNQI reports quarterly results on nursing outcomes at the nursing unit level. NDNQI is used to measure and evaluate nursing-sensitive outcomes. This evaluation helps to improve client safety and quality care.

A nurse is preparing to discharge a client who is partially paralyzed following a stroke. What should the nurse teach the client's family about recognizing caregiver role strain? Select all that apply.

The caregiver has disturbed sleep patterns. The caregiver has reduced appetite and weight. The caregiver is fearful about administering medications to the client.

The 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.

The circumference of the head is 33 cm (13 in). The newborn weighs 6 lbs (2,700 g). The newborn's hands and feet appear cyanosed.

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.

The client has no intention of making any changes in the next 6 months. The client does not show interest in information related to health behavior changes. The client becomes defensive when confronted with information regarding his or her current health behavior.

An emaciated older adult with dementia develops a large pressure ulcer after refusing to change position for extended periods of time. The family blames the nurses and threatens to sue. What is considered when determining the source of blame for the pressure ulcer?

The client should have been turned regularly.

When assessing a client, the nurse notices that he or she has reached the action stage of health behavior change. What should the nurse expect to be the client's reaction after providing suggestions for change?

The client's previous habits may prevent taking action related to new behaviors.

The registered nurse tells a nursing student, "In the nursing model, the registered nurse is responsible for all aspects of care for one or more clients during a shift of care and the care can be delegated." Which disadvantage would be most likely related to this nursing model?

The continuity of care is a problem

What should the nurse include in dietary teaching for a client with a colostomy?

The diet should be adjusted to include foods that result in manageable stools.

A registered nurse is educating a nursing student about the similarities and differences between the deontological and utilitarianism systems of ethics. What information should the nurse provide? Select all that apply.

The difference between utilitarianism and deontology is the focus on outcomes. Utilitarianism takes into consideration the usefulness of an action; deontology does not look into consequences. Utilitarianism measures the effect that an act will have; deontology looks to the presence of principles regardless of the outcome.

What should the nurse teach the parents about introducing a 6-month-old infant to solid foods?

The infant should be offered one new solid food at a time.

What should the nurse teach the parents of an infant about the use of car seats?

The infant should be restrained properly in a federally approved car safety seat.

The registered nurse teaches a nursing student about the implementation process of nursing. Which example does the registered nurse use while describing indirect care interventions using his or her knowledge?

The management of the client's environment to prevent infections

In what instances can a minor give consent for himself or herself for medical treatment? Select all that apply.

The minor can give consent for any venereal disease. The minor can give consent if he or she is lawfully married. The minor can give consent for a drug or substance abuse.

What does a community-based nurse do as a change agent? Select all that apply.

The nurse empowers clients and their families to creatively solve problems. The nurse works with clients to solve problems and helps clients identify an alternative care facility. The nurse empowers clients to become instrumental in creating change within a health care agency.

While interacting with an older adult, the nurse leans towards the client. What does this posture convey?

The nurse is involved and interested in the interaction.

Which nursing actions reflect Leininger's caring theory in practice?

The nurse learns culturally specific behaviors to meet the client's needs.

Which nursing actions may help in effective assessment of older clients? Select all that apply.

The nurse makes eye contact with the client. The nurse smiles at the clients during the interaction.

In order to prolong a hospitalization stay, the nurse documents in a client's electronic health record (EHR) that there are no signs of recovery. However, in reality, the client appears to be cured of the illness. What legal implication does the nurse's action have?

The nurse may be charged with libel.

A registered nurse is explaining the American Nurses Association (ANA) standards of nursing practice to a nursing student. Which explanation provided by the registered nurse is an example of evaluation?

The nurse monitors the oral mucosa and gums for bleeding or infection after providing oral care to a comatose client.

During a newborn assessment the nurse identifies that the temperature, pulse, respirations, and other physical characteristics are within the expected range. The nurse records these findings on the clinical record. Legally, how should the nurse's action be interpreted?

The nurse performed her role correctly.

What professional responsibility does the nurse display as a client's advocate?

The nurse protects the client's human and legal rights and provides assistance in asserting said rights.

The nurse follows the American Nurses Association (ANA) standards of nursing practice when caring for a client. Which scenario qualifies for the implementation level of care?

The nurse provides a back massage to a client who complains of restlessness due to back pain.

A nurse notices that a client is in spiritual distress. Which nursing action establishes the nurse as a caregiver?

The nurse provides therapeutic treatment to the client.

While reviewing the performance of a newly appointed nurse, the chief operational officer finds that the nurse excels at using reflective journaling. What activity of the nurse would lead the chief operational officer to this conclusion?

The nurse recalls, thinks, analyzes and learns from day-to-day work situations.

A client with coronary artery disease has a sudden episode of cyanosis and a change in respirations. The nurse starts oxygen administration immediately. Legally, should the nurse have administered the oxygen?

The nurse's observations were sufficient, and therefore oxygen should have been administered

A nurse is caring for a client with Parkinson's disease. The nurse notes that the client belongs to a distinct culture and is estranged from family members. Which nursing activities display the use of evidence-based practice, as per the 21st century competencies of the Institute of Medicine? Select all that apply.

The nurse refers to several journals to understand the client's cultural practices of the client. The nurse collaborates with an interpreter to teach the client about medical procedures. The nurse evaluates data about the incidence of Parkinson's disease in the client's community. The nurse customizes the care plan based on extensive research about the client's culture.

What should a nurse do in order to comply with the ethic of nonmaleficence in the healthcare setting?

The nurse should focus on doing no harm.

An elderly adult suffered an injury after falling down in the washroom. The primary healthcare provider performed a surgical procedure on the client and orders a blood transfusion. A family member of the client mentions that blood transfusions are not permitted in their community. What should the nurse do in order to handle the situation?

The nurse should inform the primary healthcare provider and not give blood to the client.

What points regarding the Good Samaritan Act of 1997 should the nurse remember? Select all that apply.

The nurse should provide care that is consistent with his or her level of expertise. Good Samaritan laws limit liability and offer legal immunity if a nurse helps at an accident scene. Good Samaritan laws were enacted to encourage healthcare workers to provide assistance during emergencies.

Which action of the nurse would be inappropriate in the context of critical thinking skills for making clinical decisions in nursing practice?

The nurse should rely on his or her knowledge and experience when planning and implementing a client care plan. Clinical decision-making in nursing practice is based on critical thinking skills. The nurse uses knowledge and experience in critical thinking to plan and implement care plans for client care. The nurse would observe changes in clients to help detect problems early. These new problems, if identified early, may help in prompt treatment. Following the direction of the higher authority in completing the identified care aspects may not necessarily need knowledge and experience. Notifying the primary healthcare provider about a client's condition does not involve critical thinking skills. 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 application in practice would best suit the critical thinking attitude called integrity?

To be able to recognize personal opinions that may conflict with a client

A nurse is providing care to a client 8 hours after the client had surgery to correct an upper urinary tract obstruction. Which assessment finding should the nurse report to the surgeon?

Urine output of 20 mL/hr

To prevent septic shock in the hospitalized client, what should the nurse do?

Use aseptic technique during all invasive procedures.

What important teaching strategies should the nurse take into consideration to bring a change in the client's lifestyle? Select all that apply.

Use written resources at an appropriate reading level. Practice active listening, and ask the client how he or she prefers to learn. Start with identifying what information the client knows regarding health risks related to poor lifestyle choices.

What activities should the nurse consider to be a part of the tertiary level of preventive care? Select all that apply.

Using a sheltered colony Providing selective placement Providing work therapy in hospitals

A nurse caring for a client who presents with herpes zoster conducts extensive research on the disease to formulate the care plan. In addition, the nurse adds photos of the client's infected area to the electronic health record (EHR) to evaluate progress toward recovery. The nurse also educates the client on maintaining proper hygiene to prevent the spread of the infection. Which competencies does the nurse display according to the Institute of Medicine (IOM) competencies of the 21st century? Select all that apply.

Using informatics Using evidence-based practice Providing patient-centered care

Which example in nursing practice would demonstrate Watson's carative factor called forming a human-altruistic value system?

Using self-disclosure to promote a therapeutic alliance with the client

A nursing student is listing examples of healthcare services. Which scenario is an example of restorative care?

Visiting a private residence to perform maggot-aided debridement therapy of a client's wound

A client with a leg fracture is hospitalized. The registered nurse instructs the nursing student to interrogate the client to ascertain the reason for the injury. Which question would help to determine an extrinsic factor?

Were you wearing inappropriate shoes?

What does the resources aspect of the American Nurses Association (ANA) standards of professional performance describe?

When a nurse uses appropriate nursing services that are safe, effective, and financially responsible

illness prevention

actual or potential health threats