PassPoint Practice

The nurse is making client rounds following shift report. Which client should the nurse assess first?

a 75-year-old man with metastatic prostate cancer with a pathologic fracture of the femur who is in pain The nurse should first assess the 75-year-old man with prostate cancer because of the client's age, need for pain management, extended bed rest, and the potential for preexisting nutritional deficits. The nurse should plan to spend a focused but short time with the woman receiving internal radiation. The client who will receive chemotherapy will require more observation after receiving the medication. The nurse can assess the client who will have a central venous catheter after assuring the older client is comfortable.

An apartment fire spreads to seven apartment units. Victims suffer burns, minor injuries, and broken bones from jumping from windows. Which client should be transported first?

a middle-aged man with no injuries who has rapid respirations and coughs The man with respiratory distress and coughing should be transported first because he is probably experiencing smoke inhalation. The pregnant woman is not in imminent danger or likely to have a precipitous childbirth. The 10-year-old is not at risk for infection and could be treated in an outpatient facility. First-degree burns are considered less urgent.

When prioritizing a client's care plan based on Maslow's hierarchy of needs, a nurse's first priority would be:

administering pain medication. In Maslow's hierarchy of needs, pain relief is on the first layer. Love and belonging, as in allowing family members to visit are on the fourth layer. Activity, as in ambulation, is on the second layer. Safety, as in placing wrist restraints on the client, is on the third layer.

Which philosophy should the nurse integrate into the plan of care for a client and family to help them best cope during the final stages of the client's illness?

living each day as it comes as fully as possible When supporting the friends or family of a terminally ill client, it is best to focus on the present. This can be accomplished by living each day to its fullest. Friends and families also want to know what to expect and want someone to listen to them as they express grief over the approaching death. Focusing on the past can interfere with enjoying the present. Expecting the worst interferes with focusing on day-to-day positive experiences. Planning ahead is inappropriate because of uncertainty when the length of life is unknown.

A client's arterial blood gas values are shown. The nurse should monitor the client for:

metabolic acidosis The pH of 7.24 indicates that the client is acidotic. The carbon dioxide level is normal, but the HCO3- level is decreased. These findings indicate that the client is in metabolic acidosis.

Which statement reflects appropriate documentation in the medical record of a hospitalized client?

"Client's skin is moist and cool." Documentation should include data that the nurse obtains only by hearing, seeing, smelling, or feeling. The nurse should record findings or observations precisely and accurately. Documentation of a leg ulcer should include its exact size and location. Documenting observed client behaviors or conversations is appropriate, but drawing conclusions about a client's feelings is not. Stating that the client had a good day doesn't provide precise enough information to be useful.

A nurse is assessing the family of a 10-year-old male child brought into the emergency department with severe injuries. Which statements made by the parents could indicate child abuse?

"His injury happened a few days ago, but I didn't think it was bad." A delay in seeking treatment for a child's serious injuries is a sign of abuse. Anxiety is expected and is a normal response. The parent's specific description of the origin of the injury is not congruent with child abuse. In abuse cases, vague descriptions of the injuries are more common than detailed ones, and abusers often prevent a child from explaining the nature of his/her injuries rather than encouraging it.

A nurse is performing a preoperative assessment. Which client statement should alert her to the presence of risk factors for postoperative complications?

"I've cut my smoking down from two packs to one pack per day." Smoking one pack of cigarettes per day reduces the activity of the cilia lining the respiratory tract, increasing the client's risk of ineffective airway clearance after surgery. Lack of solid foods for 2 days before surgery, no history of previous surgery, or anxiety about surgery wouldn't increase the risk of postoperative complications.

Which client should the nurse assess first?

A client being treated for chronic stable angina who reports a recent increase in chest pain frequency. A report of increasing frequency of chest pain suggests that the client may have developed unstable angina that can lead to an acute coronary syndrome. It requires additional testing and immediate assessment. The diabetic client's A1C level is within normal limits. Pitting edema and weight gain are expected findings with right side heart failure exacerbations—this client is not unstable. The hypertensive client is not in any acute distress.

A client who is in the emergency department after a car accident is displaying anxiety, lack of attention, dizziness, nausea, tachycardia, and hyperventilation. Which statement would indicate that the nurse is reacting to the client's relief behavior rather than the client's needs?

"There is nothing physically wrong with you. You need to stop breathing so rapidly." In this response, the nurse is addressing the client's hyperventilation and other somatic symptoms, rather than the client's feelings about the accident. The other options address the client feelings about the accident.

A client states, "If my heart stops beating, I do not want to be resuscitated." Which action should the nurse take?

Ask the client if he discussed this with the healthcare provider. When a client is admitted to a hospital the nurse is responsible for providing information about the client's rights to information, informed consent, timely responses to requests for services, and treatment refusal. The primary right to decide belongs to the client or family, but a healthcare provider's order must be obtained and should describe the actions that the nurses should take if the client requires CPR. The nurse should ask if the client has discussed these wishes with the healthcare provider in order to assist with obtaining the written order. A notarized advance directive is not needed to establish the client's wishes.

A nurse is developing a care plan for a client who is a single parent. The client is experiencing anxiety after the loss of a job and is verbalizing concerns regarding the ability to meet role expectations and financial obligations. Which of the following is most important for the nurse to include in the plan of care?

Determine the client's ability to cope with the job loss and family obligations. The client is experiencing stressors that are making it difficult to cope, resulting in anxiety. It is important to assess the client's coping abilities related to the job loss and meeting family obligations. This situation could become a crisis if it overwhelms the client's usual methods of coping. The client is a single parent, which also adds the burden of childcare. The client is not concerned about the family dynamics or obsessive thoughts. Responding to the client's cues is vital in addressing the client's concerns.

When a nurse asks himself or herself questions such as "Why am I here?" the nurse is attempting to

Develop a philosophical base for clearer thinking. In terms of spiritual care, your own background, family, culture, and religion are integral parts of interactions with clients. For this reason, taking a step back and examining your own spirituality, values, and beliefs is essential.

A nurse is caring for an infant who is to be administered an enema. What spiritually oriented interventions could the nurse follow with newborns and infants?

Encourage parents to be present during the treatment. When caring for infants and newborns, the best nursing intervention is to encourage the parents to be present during the medical treatment. There is no need for the nurse to ask for a child specialist to be present during the treatment. Instead, the nurse should involve the parents in the caring process as the infant will feel more secure and comfortable in the presence of the parents. Providing the infant with toys, a feeding bottle, or trying to explain that it will be over soon will not pacify the child.

While preparing to examine a 6-week-old infant's scrotal sac and testes for possible undescended testes, which would bemost important for the nurse to do?

Ensure that the room is kept warm. A cold environment can cause the testes to retract. Cold and touch stimulate the cremasteric reflex, which causes a normal retraction of the testes toward the body. Therefore, the nurse should warm the hands and make sure that the environment also is warm. Checking the diaper for urination provides information about the infant's voiding and urinary function, not information about the testes. Giving the infant a pacifier may help to calm the infant and possibly make the examination easier, but the concern here is with the temperature of the environment. Tapping on the inguinal ring would not be helpful in assessing the infant.

The nurse is assessing a client's deep tendon reflexes. Which graphic shows assessing the biceps reflex?

Explanation: To test the biceps reflex, the client's elbow is flexed at a 45° angle. The nurse places his/her thumb or index finger over the biceps tendon and strikes the digit with the pointed end of the reflex hammer, watching and feeling for the contraction of the biceps muscle and flexion of the forearm. Option A shows assessment of the patellar reflex. Option B shows assessment of the brachioradialis reflex. Option D shows assessment of the triceps reflex.

A mastectomy is recommended for a 68-year-old client diagnosed with breast cancer a week ago. When approached about giving consent for the mastectomy, the client says, "What is the use in trying to get rid of the cancer? It will just come back! I cannot handle another thing—having diabetes is enough. Besides, I am getting old. It would be different if I were younger and had more energy." What should the nurse do?

Explore with the client her feelings about her health problems and proposed surgery. While the client does have a right to accept or reject treatment, she has not explored her feelings, her possible mastectomy, or the future. The nurse should assist the client in exploring her feelings and moving toward a fuller understanding of her options. Giving the client survival rates indicates that the nurse feels she should have the surgery and negates her fears and concerns. While the chaplain might be helpful, this step should be done after the client has explored her feelings.

A nurse is developing a nursing diagnosis for a client. Which information should she include?

Factors influencing the client's problem A nursing diagnosis is a written statement describing a client's actual or potential health problem. It includes a specified diagnostic label, factors that influence the client's problem, and any signs or symptoms that help define the diagnostic label. Actions to achieve goals are nursing interventions. Expected outcomes are measurable behavioral goals that the nurse develops during the evaluation step of the nursing process. The nurse obtains a nursing history during the assessment step of the nursing process.

The nurse finds a client lying on the floor next to the bed. After returning the client to bed, assessing for injury, and notifying the health care provider (HCP), the nurse fills out an incident report. What should the nurse do next?

Give the incident report to the nurse-manager. The incident report should be given to the nurse-manager. The incident report should not be placed on the medical recordbecause it is considered a confidential communication and cannot be subpoenaed by a client or used as evidence in lawsuits. It is appropriate, ethical, and legally required that the fall be documented in the medical record. Unless there is a change in the client's condition reflecting an injury from the fall, there is no need to notify the family. If the family does need to be notified, the nurse-manager or the HCP should place the call.

The nurse states on shift handoff that the client has an elevated uric acid level of 8.2 mg/dl (487.8 mmol/L). Which inflammatory process would the nurse assess for during client assessment?

Gout Normal gout levels are 4 to 8 mg/dl (237.9 to 475.9 mmol/L). Uric acid levels which exceed 6 mg/dl (356.9 mmol/L) provides an elevated risk for gout. Gout is a medical condition with symptoms of acute inflammatory arthritis that is caused by high levels of uric acid in the blood. The client can develop uric acid crystal deposits in the joint. The nurse would assess joint areas for pain, redness and swelling. Rheumatoid arthritis is a chronic disease of joint inflammation and pain. Lupus erythematous is a chronic tissue disorder of the connective tissue and is known to have an elevated antinuclear antibody level. Osteoporosis has a deficiency in the serum calcium level.

The nurse is notifying the health care provider via telephone of a change in condition of a client diagnosed with an exacerbation of asthma. Arrange the nursing statements in order as they would be communicated using the SBAR method. All options must be used.

Hello. My name is Nurse Jones from Unit D. I am notifying you because Bob Smith has become increasingly more short of breath with audible wheezing this afternoon. Mr. Smith was admitted yesterday with an exacerbation of Asthma. He typically controls his asthma with oral medication and inhalers at home. He is ordered albuterol treatments twice daily. Oxygen is prescribed at 2 liters. Respirations are now 32 breaths/minute. The pulse oximeter is 89%. Lungs reveal wheezing in all lung fields. Slight nasal flaring is noted. I recommend that we increase his oxygen dose and prescribe an extra albuterol treatment. SBAR communication stands for Situation, Background, Assessment, and Recommendation. First, the nurse must identify his/herself and where he /she is calling from. Next, the nurse would begin explaining the client situation (change in condition). The nurse would provide background information such as diagnosis, admission status and date. The nurse would provide a focused assessment on the area of concern. Lastly, the nurse would offer a recommendation for client care.

A community health nurse is planning to address the physical needs of older adults living in their homes. What primary areas would be included in this discussion?

Importance of exercise, balanced nutrition, mobility and safety needs This choice provides teaching regarding health promotion and illness and injury prevention for elderly clients living in their homes. It is important to ensure that elderly clients are meeting their needs of exercise, nutrition, mobility, and safety to be able to manage in their own homes. These are the primary physical needs that could pose problems for elderly clients. Assessment of mobility patterns focuses only on mobility. Social support systems do not address physical ones. By this time, prevention of deficits is difficult; aids to support adequate hearing and seeing are more practical. Physician visits are important, but they focus on health problems more than on meeting physical needs.

A group of nursing students are reviewing current nursing Codes of Ethics. Such a code is important in the nursing profession because:

Nursing practice involves numerous interactions between laws and individual values. Explanation: A code of ethics is necessary to guide nurses' conduct, especially with regard to the interaction between laws and individual values. Diversity and legal liability do not provide the main justification for a code of ethics, though each is often a relevant consideration. The fact that nurses often carry out the orders of others is not the justification for a code of ethics.

The nurse is caring for a postoperative client who has not voided since before surgery. Which is the nurse's most appropriate action?

Palpate for the bladder above the symphysis pubis Anesthesia may cause urinary retention. The kidneys typically produce 35-55 mL of urine per hour; when full, the bladder becomes palpable above the symphysis pubis. The first step is to assess if the bladder is distended by palpating the suprapubic area. The other actions would not be appropriate actions.

A client with a fetal demise at 40 weeks asks the nurse, "How could God let this happen?" An appropriate goal for the client with a nursing diagnosis of "spiritual distress related to infant loss as verbalized by the client" would be that the client will?

Participate in supportive spiritual practices. The goal for the client should focus on supporting the client's strengths and utilizing what techniques have worked in the past.

A nurse is palpating a client's pulse on the inner aspect of his ankle, below the medial malleolus. Which pulse is the nurse assessing?

Posterior tibial To evaluate the posterior tibial pulse, the nurse palpates the inner aspect of the ankle, below the medial malleolus. The nurse palpates medially in the antecubital space to evaluate the brachial pulse; midway between the superior iliac spine and symphysis pubis to assess the femoral pulse; and along the top of the foot, over the instep, to evaluate the dorsalis pedis pulse.

Which factor should a nurse anticipate having the most influence on the outcome of a client facing a crisis situation?

Previous coping skills Coping is the process through which a person uses cognitive and noncognitive resources to resolve problems. Cognitive responses result from learned skills; noncognitive responses are automatic and focus on relieving discomfort. Previous coping skills are cognitive in nature and include the thought and learning necessary to identify the source of stress in a current crisis situation. Therefore, such coping skills would have the most influence on the outcome of a crisis situation. Previous coping skills could determine whether age has a positive or negative impact during a crisis. Although sometimes useful, noncognitive measures, such as self-esteem, may prevent the person from learning more about the crisis, as well as arriving at a better solution to the problem. The involved person's correct or incorrect perception of the problem could result in a positive or negative outcome.

A nurse is administering a prescribed dose of an injection to a middle-aged client with Bell's palsy. What are the sources of fulfillment in the middle-years of an adult client's life?

Productive activity The middle years are fulfilled through productive activity—in Erikson's term, generativity. This time is of growth and renewed questioning, in some ways very similar to adolescence. For young adults, their beliefs and attitudes change due to some situations such as advanced study or education or new religious affiliations possibly intertwined with achieving intimate relationships, choosing careers, and starting families. The challenge during this stage is to establish one's own sense of faith and commitment based on personal experience and reflection on meaning in life.

A student nurse requires additional teaching if which of the following factors is identified as contributing to a client's Risk for infection?

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

What would the nurse recognize as a common goal of discharge planning in all care settings?

Providing continuity of care for the client A common goal of discharge planning in all settings is providing continuity of care for the client. This action aids the client's transition to a new setting and can shorten facility stays. Providing financial assistance isn't a goal of discharge planning, although the nurse may make referrals to the appropriate department for financial assistance. Rather than preventing the need for follow-up visits, the nurse should encourage the client to return for these visits.

A client has the following arterial blood gas values: pH, 7.30; PaO2, 89 mm Hg; PaCO2, 50 mm Hg; and HCO3-, 26 mEq/L. Based on these values, the nurse should suspect which condition?

Respiratory acidosis This client has a below-normal (acidic) blood pH value and an above-normal partial pressure of arterial carbon dioxide (PaCO2) value, indicating respiratory acidosis. In respiratory alkalosis, the pH value is above normal and the PaCO2 value is below normal. In metabolic acidosis, the pH and bicarbonate (HCO3-) values are below normal. In metabolic alkalosis, the pH and HCO3- values are above normal.

The nurse is providing care for a client with a tracheotomy whose pulse oximeter has recently alarmed, showing the oxygen saturation to be 77%. The nurse has repositioned the client and applied supplemental oxygen, interventions that have raised the oxygen levels to 80% and somewhat decreased work of breathing. The client is not in immediate distress, and level of consciousness remains high. The nurse should page which of the following practitioners?

Respiratory therapist. A respiratory therapist is an expert in lung function and oxygenation whose expertise is needed in the care of this client. Because the client is not experiencing severe distress or respiratory arrest, the nurse is justified in forgoing contact with the physician in the short term. A physical therapist or occupational therapist is not likely to provide needed interventions at this time.

When recording data regarding the client's health record, the nurse mentions the analysis of the subjective and objective data in addition to detailing the plan for care of the client. Which of the following styles of documentation is the nursing implementing?

SOAP charting. The nurse is using the SOAP charting method to record details about the client. In SOAP charting, everyone involved in a client's care makes entries in the same location in the chart. SOAP charting acquired its name from the four essential components included in a progress note: S = subjective data; O = objective data; A = analysis of the data; P = plan for care. Hence, it involves mentioning the analysis of the subjective and objective data in addition to detailing the plan for care of the client. Narrative charting is time-consuming to write and read. In narrative charting, the caregiver must sort through the lengthy notation for specific information that correlates the client's problems with care and progress. Focus charting follows a DAR model. PIE charting is a method of recording the client's progress under the headings of problem, intervention, and evaluation.

A nurse determines that a client has 20/40 vision. Which statement about this client's vision is true?

The client can read from a distance of 20′ (6 m) what a person with normal vision can read at a distance of 40′. The numerator, which is always 20, is the distance in feet between the vision chart and the client. The denominator indicates from what distance a person with normal vision can read the chart.

A nurse is helping a client ambulate for the first time after 3 days of bed rest. Which observation by the nurse suggests that the client tolerated the activity without distress?

The client's pulse and respiratory rates increased moderately during ambulation. Pulse and respiratory rates normally increase during, and for a short time after, ambulation, especially if it is the first ambulation after 3 days of bed rest. Vital signs should return to baseline within 5-10 minutes after activity. Dizziness, weakness, and profuse perspiration are definite signs of activity intolerance. A client who tolerates ambulation well holds his head erect, gazes straight ahead, and keeps his toes pointed forward. A client who ambulates with his head down, gaze cast down, and toes pointed outward is exhibiting activity intolerance.

Using the Morse Fall Risk scale (see exhibit), the nurse should initiate highest fall risk precautions for which client?

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

A client presents to the OB triage unit with no prenatal care and painless bright red vaginal bleeding. Which interventions are most indicated?

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

The nurse is obtaining a health history from an adult from Mexico. The nurse should interpret the findings by understanding that in this client's culture, what are highly valued?

children In Mexican culture, children are highly valued and are closely protected by godparents. The tradition of the family is all-encompassing, and the health care provider (HCP) gains trust and improved compliance rates by including the family in teaching and health care matters. Typically, older adults are highly regarded and respected in Asian cultures.

The nurse is assessing a client's nutritional status before surgery. Which observation would indicate poor nutrition in a 5-foot 7-inch (170 cm) female client who is 21 years of age?

brittle nails Brittle nails indicate poor nutrition. Poor posture indicates that the client does not stand up straight and use her muscles to support herself. A dull expression reflects the client's affect and emotional status. The client's weight of 128 lb (58.1 kg) is within normal range.

The nurse manager has assigned a nurse as the circulating nurse for a surgical abortion. The nurse has a religious objection and wishes to refuse to participate in an abortion. The nurse manager of the operating room should:

change the assignment without comment. The nurse should not be required to participate in an abortion if it contradicts the nurse's religious beliefs. The behavior should not be reflected negatively on the nurse's evaluation. Preparing equipment and supplies for the case may be viewed as the same as circulating for the case. The nurse has a right not to participate in an abortion unless it is an absolute emergency and no one else is available to care for the client.

When auscultating a client's chest, a nurse assesses a second heart sound (S2). This sound results from:

closing of the aortic and pulmonic valves. The S2 results from closing of the aortic and pulmonic valves. The first heart sound (S1) occurs when the mitral and tricuspid valves close.

Which goal is an expected outcome for a client recovering from a total laryngectomy? The client will:

communicate feelings about body image changes. It is important that the client be able to communicate his or her feelings about the body image changes that have occurred as a result of surgery. Open communication helps promote adjustment. The client may not regain the ability to taste and smell food because of no longer breathing through the nose or because of radiation therapy treatments, or both. A gastrostomy tube would not typically be placed after a total laryngectomy, nor would it be necessary for the client to demonstrate sterile suctioning technique for stoma care. The client would use clean technique.

A client who had an exploratory laparotomy 3 days ago has a white blood cell (WBC) differential with a shift to the left. The nurse instructs unlicensed assistive personnel (UAP) to report which clinical manifestation of this laboratory report?

elevated temperature A shift to the left means that more immature than mature WBCs are at the site of inflammation or infection. Immature WBCs are less effective at phagocytosis and do not produce classic signs of inflammation, such as pus, redness, swelling, or heat. Fever is the only sign; therefore, it is a significant sign of infection in a client with immature or depressed WBCs.

A client is transferred from the emergency department to the locked psychiatric unit after attempting suicide by taking 200 acetaminophen tablets. The client is now awake and alert but refuses to speak with the nurse. In this situation, the nurse's first priority is to:

ensure safety by initiating suicide precautions. The nurse's first priority is to keep a suicidal client safe and alive. Although establishing a rapport and promoting trust are important in psychiatric nursing, neither is the highest priority. Using restraints is inappropriate and could be interpreted as punishment of the client or a convenience for the nurse. Trying to communicate in writing is also inappropriate because there is no indication that the client can't hear.

A client was brought to the emergency department following a motor vehicle accident and has phrenic nerve involvement. The nurse should assess the client for:

ineffective breathing pattern. The diaphragm is the major muscle of respiration; it is made up of two hemidiaphragms, each innervated by the right and left phrenic nerves. Injury to the phrenic nerve results in hemidiaphragm paralysis on the side of the injury and an ineffective breathing pattern. Consciousness, cardiac function, and urinary elimination are not affected by the phrenic nerve.

A nurse is assessing a client's abdomen after abdominal surgery. Place the assessment techniques in the order in which the nurse should conduct them. All options must be used.

inspection auscultation percussion palpation When assessing a client's abdomen, the nurse should first inspect the contour and symmetry of the abdomen. Next, the nurse should auscultate for bowel sounds. Auscultation is performed before percussion and palpation because these latter techniques can alter the character of the bowel sounds. Percussion and palpation are the last steps of physical assessment of the abdomen.

A child with meningococcal meningitis is being admitted to the pediatric unit. In preparation for the child's arrival, the nurse should first?

institute droplet precautions. The child with meningococcal meningitis requires droplet precautions for at least the first 24 hours after effective therapy is initiated to reduce the risk of transmission to others on the unit. After the child has been placed on droplet precautions, other actions, such as taking the child's vital signs, asking about medication allergies, and inquiring about the health of siblings at home, can be performed.

When percussing a client's chest, the nurse should expect to hear:

resonance. Resonance is a normal finding on percussion of healthy lung tissue. Hyperresonance may occur on percussion of hyperinflated lungs such as in a client with emphysema. When percussing over the abdomen, the nurse may assess tympany, such as with a gastric air bubble or intestinal air. Dullness occurs over the liver, a full bladder, and a pregnant uterus. (less)

A 42-year-old client was admitted from a homeless shelter with a diagnosis of tuberculosis and alcoholism. It is essential that which health care team member attends the care conference to discuss discharge planning and community resources?

social worker The social worker is the most essential team member to be involved in discharge planning to meet the client's needs and offer suggestions for the best community resources. There is no indication that the client should follow a special diet, so a dietitian is not needed at this time. The pharmacist may be consulted to teach the client about taking medications, but the focus of the care conference is planning for discharge to the community. The infection control nurse should follow up with teaching about preventing the spread of the disease after discharge.

The nurse notices that a client's heart rate decreases from 63 to 50 bpm on the monitor. The nurse should first:

take the client's blood pressure. The nurse should first assess the client's tolerance to the drop in heart rate by checking the blood pressure and level of consciousness and determine if atropine is needed. If the client is symptomatic, atropine and transcutaneous pacing are interventions for symptomatic bradycardia. Once the client is stable, further physical assessments can be done.

A client with type 1 diabetes is admitted to the emergency department with dehydration following the flu. The client has a blood glucose level of 325 mg/dL (18 mmol/L) and a serum potassium level of 3.5 mEq (3.5 mmol/L). The health care provider (HCP) has prescribed 1,000 mL 5% dextrose in water to be infused every 8 hours. Prior to implementing the HCP's prescriptions, the nurse should contact the HCP, explain the situation, provide background information, report the current assessment of the client, and:

verify the prescription for 5% dextrose in water. The client needs fluid volume replacement due to the dehydration. However, the nurse should verify the prescription for IV dextrose with the HCP due to the risk of hyperglycemia that dextrose would present when administered to a client with diabetes. The potassium level is within normal limits. The client does not have restrictions on oral fluids, and the nurse can encourage the client to drink fluids. The client does not need to be placed in isolation at this time.

Before a transesophageal echocardiogram, a nurse gives a client an oral topical anesthetic spray. When the client returns from the procedure, the nurse observes that he has no active gag reflex. In response, the nurse should:

withhold food and fluids. Following a transesophageal echocardiogram in which the client's throat has been anesthetized, the nurse should withhold food and fluid until the client's gag reflex returns. There's no indication that oral airway placement would be appropriate. The client should be in the upright position, and the nurse needn't insert an NG tube.

An 80-year-old client comes to the clinic reporting shortness of breath. When listening to the client's lungs, the nurse hears crackles (intermittent, high- and low- pitched popping sounds in the lower bases of the lungs) during inspiration. In which conditions might the nurse auscultate crackles? Select all that apply.

• Pneumonia • Pulmonary edema • Acute respiratory distress syndrome Crackles are typically heard on inspiration, can be low- or high-pitched, and occur when air is drawn through fluid in the lung's passageways. They can be classified as fine or course. They may be present on auscultation in a client with acute respiratory distress syndrome, pneumonia, and pulmonary edema. Crackles are not heard in clients with epiglottitis or cardiac tamponade.

A client is admitted to the preoperative clinic for a breast biopsy. Which information would the nurse enter into the medical record as objective data?

Blood pressure 130/90 mm Hg; pulse 100 bpm; respirations 14 breaths/min Objective data is information that the nurse observes or collects by observation. The other options fall into the subjective data category of information.

Which finding indicates that a client who has been raped will have future adjustment problems and need additional counseling?

Her parents show shame and suspicion about her part in the rape. The potential for problems in adjusting after a rape will be increased when those around the victim treat her as though she is to blame for the rape, especially when she already may feel some guilt and shame about it. A rape victim is likely showing adjustment to her experience when she is upset about her experience, when she seeks out formerly ignored relatives and friends for support, or when she attempts to help other rape victims. A rape victim is likely showing adjustment to her experience when she is upset about her experience, when she seeks out formerly ignored relatives and friends for support, or when she attempts to help other rape victims. A rape victim is likely showing adjustment to her experience when she is upset about her experience, when she seeks out formerly ignored relatives and friends for support, or when she attempts to help other rape victims.

A client presents to the emergency room with abdominal pain and upper GI bleeding. The client is sweating and appears to be in moderate distress. Which nursing action would be a priority at this time?

Obtain vital signs. The priority nursing action is vital signs. Vital signs provide valuable information on the internal body system. Symptoms of shock, such as low blood pressure, a rapid weak pulse, cold clammy skin, and restlessness, can be monitored. Assessing bowel sounds and abdominal tenderness can provide useful data but is not a priority. Documentation is a lower priority and a physician's order is needed for an NG tube placement.

A nurse is maintaining a problem-oriented medical record for a client. Which of the following components of the record describes the client's responses to what has been done and revisions to the initial plan?

Progress note. In a problem-oriented medical record, progress notes describe the client's responses to what has been done and revisions to the initial plan. The database contains initial health information about the client. The problem list consists of a numeric list of the client's health problems. The plan of care identifies methods for solving each identified health problem.

What are important nursing responsibilities when a referral to other health team members has been made for a client?

Sharing assessment information and information on the client's capability and level of participation in meeting activities of daily living Sharing assessment findings and relevant information helps prepare other health team members and helps coordinate the team efforts, which is one of the nurse's primary roles in relation to the health team.

A nurse is assessing a client's abdomen. Which finding should the nurse report as abnormal?

Shifting dullness over the abdomen Shifting dullness over the abdomen indicates ascites, an abnormal finding. Dullness over the liver, bowel sounds occurring every 10 seconds, and vasular sounds over the renal arteries are normal abdominal findings.

The nurse is performing an assessment on a client after her third electroconvulsive therapy (ECT). Which finding should she anticipate most frequently?

Short-term memory loss Short-term memory loss is the most common adverse effect of ECT. In many cases, the memory does not return. ECT does not affect the heart. A seizure is not an adverse effect; rather, it is intentionally induced. Brain damage caused by ECT has not been substantiated. A headache is common but not the most frequent effect.

Assessment of a client who has just been admitted to the inpatient psychiatric unit reveals an unshaven face, noticeable body odor, visible spots on the shirt and pants, slow movements, gazing at the floor, and a flat affect. Which of the following should the nurse interpret as indicating psychomotor retardation?

Slow movements. Psychomotor retardation refers to a general slowdown of motor activity commonly seen in a client with depression. Movements appear lethargic, energy is absent or lacking, and performance of activity is slow and difficult. A flat affect reflects a lack of emotion. An unkempt appearance reflects lack of self-care. Avoiding eye contact reflects low self-esteem or suspiciousness.

Which of the following factors should be the primary factor in a nurse's decision whether to pray with a patient?

The patient's openness to being prayed for. Explanation: Many factors influence the nurse's decision to pray with a patient. Central among these, however, is the question of whether the patient is open to this possibility. This factor is more important than the nurse's familiarity with specific prayer traditions, the patient's medical condition, or the presence or absence of a chaplain.

A nurse preceptor is reviewing documentation by a new nurse. Which of the following chart entries would require the preceptor to provide instruction about appropriate notation?

Angrily stated, "My doctor is rude." Offered the name of another personal healthcare provider. Documentation should contain data describing information the nurse obtains through the special senses of hearing, touch, vision, or smell. The documentation should be specific, precise, and accurate. It should not contain judgmental information but may contain descriptions of actions and quotes of what a client said. The nurse should support clients' decisions but should not interfere with the doctor-client relationship.

The nurse is removing the client's staples from an abdominal incision when the client sneezes and the incision splits open, exposing the intestines. What should the nurse do first?

Cover the abdominal organs with sterile dressings moistened with sterile normal saline. When a wound eviscerates (abdominal organs protruding through the opened incision), the nurse should cover the open area with a sterile dressing moistened with sterile normal saline and then cover it with a dry dressing. The surgeon should then be notified to take the client back to the operating room to close the incision under general anesthesia. The nurse should not press the emergency alarm because this is not a cardiac or respiratory arrest. The nurse should have the visitors and family leave the room to decrease the chance of airborne contamination, but the primary focus should be on covering the wound with a moist, sterile covering.

When changing a wet-to-dry dressing covering a surgical wound, what should the nurse do?

Cover the wet packing with a dry sterile dressing. A wet-to-dry dressing should be able to dry out between dressing changes. Thus, the dressing should be moist, not dry, when applied. As the moist dressing dries, the wound will be debrided of necrotic tissue and exudate. Normal saline is most commonly used to moisten the sponge; Burow's solution will irritate the wound. The sponge should not be packed into the wound tightly because the circulation to the site could be impaired. The moist sponge should be placed so that all surfaces of the wound are in contact with the dressing. Then the sponge is covered and protected by a dry sterile dressing to prevent contamination from the external environment.

A patient from Pakistan informs the nurse of his cultural dietary requests. The nurse responds to the special dietary needs by stating, "You are now living in the United States, and you should try to start eating those foods common to an American diet." This inappropriate response is an example of:

Cultural imposition. Explanation: The nurse's response is an example of cultural imposition, which is defined as the belief that everyone should conform to the majority belief system. Cultural blindness is the result of ignoring differences and proceeding as though they do not exist. In this situation, the nurse did not ignore the request but inappropriately responded to it. Cultural diversity is defined as a diverse group in society, with varying racial classifications and national origins, religious affiliations, languages, physical sizes, genders, sexual orientations, ages, disabilities, socioeconomic statuses, occupational statuses, and geographic locations. Cultural assimilation occurs when members of a minority group live within a dominant group and lose the cultural characteristics that make them different.

A nurse reports to the hospital occupational health nurse (OHN) that he/she was splashed with blood during the resuscitation of an HIV-positive client. The nurse asks the OHN when he/she will know whether he/she is positive or negative for HIV infection. Which of the following is the most appropriate response by the OHN?

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

A nurse administers morphine sulfate as ordered for pain. The client experiences nausea and vomiting and a decrease in respiratory rate. When documenting this event in the health record, which of the following would be considered subjective data?

"Client seems very nauseated." This statement is subjective because it is the nurse's interpretation. The other options are incorrect because they reflect objective data.

To evaluate a client's cerebellar function, a nurse should ask:

"Do you have any problems with balance?" To evaluate cerebellar function, the nurse should ask the client about problems with balance and coordination. The nurse asks about difficulty speaking or swallowing to assess the functions of cranial nerves IX, X, and XII. Questions about muscle strength help her evaluate the client's motor system.

The client who has a history of angry outbursts when frustrated begins to curse at the nurse during an appointment after being informed that she will have to wait to have her medication refilled. Which response by the nurse is most appropriate?

"I will not continue to talk with you if you curse." Stating, "I will not continue to talk with you if you curse," sets limits on the client's behavior and points out the negative effects of her behavior. Therefore, this response is most appropriate and therapeutic. The statement, "You are being very childish," reprimands the client, possibly causing the anger to escalate. The statement, "I am sorry if you cannot wait," fails to provide feedback to the client about her behavior. The statement, "Come back tomorrow and your medication will be ready," ignores the client's behavior, failing to provide feedback to the client about the behavior. It also shows poor nursing judgment because the client may need her medication before tomorrow or may not return to the clinic the following day.

A female with bilateral breast implants asks if she still needs to do breast examinations because she does not know what to feel for. Which of the following is the nurse's best response?

"I will show you the correct technique as I do the breast examination." The client needs to become more confident and knowledgeable about the normal feel of the implants and her breast tissue. The best technique is for the nurse to demonstrate breast self-examination (BSE) to the client as the nurse conducts the clinical breast examination. Implant surgery does not exclude the need for monthly BSE. A mammogram is not a substitute for monthly BSE.

The client exhibits a flat affect, psychomotor retardation, and depressed mood. The nurse attempts to engage the client in an interaction but the client does not respond to the nurse. Which response by the nurse is most appropriate?

"I will sit here with you for 15 minutes." The most appropriate action is for the nurse to remain with the client even if the client does not engage in conversation with the nurse. A client with severe depression may be unable to engage in an interaction with the nurse because the client feels worthless and lacks the necessary energy to do so. However, the nurse's presence conveys acceptance and caring, thus helping to increase the client's self-worth. Telling the client that the nurse will come back later, stating that the nurse will find someone else for the client to talk with, or telling the client that the nurse will get her something to read conveys to the client that she is not important, reinforcing the client's negative view of herself. Additionally, such statements interfere with the client's development of a sense of security and trust in the nurse.

A client has entered a smoking cessation program to quit a two-pack-a-day cigarette habit. The client has not smoked a cigarette for 3 weeks and tells the nurse about fears of starting smoking again because of current job pressures. What would be the most appropriate reply for the nurse to make in response to the client's comments?

"It is good that you can talk about your concerns. Try calling a friend when you want to smoke." It is important for individuals who are engaged in smoking cessation efforts to feel comfortable with sharing their fears of failure with others and seeking support. Although fewer than 5% of smokers successfully quit on their first attempt, it is not helpful to tell a client to anticipate failure. Telling the client to exercise more self-control does not provide support. Taking a vacation to avoid job pressures does not address the issue of how to manage the desire to smoke when in a stressful situation.

A nurse working in the emergency department receives an order from an orthopedic surgeon to obtain written consent from a client for the surgical repair of a fractured forearm. The surgeon has not seen the client but has reviewed the radiographs in the operating room between cases. Which of the following would be the most appropriate response by the nurse to the surgeon?

"It is your responsibility to obtain informed consent from the client." It is the surgeon's responsibility to obtain the informed consent after explaining the procedure to the client, including the risks, benefits, and alternatives. The other options are incorrect because they place the responsibility for obtaining informed consent on another person.

After teaching a group of students who are volunteering for a local crisis hotline, the nurse judges that further education about crisis and intervention is needed when a student makes which statement?

"Most people in crisis will be calling the line once every day for at least a year." The concern that someone may call the crisis hotline every day for a year indicates that further understanding about crisis and crisis intervention is needed. A crisis situation is time-limited, typically resolving in 4 to 6 weeks if handled effectively. If a person calls the line daily for a year, that person has not been properly dealt with or is probably in a highly disorganized state requiring an alternative intervention. The nurse needs to further review and clarify the material presented. Callers are typically in pain, overwhelmed, and exhausted when they call. A crisis can help an individual cope better in the future if he learns to handle the situation.

A 19-year-old client has undergone an examination and had evidence collected after being raped. Her father is overheard yelling at his daughter, "You are going to tell me who did this to you. What is his name?" Which is the nurse's best response?

"Please come with me, sir. I need some important information." With this level of anger in a crisis, the father needs simple but firm directions to leave the room, calm down, and then to talk. Doing so relieves the daughter of any pressure from her father. Telling the father to stop yelling or be quiet provides no concrete directions to the father and may embarrass him in front of his daughter. Telling the father that if he does not stop yelling, the nurse will call Security is a threat, possibly leading to an escalation of the situation.

A nurse is admitting a client to the palliative unit and discussing advanced directives. Which of the following statements made by the client leads the nurse to believe the client requires clarification around advanced directives?

"This will stop my daughter-in-law from putting me in a home." Advanced directives or a "living will" allow clients to convey their wishes for treatment, alternative decision makers, and end of life treatment, but do not specifically address issues of placement in a long-term care facility.

A 17-year-old high school senior calls the clinic because she thinks she might have gonorrhea. She wants to be seen but wants assurances that no one will know. Which is the most appropriate response by the nurse?

"We can see you without your parents' consent but have to report any positive results to the public health department." While some areas may specify a minimum age for treatment (usually 12 to 14 years), generally adolescents have the right to seek treatment for sexually transmitted infections without their parents' permission. These medical records are not shared with parents without the client's permission. However, adolescents must be made aware that certain infections, including gonorrhea, must be reported by law to public health agencies. Partner notification will also take place, but methods vary.

As a client is being admitted to the facility, her husband asks the nurse why she must sign a statement confirming that she has been told of her rights to communicate her wishes about life support and resuscitation. How should the nurse respond?

"We make sure our clients know they have the right to specify advance directives and appoint someone to speak for them." Telling the client's husband that clients have the right to specify advance directives and appoint someone to speak for them provides factual information. The other options don't answer the husband's question or provide the information he requested.

A client has identified to the community mental health nurse that an inability to be assertive with the client's boss has contributed to long work hours and increased stress and anxiety. To assist the client, which of the following questions would be most appropriate for the nurse to ask?

"What have you done so far to try to solve this problem?" To help the client resolve this situation, the nurse assists the client in determining what has worked or not worked in the past. This general understanding helps the client see the bigger picture and begin the problem-solving process. Immediately seeking alternatives is not advised. It is important to focus on helping the client identify strengths to manage the work situation, rather than providing quick solutions at this early stage of assessment.

The client hospitalized for diagnosis and treatment of atrial fibrillation states to the nurse, "Please hand me the telephone. I need to check on my stocks and bonds." Which response by the nurse is most therapeutic?

"You have atrial fibrillations. Let us talk about what that means." The nurse must present reality to the client about his condition to help decrease his denial about his physical status. By stating the name of the condition and talking about what it means, the nurse provides the client with information and conveys concerns about him and a willingness to help him understand his illness. It may not be true that the client would be made more upset by the call; the news might be good. However, this statement does not provide the client with the reality of his condition. Telling the client that he really does not care or asking the client if he realizes that he has a life-threatening condition is belittling and may make the client defensive.

A registered nurse (RN) is assigning care on the oncology unit and assigns the client with Kaposi's sarcoma and human immunodeficiency virus (HIV) infection to the unlicensed assistive personnel (UAP). This person does not want to care for this client. How should the nurse respond?

"You seem worried about this assignment." The RN assigning care should first give the UAP the opportunity to explore concerns and fears about caring for a client with HIV infection. Reassigning care for this client, assisting with care, and reviewing precautions do not address the present concern or create an environment that will generate useful knowledge regarding future assignments for client care.

A client, age 40, is admitted for treatment of a breast tumor. She asks the nurse, "Do you think I have cancer?" Which response by the nurse is most therapeutic?

"You sound concerned about what the physicians will tell you." This response allows the client to express her feelings and promotes further discussion. Referring the client to the physician ends the discussion and prevents exploration of the client's feelings. Generalizing about most women shifts the focus from the client. The statement about the need for tests is true but doesn't focus on the client's feelings and concerns.

A client admitted for treatment of a colon tumor, asks, "Do I have cancer?" Which response by the nurse would be best?

"You sound concerned about what's happening." This response conveys empathy and invites further discussion of the client's concerns. The other options block communication by failing to address the client's concerns and feelings.

As the nurse helps a client to the bathroom, the client says, "When you get to the point where you can't even go to the bathroom by yourself, you might as well be dead." Which response by the nurse is most therapeutic?

"You sound really discouraged today." Sharing an observation with the client conveys awareness of his feelings and promotes further communication. Spouting clichés, disagreeing with the client, or asking why the client feels a certain way doesn't promote therapeutic communication.

The parent of an 18-year-old with chronic renal disease states, "My son has so many problems. I'm really worried that he will not get the right care if he gets sick at college." The nurse should tell the parent:

"Your son can make an e-health history to facilitate his care if he gets sick away from home." Access to a well-constructed e-history will facilitate care if the adolescent becomes ill while at college. Because the client is 18, legally the nurse cannot transfer the records to the school without permission. Also, the adolescent may need to seek treatment in facilities other than the health center. Instructing the adolescent to always carry the nephrologist's phone number is not bad advice, but compliance may vary and there is no guarantee the provider will be available in all instances. Telling the parent that the son must learn to manage his own disease does not address the parent's concern. (less)

What is the most appropriate nursing diagnosis for the client with acute pancreatitis?

Deficient fluid volume Clients with acute pancreatitis often experience deficient fluid volume, which can lead to hypovolemic shock. Vomiting, hemorrhage (in hemorrhagic pancreatitis), and plasma leaking into the peritoneal cavity may cause the volume deficit. Hypovolemic shock will cause a decrease in cardiac output. Gastrointestinal tissue perfusion will be ineffective if hypovolemic shock occurs, but this wouldn't be the primary nursing diagnosis.

What is a priority for the nurse developing a plan with a client admitted to the hospital with an acute exacerbation of rheumatoid arthritis?

Achieving a controlled level of pain and fatigue throughout the day. Symptoms of rheumatoid arthritis include localized pain, stiffness, and decreased joint mobility after a period of rest, such as after sleeping. This can be more localized, which causes symptoms such as pain or stiffness. Lack of mobility over a period of time can increase the symptoms. Other answers are incorrect because they do not reflect management of care. Working on a positive self image is about self esteem. Always performing activities of daily living does not reflect promoting management; clients do not need to be independent. Accepting and working toward understanding is not about management.

A nurse is caring for a client with a fresh postoperative wound following a femoral-popliteal revascularization procedure. The nurse fails to routinely assess the pedal pulses on the affected leg, and missed the warning sign that the blood vessel was becoming occluded. The nurse manager is made aware of the complication and the nurse's failure to assess the client properly. What action should be taken by the nurse manager?

Address the nurse's omissions as negligent behavior. Negligence refers to careless acts on the part of an individual who is not exercising reasonable or prudent judgment. It also refers to the failure to do something that a reasonable person (another nurse) would do.

Which client should the nurse assess first?

A client newly diagnosed with hypertension, with a blood pressure of 164/92 mm Hg who is having chest pain. The client with chest pain may be experiencing acute myocardial infarction and is unpredictable. A rapid assessment and intervention are needed. The remaining clients are all stable and have expected symptoms associated with their diagnosis.

If a mass casualty incident occurs near an acute care unit, which of the following is the nurse responsible for when implementing a disaster preparedness plan?

A formal written plan of action for coordinating the response of the hospital staff and for designating how different areas will be used When a disaster occurs, a formal written plan of action is put into place. Nurses will be notified via telephone if not on duty and will be asked to come in. Those working in the hospital will be sent to the various designated areas within the hospital to care for clients who will be brought in. This plan needs to identify how areas will be used so there is not indecision at the time of the disaster. These are important components of a disaster preparedness plan. A formal fan-out contact list would be in place. Nurses need to commit to the disaster, not just have a volunteer plan. The disaster plan needs to focus on having health professionals and supplies available.

What is the best way for a nurse to maintain security when using computerized client records?

A nurse shouldn't give her computer access code to other health care personnel involved in direct client care. To maintain security of client information, a nurse should never give her computer access code to anyone. If others use her code, inappropriate accessing of information by others would be traced to her. All authorized health care personnel in a facility have individual access codes. It's never appropriate for a nurse to stay logged in to a computer so that others can use it or share her computer access code with another person.

While meeting with the nurse, a client's wife states, "I do not know what else to do to make him stop drinking." The nurse should refer the wife to which organization?

Al-Anon Al-Anon is a self-help group for spouses and significant others that provides education and support and helps participants learn to lead their own life without feeling responsible for the individual with an alcohol problem. Alateen provides support for teenaged children of a person with an alcohol problem. Employee assistance programs help employees recover from alcohol or drug dependence while retaining their positions or jobs. Alcoholics Anonymous provides support for the individual with alcohol problems to attain and maintain sobriety.

The nurse is conducting a health history of a child. The mother states that the client continually has a cold all winter with a runny nose, is not doing well in school, and is itching all the time. The nurse suspects the child has which of the following?

Allergies In children, many symptoms of allergies are often vague and general. They revolve around frequent cold-like symptoms, allergic rhinitis, and pruritus. These symptoms are distracting to children and can affect their ability to concentrate in school. The "itching all the time" descriptor lends itself to allergies and histamine release rather than sinusitis, ringworm, and fifth disease.

A young man makes an appointment to see the psychiatric nurse at the Employee Assistance Program of a large corporation because his boss is sending him provocative e-mails and making seductive remarks on his voice mail at home. The nurse informs him about corporate workplace violence guidelines, and he agrees to work with corporate security on the issue. What should the nurse do next?

Ask the client about his reactions to this situation. It is important to know the client's reactions in order to plan appropriate interventions. Until the client's reactions are known, it is premature to suggest a job transfer, file a report to his boss's supervisor, or alert his coworkers.

A nurse wants to ensure inclusiveness in language regarding family when developing a plan of care for a client. Which of the following is the most important action for the nurse to take to ensure that the plan is inclusive?

Ask the client to identify who is considered family. In a client's plan of care, family consists of people identified by the client as family members. The other options may be accurate, too, but in order to create a client-centered care plan, all members identified by the client should be included as family.

A client insists on leaving against medical advice (AMA). Which of the following would be the best action by the nurse?

Ask the provider to inform the client of potential complications. A client has the right to refuse care including the right to leave an agency against medical advice. The nurse does not encourage the client to leave and cannot hold the client against their will. However, it is the role of the provider to inform the client of potential complications of leaving the agency.

A nurse is caring for a client who is exhibiting signs and symptoms characteristic of a myocardial infarction (MI). Which statement describes priorities the nurse should establish while performing the physical assessment?

Assess the client's level of pain, and administer prescribed analgesics. The cardinal symptom of MI is persistent, crushing substernal pain or pressure. The nurse should first assess the client's pain and prepare to administer nitroglycerin or morphine for pain control. The client must be medically stabilized before pulmonary artery catheterization can be used as a diagnostic procedure. Anxiety and a feeling of impending doom are characteristic of MI, but the priority is to stabilize the client medically. Although the client and his family should be kept informed at every step of the recovery process, this action isn't the priority when treating a client with a suspected MI.

The nurse notices redness, swelling, and induration at a surgical wound site. What should the nurses next action be?

Assess the client's temperature. Infection produces signs of redness, swelling, induration, warmth, and possibly drainage. Since there could be a worsening situation occurring, further evaluation of the client is needed to determine the urgency of the situation. Assessment of the temperature should be the next step to determine how the client is responding to the infection. The white blood cells can also determine patient's response, but the priority should be the temperature. The wound needs to be re-dressed, but this would occur after speaking with the health care provider in case a culture may be ordered, which would be inaccurate if the wound was cleaned first.

A client with Parkinson's disease who is scheduled for physiotherapy is experiencing nausea and weakness. What is the most appropriate action by the nurse?

Assess the nausea and weakness and call physiotherapy to cancel or reschedule the appointment. Gathering information regarding possible causes of nausea helps identify changes and factors that relate to the changes. Modifying the schedule helps, according to the changed state. Although administering an antiemetic may be beneficial, movement and activity right after will not be helpful because the medication has not taken effect. Diet is not the issue, so the diet-related choices are not correct.

When a client returns from the recovery room postmastectomy, an initial postoperative assessment is performed by the nurse. What is the nurse's priority assessment?

Assessing the vital signs and oxygen saturation levels This correct response is based on principles of ABCs. The return of urinary function after anesthesia usually takes 6 or more hours, so this assessment is not a priority upon return from the recovery room. Checking the dressing and level of pain are both important, but not the priority.

A nursing assessment for a client with alcohol abuse reveals a disheveled appearance and a foul body odor. What is the best initial nursing plan that would assist the client's involvement in personal care?

Assisting the client with bathing and dressing by giving clear, simple directions This action would provide a disorganized client with the necessary structure to encourage participation and support of self-image. The other answers are incorrect because they do not support nurse promotion of client health. The client is not confused and does not require a schedule; however, the client does need some assistance. Full assistance is not required. (less)

Which strategy is the most effective for a nurse to use to reduce the number of children involved in automobile accidents who were not wearing seat belts?

Attend a school board meeting to advocate for classes teaching children seat belt safety. The best strategy to affect child seat belt safety is to attend the school board meeting and advocate for educational programming. The programming could be simple and done quickly. This action also targets the best audience.

A nurse is caring for a client whose left foot was surgically removed due to gangrene. The client tells the nurse that focusing more on his spiritual life helped him overcome the loss of his foot. Which of the following statements appropriately describes the spiritual dimension?

Being in harmony with the universe. The spiritual dimension tries to be in harmony with the universe, strives for answers about the infinite, and comes into focus when the person faces emotional stress, physical illness, or death. Worshiping family and friends or seeking joy from materialistic objects can make a personal happy on an individual level, but the spiritual dimensions is a quality that goes beyond religious affiliation and strives for inspiration, reverence, awe, meaning, and purpose even for those who do not believe in any god.

The nurse is observing a nursing student palpating a client's maxillary sinuses. The nurse determines that the student has correctly palpated the client's maxillary sinuses when the student palpates which area?

Below the client's cheekbones To palpate the maxillary sinuses, the nurse should place her hands on either side of the client's nose, below the cheekbone (zygomatic bone). To palpate the frontal sinuses, the nurse places her thumb just above the client's eye, under the bony ridge of the orbit. No sinuses are located on the bridge of the nose or in the temporal area.

A nurse prepares to assess a client who has just been admitted to the health care facility. During assessment, the nurse performs which activity?

Collects data During the assessment step of the nursing process, the nurse collects relevant data from various sources. She formulates nursing diagnoses during the nursing diagnosis step and develops a care plan and writes appropriate client outcomes during the planning step.

A client who has been using a combination of drugs and alcohol is admitted to the emergency unit. Behavior has been combative and disoriented. The client has now become uncoordinated and incoherent. What is the priority action by the nurse?

Complete a thorough assessment, including a Glasgow Coma Scale, and place the client in a location for frequent monitoring. This client has been ingesting an unknown amount of drugs and alcohol and is now exhibiting a change in neurologic status. It is a priority to carefully assess and closely monitor for any deterioration. The other choices are incorrect because a family member is not qualified to monitor the client. The client would eventually be referred to an addition team but is not medically stable. Sedation is not appropriate at this time.

A client is admitted with fatigue, anorexia, weight loss, and inability to sleep, which started 1 month after the death of his spouse. Which nursing diagnosis is most appropriate for this client?

Complicated grieving Behavioral manifestations of Complicated grieving include changes in eating habits, sleep patterns, and activity levels. Diagnoses of Activity intolerance, Ineffective role performance, and Low self-esteem don't include these defining characteristics.

A health care provider (HCP) prescribes a lengthy x-ray examination for a client with osteoarthritis. Which action by the nurse would demonstrate client advocacy?

Contact the X-ray department, and ask the technician if the lengthy session can be divided into shorter sessions. Shorter sessions will allow the client to rest between the sessions. Changing the HCP's prescription to a different examination will not provide the information needed for this client's treatment. Acetaminophen is a nonopioid analgesic and an antipyretic, not an anti-inflammatory agent; thus it would not help this client avoid the adverse effects of a lengthy x-ray examination. Although the x-ray table is hard, it is not possible to provide padding and obtain the needed diagnostic x-rays.

A client is admitted to the hospital with aspiration pneumonia secondary to progression of Parkinson's disease. Which assessment finding should the nurse anticipate?

Coughing when drinking liquids In Parkinson's disease, dysarthria, or impaired speech, results from a disturbance in muscle control. Muscle rigidity, not flaccidity, causes resistance to passive muscle stretching. The client may exhibit a mask-like appearance rather than a pleasant and smiling demeanor. Tremors should decrease, not increase, with purposeful movement and sleep. When the disease is advanced, swallowing is impaired and coughing would indicated aspiration.

A female client is admitted to the emergency department after being sexually assaulted. The nurse notes that the client is sitting calmly and quietly in the examination room and recognizes this behavior as a protective defense mechanism. What defense mechanism is the client exhibiting?

Denial Denial is a protective and adaptive reaction to increased anxiety. It involves consciously disowning intolerable thoughts and impulses. This response is commonly seen in victims of sexual abuse. In intellectualization, the client attempts to avoid expressing emotions associated with the stressful situation by using logic, analysis, and reasoning. A client who uses regression reverts to an earlier developmental level in response to stress. With displacement, the client transfers his feelings for one person toward another, less-threatening person.

A nurse identifies a client's responses to actual or potential health problems during which step of the nursing process?

Diagnosis The nurse identifies human responses to actual or potential health problems during the diagnosis step of the nursing process, which encompasses the nurse's ability to formulate a nursing diagnosis. During the assessment step, the nurse systematically collects data about the client or his family. During the planning step, she develops strategies to resolve or decrease the client's problem. During the evaluation step, the nurse determines the effectiveness of the care plan.

With shorter lengths of stay becoming the norm, which statement is true of the stages of the nurse-client relationship?

Different phases of the relationship involve emphasizing different processes and goals related to client needs. With the shorter lengths of stay, the processes and goals of a particular stage are chosen according to the client's current needs and abilities. Building trust (orientation stage) is a priority with psychotic and suspicious clients. It is less crucial for the client ready to work on issues. Making referrals (termination stage) is appropriate for all clients regardless of their needs. The other needs will be addressed in counseling after discharge. Teaching skills (working stage) is appropriate for clients with insight and readiness for change. They may not be appropriate for clients with severe psychosis or suspiciousness, especially if denial is present.

Which of the following sounds should the nurse expect to hear when percussing a distended bladder?

Dullness. A distended bladder produces dullness when percussed because of the presence of urine. Hyperresonance is a percussion sound that is present in hyperinflated lungs. Tympany, a loud drumlike sound, occurs over gas-filled areas such as the intestines. Flat sounds occur over very dense tissue that has no air present.

Because of an outbreak of influenza among the nursing staff, the hospital is very short staffed. The nurse manager prioritizes client needs on the surgical unit by which strategy?

ensuring that clients receive medications but omitting full bathing when possible Daily bathing is not required to meet standards of care. Rescheduling surgeries is not a strategy for meeting nursing care needs of clients. Medications are required to be given as prescribed to maintain standards of care and efficacy of the medication. UAPs are not licensed to administer analgesics.

Tachycardia can result from:

fear, pain, or anger. Fear, anger, stress, or pain can increase heart rate (tachycardia). Decreases in heart rate (bradycardia) can stem from vomiting, suctioning (causing vagal nerve stimulation), or certain medications.

The nurse is performing a focused assessment on a client's gastrointestinal system. Which assessment best determines an expected finding?

High pitched gurgling noises in four abdominal quadrants High-pitched gurgles heard in four abdominal quadrants are a normal finding. Decreased bowel motility causes two or three bowel sounds per minute; increased bowel motility causes hyperactive bowel sounds. Abdominal cramping causes hyperactive, high-pitched tinkling bowel sounds and may indicate a bowel obstruction.

A visitor to the surgical unit asks the nurse about another client on the unit. The visitor viewed the client's name on the computer screen of another nurse at the nurses' station and recognized the client as a relative. What is the first action of the nurse in relation to this situation?

Inform the other nurse that the viewed screen resulted in a breach of confidentiality. Nurses must protect the privacy of all client information, and this includes information on an electronic medical record. The computer screen at the nurses' station should not be in view of anyone other than the person accessing the record. The other answers are incorrect because they breach client confidentiality.

A client scheduled to have a surgery for a hernia the next day is anxious about the whole procedure. The nurse assures the client that surgery for hernias is very common and that the prognosis is very good. What skills of the nurse are reflected here?

Interpersonal skills. The scenario reflects the nurse's interpersonal skills. It shows how a person relates with others. The nurse shows imaginal skills when he or she envisions a plan for adapting and personalizing client care. Instrumental skills are associated with basic physical and intellectual competencies. Systems skills are those that help the nurse see the whole picture and how various parts relate.

During the termination phase of a nurse-client relationship, which intervention may lead to client confusion?

Introducing new issues to the client The nurse shouldn't introduce new issues during the termination phase because doing so may confuse the client. This phase is a time for wrapping up the relationship. It's appropriate for the nurse to refer the client to support groups. Reviewing what's been accomplished during the relationship is a goal of the termination phase. The client may express sadness during the termination phase, but this is a normal response.

During therapy, a client on the mental health unit is restless and is starting to make sarcastic remarks to others in the therapy session. The nurse responds by saying, "you look angry." Which of the following communication techniques is the nurse using?

Making observations The nurse has provided direct feedback as an observation to the client and the group. The nurse is not mirroring the behavior or seeking clarification or an explanation of the behavior. This is not an open-ended question. Making direct observations and providing feedback in this manner is useful in demonstrating attention and concern for group members as well as providing an external vantage point on behaviors exhibited in a group setting. While such a statement makes a space for later clarification, this statement itself if not a statement of clarification, it is simply an observation.

A nurse is caring for a client with multiple sclerosis. The client informs the nurse that a lawyer is coming to prepare a living will and requests the nurse to sign as witness. Which of the following actions should the nurse take?

Note that the nurse caring for the client cannot be a witness. A living will is an instructive form of an advance directive. It is a written document that identifies a person's preferences regarding medical interventions to use in a terminal condition, irreversible coma, or persistent vegetative state with no hope of recovery. Employees of the health care facility should not sign as witnesses; therefore, the nurse cannot sign as witness. Refusing a client may not be a good communication method; instead, the nurse could politely indicate the reason for declining. Calling for a physician or asking another colleague to sign is an inappropriate action.

A 57-year-old woman with breast cancer who does not speak English is admitted for a lumpectomy. Her daughter, who speaks English, accompanies her. In order to obtain admission information from the client, what should the nurse do?

Obtain a trained medical interpreter. A trained medical interpreter is required to ensure safety, accuracy of history data, and client confidentiality. The medical interpreter knows the client's rights and is familiar with the client's culture. Using the family member as interpreter violates the client's confidentiality. Using the UAP or limited Spanish and nonverbal communication do not ensure accuracy of interpretation and back-translation into English.

Why should the nurse avoid palpating both carotid arteries at one time?

Palpating both arteries at one time may cause severe bradycardia. The nurse must palpate the carotid arteries one at a time to prevent severe bradycardia and impairment of cerebral circulation. The nurse must also remember to avoid massaging the carotid sinus, located at the bifurcation of the carotid arteries; the resulting bradycardia could lead to cardiac arrest.

Which of the following findings in a client who recently underwent a total hip replacement would require a nurse to take immediate action?

Red painful area on the calf of the affected leg Deep vein thrombosis is a complication of total joint replacement and manifestations include a red tender calf. Ecchymosis around the incision site is a normal finding. The client's diaphoresis, fluid volume deficit, and edema in the nonaffected leg should be further assessed; however, the priority is the red tender calf.

The parents of an infant who just died from sudden infant death syndrome (SIDS) are angry at God and refuse to see any members of the clergy. Which nursing diagnosis is most ¬appropriate?

Spiritual distress The defining characteristic of Spiritual distress includes anger and refusing to interact with spiritual leaders. While anger is part of the grieving process, there's no indication that the parents aren't coping effectively or experiencing Complicated grieving. Since Chronic sorrow, as the name implies, occurs over a period of time and may be cyclical, this isn't an appropriate nursing diagnosis since the death has just occurred.

In preparation for discharge, the nurse is reviewing information related to new dietary guidelines with the client. This is an example of which step in discharge planning?

Providing client teaching. The nurse is teaching the client important information about self-care at home prior to discharge. The initial step in discharge planning is collecting and organizing data about the client, because this provides information on the client's healthcare needs. Home referrals may be made after the teaching process, based upon orders provided by the physician. Developing goals may occur after the teaching process, because the goals need to be realistic.

A client who just underwent a mastectomy is due to arrive at the post-surgical care unit. Which of the following actions should the nurse prioritize when attempting to establish an effective relationship with the client?

Recognize and address the client's anxiety. An early priority when admitting a client to a unit and establishing a relationship is to recognize and take steps to reduce anxiety. Assessing and addressing learning needs are important goals but should be addressed after the client has been settled on the unit. HIPAA should have been explained to the client earlier in her admission.

A client with colorectal cancer has been presented with her treatment options but wishes to defer any decisions to her uncle, who acts in the role of a family patriarch within the client's culture. By which of the following is the client's right to self-determination best protected?

Respecting the client's desire to have the uncle make choices on her behalf. The right to self-determination (autonomy) means that decision-making should never be forced on anyone. The client has the autonomous right to defer her decision making to another individual if she freely chooses to do so.

The nurse is meeting with a community group to discuss the changes that need to be made to meet their health needs after a community assessment has been done. One cultural group is insisting their views need to be implemented because they are in the majority in that community. What is the best action by the nurse?

Seek input from all groups and strive for consensus on what would benefit most or all of these people. The responsibility is to conduct the community assessment and to identify the key needs. All members need to have representation in this process. It is best to strive for consensus on what the key issues are and to implement programs that would benefit most of the people, rather than responding to one interest group. Listening to the majority viewpoint or helping everyone to change their views and have homogeneity would not be effective. Decisions based on the community alone are also not an appropriate answer.

What is a generally accepted criterion of mental health?

Self-acceptance Self-acceptance is a generally accepted criterion of mental health and serves as the basis for healthy relationships with others. Some degree of anxiety is necessary to stimulate growth and adaptation. Self-control and self-direction — not the ability to control others — indicate mental health. Happiness, though desirable, isn't an effective indicator of mental health because even mentally healthy people may be unhappy when faced with such events as illness, loss, and death.

When inspecting a client's skin, a nurse finds a circumscribed elevated area filled with serous fluid. What term should the nurse use to document this finding?

Vesicle A vesicle is a circumscribed skin elevation filled with serous fluid. A flat, nonpalpable, colored spot is a macule. A solid, elevated, circumscribed lesion is a papule. An elevated, pus-filled, circumscribed lesion is a pustule.

A nurse has attended an in-service workshop to address the phenomenon of ageism in the health care system. Which of the following practices is indicative of ageism?

Speaking to older adults in a way one would with clients who have mild cognitive deficits. Accommodation of normal, age-related changes such as decreased skin turgor and slightly decreased nutritional needs is not an indication of ageism. Similarly, safety measures are unlikely to be motivated by ageist beliefs. Assuming that all older adults have cognitively deficits, however, is an indication of ageism.

Which child should the nurse assess as demonstrating behaviors that need further evaluation?

Stephen, age 2, who is indifferent to other children and adults and is mute Indifference to other people and mutism may be indicators of autism and would require further investigation. A 2-year-old who talks to himself and refuses to cooperate with toilet training is displaying behaviors typical for this age. Occasional thumb sucking and not having spent the night with a friend would be normal at age 6. Threatening to run away when angry is considered within the range of normal behaviors for a 10-year-old child.

A client is admitted to the emergency department with a ruptured abdominal aortic aneurysm. No family members are present, and the surgeon instructs the nurse to take the client to the operating room immediately. Which of the following actions should the nurse take regarding informed consent?

Take the client to the operating room for surgery without informed consent. All attempts should be made to contact the family, but delaying life-saving surgery is not an option. The other options are not correct because the surgeon can perform surgery without consent if there is a risk of loss of life or limb if the surgery is not performed. The nurse should take the client to the operating room.

The charge nurse on the postpartum unit has received a report about a client who has just experienced a fetal demise and will be ready for transfer out of the labor unit in about 2 hours. The client has asked her primary nurse if she can stay on the obstetrical unit since she has found support from the nursing staff there. What action should the charge nurse on the postpartum unit take?

Talk to the mother first and decide on a location that is mutually agreeable. The nurse on the postpartum unit should discuss with the client what her wishes are and mutually agree on a location. The charge nurse better understands the current and future needs of the client experiencing this type of loss as the client may or may not be thinking well or clearly at the moment. The postpartum unit is full of sounds of infants, and although being in a room by herself may support the need for separation, it is often in the best interest of the client to locate her away from the noise of the babies. Placing the client on another unit will remove her from the support she is seeking. On the other hand, she will not be hearing crying infants. This has often been the location for someone experiencing a loss. Discharging the mother home as soon as she is stable physically is also a possibility, but the nurse must also assess the client's emotional stability and preferences for grieving.

A nurse is caring for a client who has experienced an acute exacerbation of Crohn's disease. Which assessment best indicates that the disease is under control?

The client exhibits signs of adequate GI perfusion with normal bowel sounds. Adequate GI perfusion can be maintained only if Crohn's disease is controlled. If the client experiences acute, uncontrolled episodes of Crohn's disease, impaired GI perfusion may lead to a bowel infarction. Positive self-image, a manageable level of discomfort, and intact skin integrity are expected client outcomes, but aren't related to control of the disease.

What short-term goal for a client hospitalized with a stress related disorder is most realistic?

The client will write a list of strengths and needs. Writing a list of strengths and needs is short-term, achievable, and measurable. Achieving positive self-esteem would occur over the long term. Going to school involves complex future steps to a long-term goal. Using skills is likely to be stressful and is best attempted after the client has done a self-assessment.

A nurse has received change-of-shift-report and is briefly reviewing the documentation about a client in the client's medical record. A recent entry reads, "Client was upset throughout the morning." How could the charting entry be best improved?

The entry should include clearer descriptions of the client's mood and behavior. Entries in the medical record should be precise, descriptive, and objective. An adjective such as "upset" is unclear and open to many interpretations. As such, the nurse should elaborate on this description so a reader has a clearer understanding of the client's state of mind. Stating the apparent reasons that the client was "upset" does not resolve the ambiguity of this descriptor. Cognitive and psychosocial issues are valid components of the medical record. Responses and interventions should normally follow assessment data but the data themselves must first be recorded accurately.

A home care nurse is caring for a paralyzed client who needs regular position changes and back massages. A man identifying himself as a family friend inquires if he can be of any help to the family. What should be the nurse's response be?

The nurse should ask the man to talk to the family directly. The nurse should ask the man to talk to the family directly. Revealing information about the client's care is a violation of the client's privacy. The nurse should not invite the gentleman for a learning session, because doing so would be a breach of the client's right to privacy. Referring him to a social worker is not an appropriate choice.

A dying patient requests that the nurse pray with him. The nurse is not accustomed to praying aloud but is comfortable praying silently. What is the best approach for this nurse to follow to pray with this patient?

The nurse should select a formal prayer or Bible passage to use to pray aloud. A nurse unaccustomed to praying aloud or in public may find it helpful to have a Bible passage or formal prayer readily available for praying. If the nurse is not comfortable praying with the patient, he or she should call the hospital chaplain or find another individual who is comfortable.

The nurse working in a long term care facility notes changes in the client of confusion and change in vital signs. Upon consulting with the health care provider, lab work and a urine culture via an indwelling catheter is ordered. Identify the location the nurse would access the urine from the catheter.

The nurse would wipe the port with an alcohol pad and then extract urine from the tubing via the port. As the urine flows through the tubing, the can would place stop the flow of urine distally so that urine would stay in the area of the port and "back up" in the tubing. This allows enough urine for the culture to be obtained

A nurse is evaluating a family in which chronic child abuse has occurred, and the parents have experienced chronic alcohol and drug abuse. Significant social supports have been established by social services and the parents have both received drug and alcohol treatment and parenting classes. Which of the following indicates that the parents have progressed in their treatment??

The parents report an understanding of normal growth and development. Understanding normal growth and development helps the parents have more reasonable expectations of their children. Spanking indicates the parents have not learned other forms of discipline. Expecting hyper-responsible behavior is not healthy, and merely hoping to attend parenting classes does not indicate an understanding of the concepts.

During a routine otoscopic examination the nurse identifies these assessment changes. Which finding requires additional action?

To perform an otoscopic examination on an adult, the nurse grasps the auricle of the ear and pulls it up and back to straighten the ear canal. For a child, the nurse grasps the auricle and pulls it down to straighten the ear canal. Normal findings should include visualization of the ossicles through the tympanic membrane, fine hairs in the auditory canal with wax, and reflection of light off the light-gray or pearly white shiny ear drum. A reddened ear drum would indicate an infection with our without pain.

A nurse is performing an assessment on an adult with hypertension who falls into the middle-old elderly population. Which of the following findings should be reported to the primary care provider?

Urine output of 600mL/24 hours Normal urinary output ranges from 30-80mL/hour. An output of 600mL/24 hours indicates a problem with urinary elimination because it is less than 30mL/hour. Normal physiologic changes associated with aging include thickened, brittle, yellow nails, diminished peripheral pulses, and increased sensitivity to glare.

The nurse is unable to palpate the client's left pedal pulses. What should the nurse do first?

Use a Doppler ultrasound device. When pedal pulses are not palpable, the nurse should obtain a Doppler ultrasound device. Auscultation is not likely to be helpful if the pulse is not palpable. Inspection of the lower extremity can be done simultaneously when palpating, but the nurse should first try to locate a pulse by Doppler. Calling the HCP may be necessary if there is a change in the client's condition.

After his spouse has visited, a client begins crying and saying that his spouse is a mean person. When the client starts pounding on the overbed table and using incomprehensible language, the nurse feels she can't handle the situation. What should the nurse do at this time?

Use the call system to request assistance. A nurse who feels she can't handle a problem should use the call system to seek assistance. The nurse should stay with the client until help arrives, unless the nurse feels that personal harm is imminent. Telling the client his spouse is under stress and instructing the client not to pound the table are inappropriate because they're nontherapeutic responses; they don't address the client's feelings or needs. Informing facility security is an overreaction to the situation at this point.

When providing nursing care to a client of African descent, which of the following cultural factors should the nurse consider?

Values and beliefs are often present oriented. Cultural factors that should be considered when providing care to client of African descent include the recognition that the family is usually matriarchal, values and beliefs are present oriented, there is strong family unity and cooperation, and families are frequently highly religious and highly respect the clergy.

A health care provider (HCP) is calling the pediatric unit and asking the nurse to go into the medical record for test results of a fellow pediatrician. How should the nurse respond to this request?

Verify that the caller is the HCP of record or has a need to know. The nurse should determine if the HCP is the HCP of record and should have access to the information in the medical record. The medical record is not for public access. The nurse would not give client information to any HCP or refuse to give information without first determining the HCP of record and/or a legitimate need to know. As an employee, the nurse should have access to medical records, but it is not acceptable to enter a medical record without justification.

The nurse should utilize SBAR communication (Situation, Background, Assessment, Recommendation) during which of the following clinical situations?

When communicating a change in a client's condition to his or her physician. SBAR communication is an increasingly common tool for interdisciplinary communication. It is not typically used during change-of-shift report nor when communicating with family members. SBAR is considered a framework for communication rather than a format for documentation.

A nurse is observing a unlicensed assistive personnel (UAP) measure a client's blood pressure. Which action by the UAP would not require further teaching?

Wrapping the cuff around the limb, with the bladder covering three-quarters of the limb circumference When measuring blood pressure, the nurse either removes the client's clothing or moves it above where the cuff will the placed. The nurse should wrap the cuff around the client's arm or leg with the bladder uninflated; the bladder should cover approximately three-quarters of the limb circumference. The nurse chooses bladder size according to the size of the extremity. Using the automatic blood pressure cuff on all clients without cleaning would cause of spread of hospital acquired infections.

A nurse is changing a client's dressing. Which observation of the wound warrants immediate physician notification?

Yellow, purulent drainage Yellow, purulent drainage suggests infection; the nurse must report this finding to the physician immediately and obtain a culture as ordered. Approximated wound edges, sutures being in place, and pink granulation tissue represent normal findings for a wound.

There has been a car accident involving four vehicles on a remote highway. The nearest emergency department is 15 minutes away. Which victim should be transported by helicopter rather than an ambulance to the nearest hospital?

a middle-aged female with cold, clammy skin; heart rate of 120 bpm; and is unconscious The middle-aged female is likely in shock; she is classified as a triage level I, requiring immediate care. The child with moderate trauma is classified as triage level III, urgent, and can be treated within 30 min. The man with asthma and the man with the severe headache are classified as emergent, triage level II, and can be transported by ambulance and reach the hospital within 15 min.

Which client has a greater risk for latex allergies?

a woman who is admitted for her seventh surgery Clients who have had long-term multiple exposures to latex products, such as would occur with six previous surgeries and recoveries, are at increased risk for latex allergies. The nurse should explore what types of surgeries these were, how involved the client's recoveries were, and whether signs of latex allergies have occurred in the past. Working as a sales clerk, having type 2 diabetes, and undergoing laser surgery do not expose a client to latex or increase the risk of latex allergy.

Which type of surgery is most likely to cause the client to experience postoperative nausea and vomiting?

abdominal hysterectomy Although any client may experience nausea and vomiting secondary to anesthetics or postoperative analgesics, the client who has had manipulation of the abdominal organs is more prone to postoperative nausea and vomiting than the client who has had a procedure such as a total joint replacement, open heart surgery, or a mastectomy.

The nurse understands that with the right help at the right time, a client can successfully resolve a crisis and function better than before the crisis, based primarily on which factor?

acquisition of new coping skills Learning new coping skills is the major factor necessary for higher functioning. Better coping is likely to lead to regaining support systems, giving up dysfunctional coping, and awareness of how to prevent future crises.

When teaching a client to perform testicular self-examination, the nurse explains that the examination should be performed:

after a warm bath or shower. After a warm bath or shower, the testes hang lower and are both relaxed and in the ideal position for manual evaluation and palpation.

A child with spastic cerebral palsy receiving intrathecal baclofen therapy is admitted to the pediatric floor with vomiting and dehydration. The family tells the nurse that they were scheduled to refill the baclofen pump today, but had to cancel the appointment when the child became ill. The nurse should:

arrange for the pump to be refilled in the hospital. To prevent a baclofen withdraw, pump refills are scheduled several days before anticipated low-volume alarms. The nurse should make it a high priority to have the pump refilled as soon as possible. Discontinuing baclofen suddenly can result in a high fever, muscle rigidity, change in level of consciousness, and even death. Waiting until the child leaves the hospital for a refill may lead to a low dose or withdraw. Waiting for the low-volume alarm puts the client at risk because medication and team members who can refill the pump may not be readily available under all circumstances.

When assessing an elderly client, the nurse expects to find various aging-related physiologic changes. These changes include:

delayed gastric emptying. Aging-related physiologic changes include delayed gastric emptying, decreased coronary artery blood flow, an increased posterior thoracic curve, and increased peripheral resistance.

On the second day after surgery, the nurse assesses an elderly client and finds the following: • blood pressure, 148/92 mm Hg; heart rate, 98 bpm; respirations 32 breaths/min • O2 saturation of 88 on 4 L/min of oxygen administered by nasal cannula • breath sounds are coarse and wet bilaterally with a loose, productive cough • client voided 100 mL very dark, concentrated urine during the last 4 hours • bilateral pitting pedal edema Using the SBAR method to notify the health care provider (HCP) of current assessment findings, the nurse should recommend that the HCP write a prescription for a(n):

diuretic medication. The client is experiencing a fluid overload and has vital signs that are outside of normal limits. The provider must be notified of the client's current status. It would be appropriate to recommend the provider administer a diuretic to correct the fluid overload. It is not appropriate to administer an antihypertensive medication or administer more fluids. It may be appropriate to administer additional oxygen, but because of the fluid volume excess the client exhibits, diuretic administration is most important. (less)

Which activity would be most appropriate to include in a playroom that will be used by children aged 13 months to 6 years?

free play with adult supervision Planning any single activity that will appeal to children from ages 13 months to 6 years is next to impossible because of the developmental differences found in such a wide age group. It would be best to allow these children to participate in free play with adult supervision. A group sing-along would be appropriate for preschoolers and school-aged children. However, toddlers have short attention spans and would most likely find it difficult to participate in a group activity, such as a sing-along. Although drawing and painting projects would be appropriate for preschoolers and school-aged children, toddlers have a tendency to put objects into their mouths. Therefore, drawing and painting projects would be inappropriate for this age group. Viewing cartoon videos would be inappropriate for young toddlers, who typically have short attention spans. Additionally, young toddlers may not understand the videos.

The nurse manager on the orthopedic unit is reviewing a report that indicates that in the last month five clients were diagnosed with pressure ulcers. The nurse manager should:

institute a quality improvement plan that identifies contributing factors, proposes solutions, and sets improvement outcomes. The problem of pressure ulcers in hospitalized clients is best addressed by using quality improvement techniques to identify the problem, determining strategies for improvement, and setting goals for outcomes. Benchmarking for comparison will indicate where this nursing unit compares with other units, but does not address the problem for this unit; having clients with pressure ulcers on any unit is not acceptable. Educational programs are more effective after there is an understanding of the problem. Chart audits and blaming do not solve the problem or address quality improvement measures.

When planning a culturally sensitive health education program, the nurse should:

integrate folk beliefs and traditions into the content. Strategies to reach clients in all cultures should include incorporating the folk beliefs and traditions of the target population into the program. Identification of a centrally located building with available access by the target population, use of materials in the native or primary language of the target population, and involvement by all community leaders will also help the program succeed.

The nurse on the orthopedic unit is receiving a client from the Post Anesthesia Care Unit (PACU). WA safe "hand-off" includes:

interactive communication between the nurse from the PACU and the nurse from the orthopedic unit. The Joint Commission and Health Council of Canada both mandate interactive hand-off communication that allows the opportunity for questioning between the giver and receiver of client information, including up-to-date information regarding the client's care, treatment and services, current condition, and any recent or anticipated changes. Nurses have primary responsibility and accountability for utilization of all nursing care provided to clients. The nurse retains the right and has the responsibility to refrain from delegating specific activities based on individual client care needs, caregiver expertise, and/or client care program requirements.

An elderly woman experiences short-term memory problems and occasional disorientation a few weeks after her husband's death. She also is not sleeping, has urinary frequency and burning, and sees rats in the kitchen. The home care nurse calls the woman's health care provider (HCP) to discuss the client's situation and background, assess, and give recommendations. The nurse concludes that the woman:

is experiencing delirium and a urinary tract infection (UTI). Delirium is commonly due to a medical condition such as a UTI in the elderly. Delirium often involves memory problems, disorientation, and hallucinations. It develops rather quickly. There is not enough data to suggest Alzheimer's disease especially given the quick onset of symptoms. Delayed grieving and adjusting to being alone are unlikely to cause hallucinations

A client with schizophrenia started risperidone 2 weeks ago. Today, he tells the nurse he feels like he has the flu. The nurse's assessment reveals the following: temperature 104.4° F (40.2° C), respirations 24 breaths/minute, blood pressure 130/102 mm Hg, pulse rate 120 beats/minute. The nurse also notes muscle stiffness and pain, excessive sweating and salivation, and changes in mental status. The nurse suspects the client is experiencing:

neuroleptic malignant syndrome. Neuroleptic malignant syndrome is a rare but potentially life-threatening reaction to an antipsychotic or neuroleptic. The cardinal symptom is a high temperature. Other commonly observed symptoms include altered mental status and autonomic dysfunction. Although fever may be present with the flu, it doesn't normally cause altered mental status or autonomic dysfunction. Malignant hyperthermia is a complication associated with general anesthesia. These findings don't suggest the client has septicemia. Findings in septicemia include severe hypotension, fever, tachycardia, and a history of a recent infection.

A nurse is caring for a client who has suffered a severe stroke. During routine assessment, the nurse notices Cheyne-Stokes respirations. Cheyne-Stokes respirations are:

progressively deeper breaths followed by shallower breaths with apneic periods. Cheyne-Stokes respirations are breaths that become progressively deeper followed by shallower respirations with apneicperiods. Biot's respirations are rapid, deep breaths with abrupt pauses between each breath, and equal depth between each breath. Kussmaul's respirations are rapid, deep breaths without pauses. Tachypnea is abnormally rapid respirations.

The charge nurse on the pediatric floor has assigned a 6-year-old girl with newly diagnosed type 1 diabetes and an 8-year-old girl recovering from ketoacidosis to the same semi-private room. The 6-year-old's mother is upset because the parent staying with the other child is male and believes the arrangement is violates her social norms. The nurse should:

reassign the children to different rooms. Sleeping in the same room with a person of the opposite sex may be viewed as a violation of norms by persons of conservative faiths. If at all possible, the charge nurse should reassign the family to a different room. While it makes sense to have two clients with similar educational needs in the same room, it is likely that the arrangement would be distressing enough to create a learning barrier. Offering the mother another place to sleep deprives the child of her parent at night. The customer service representative would only need to be involved if it became impossible to accommodate the mother's needs.

An elderly client admitted with new-onset confusion, headache, and bounding pulse has been drinking copious amounts of water and voiding frequently. The nurse reviews the laboratory results (see accompanying chart). Which of the abnormal lab values is consistent with the client's symptoms?

serum sodium This client is exhibiting behaviors and symptoms associated with hyponatremia caused by water intoxication; the nurse would expect to find confirmation of a low serum sodium level by checking the electrolyte levels. The nurse would expect this client's serum osmolality and urine specific gravity to be low, not high. The platelet count is not relevant as there is no correlation between sodium levels and platelet counts.

After administering a prescribed medication to a client who becomes restless at night and has difficulty falling asleep, which nursing action is most appropriate?

sitting quietly with the client at the bedside until the medication takes effect To promote adequate rest (6 to 8 hours per night) and to eliminate hyposomnia, the nurse should sit with the client at the bedside until the medication takes effect. The presence of a caring nurse provides the client with comfort and security and helps to decrease the client's anxiety. Engaging the client in interaction until the client falls asleep, reading to the client, or encouraging the client to watch television may be too stimulating for the client, consequently increasing rather than decreasing the client's restlessness.

A nurse measures a client's apical pulse rate and compares it with his radial pulse rate. The differential between these two pulses is called:

the pulse deficit. The differential between the apical and radial pulse rates is the pulse deficit. Pulse pressure refers to the differential between systolic and diastolic blood pressures. Pulse rhythm is the interval pattern between heartbeats. Pulsus regularis is the normal pulse pattern, in which the interval between beats is consistent.

When examining a client who has abdominal pain, a nurse should assess:

the symptomatic quadrant last. The nurse should systematically assess all areas of the abdomen, if time and the client's condition permit, concluding with the symptomatic area. Otherwise, the nurse may elicit pain in the symptomatic area, causing the muscles in other areas to tighten. This tightening would interfere with further assessment.

A mother comes to the clinic with her 5-year-old son who is complaining of a fever and sore throat. The nurse documents the client's tonsils as 3+. This rating means they're:

touching the uvula. Tonsils that touch the uvula are rated 3+. Tonsils barely visible outside the tonsillar pillar are rated 1+. Tonsils between the tonsillar pillar and the uvula are rated 2+. Tonsils that touch each other are rated 4+.

An overweight adolescent has been diagnosed with type 2 diabetes. To increase the client's self-efficacy to manage their disease, the nurse should:

utilize a peer with type 2 diabetes to role model lifestyle changes. Self-efficacy, or the belief that one can act in a way to produce a desired outcome, can be promoted through the observation of role models. Peers are particularly effective role models because clients can more readily identify with them and believe they are capable of similar behaviors. Providing a written plan alone does not promote self-efficacy. Having parents eliminate junk food and having the school nurse weigh the adolescent can be part of the plan, but these actions do not empower the client.

The nurse is receiving over the telephone a laboratory results report of a neonate's blood glucose level. The nurse should:

write down the results, read back the results to the caller from the laboratory, and receive confirmation from the caller that the nurse understands the results. To ensure client safety, the nurse should first write the results on the medical record, then read them back to the caller and wait for the caller to confirm that the nurse has understood the results. Using scrap paper increases the risk of losing the results as well as transcription errors. The nurse may receive results by telephone, and while electronic transfer to the client's medical record is appropriate, the nurse can also accept the telephone results if the laboratory has called the results to the nursery. Sending client information via e-mail is unacceptable due to potential security and privacy issues.

The nurse is caring for a client who developed fluctuating moods related to a recent cerebral vascular accident. When discussing the client's mood in a family meeting, which statements confirm a family's understanding of how to support the client? Select all that apply

• "I do not take what she says personally and try to address the issue of anger." • "I allow her to vent feelings and then find a different topic to discuss." • "Sometimes I sit down and cry too then we pick ourselves up and move on." Explanation: Changes in the brain which occur following the cerebral vascular accident can lead to periods of an emotional outburst resulting in anger or depression. Family may experience changes in their loved one which include uncharacteristic verbal outbursts or crying within usual conversation. It is important to identify that these outburst are a result of the illness and not take the outburst personally. Allowing the client to vent her feeling and experience the frustration with the client allows for the sharing of emotions and provides emotional support. Afterwards, moving on to a different topic or moving on within the day's activity does not allow the client to remain in the emotional state. Leaving the client or yelling at the client is not therapeutic to support the client through this time.

A nurse is caring for a middle-aged client who has undergone hemicolectomy for colon cancer. The client has two children. Which concepts about families would the nurse consider when providing care for this client? Select all that apply

• A family member may have more than one role at a time in the family. • Changes in sleeping and eating patterns may be signs of stress in a family. • Illness in one family member can affect all family members. • The effects of an illness on a family depend on the stage of the family's life cycle. Explanation: Illness in one family member can affect all family members, even children. Each member of a family may have several roles to perform. A middle-aged client, for example, may have the roles of father/mother, husband/wife, wage earner, child care provider, and housekeeper. When one family member cannot fulfill a role because of illness, the roles of the other family members are affected. Families move through certain predictable life cycles (such as birth of a baby, a growing family, adult children leaving home, and grandparenting). The impact of illness on the family depends on the stage of the life cycle as family members take on different roles and the family structure changes. Illness produces stress in families; changes in eating and sleeping patterns are signs of stress. (less)

Which of the following actions performed by a nurse will increase the risk of liability? Select all that apply.

• Assisting a client on ordered bed rest to walk to the toilet • Providing information to a caller about a client's diagnosis and treatment • Asking unlicensed assistive personnel to assess a client's wound Nursing standards of practice are stated within the nurse practice act of each state, territory, or province. These standards include scope of practice, delegation, professional ethics, and code of conduct. A nurse increases the risk of professional liability when performing activities outside of these standards. A nurse may not delegate a nursing task to a person, such as unlicensed assistive personnel who do not have the proper training or skills to perform the task. The nurse should not act against physician orders without a professionally based reason, such as clarifying an order. Professional ethics requires protection of client privacy. Personal health information should not be provided to a caller without the client's consent.

The nurse has just completed a client's home visit and has scheduled another client's visit immediately after. Which of the following measures should the nurse take to minimize risks of infection during home visits? Select all that apply.

• Perform hand hygiene before and after client contact. • Implement standard precautions during home visits. Hand hygiene is the most important infection control measure and is necessary before and after treating each client. Nurses use standard precautions during home care visits, including wearing gloves when contacting blood, body fluids, secretions, excretions, and contaminated items. However, neither sterile gloves nor wearing gloves at all times is necessary to control infection. Performing consecutive home visits is an acceptable practice; any accompanying risk of infection can be controlled with conscientious infection control practices.

Which activities should the nurse encourage the unlicensed assistive personnel (UAP) to assist with in the care of postoperative clients? Select all that apply.

• Reposition clients for pain relief. • Tell the nurse if clients report they are having pain. • Empty and measure indwelling urinary catheter collection bags. Nurses can delegate to the UAP to observe clients and promote their comfort following surgery and to empty and measure urinary catheter drainage bags. UAPs cannot teach clients; that is the responsibility of the registered nurse (RN) or respiratory therapist. UAPs cannot assess IV insertion sites, which is the responsibility of a RN.

The nurse is working in the intensive care unit with a client in shock. During hand-off the nurse reports the results of which assessment findings that signal early signs of the decompensation stage? Select all that apply.

• Skin color • Vital signs • Peripheral pulses • Urine output Shock is a medical emergency in which the organs and tissues of the body are not receiving adequate blood flow. Although shock can develop and progress quickly, the nurse monitors evidence of early signs that blood volume and circulation is becoming compromised. Vital signs, skin color, urine output related to blood perfusion of the kidneys and peripheral pulses all provide assessment data relating blood volume and circulation. Nutrition and gait is not related to blood circulation.

When witnessing an adult client's signature on a consent form for a procedure, the nurse verifies that the consent was obtained in an appropriate manner. What information should the nurse verify? Select all that apply.

• that the client has full awareness of the potential complications • that the client understood the information • that there was voluntary consent on the client's part • that there was adequate disclosure of information The role of the nurse in witnessing the signing of the consent is to witness that the client is informed of the procedure, understands the information, is aware of potential complications, and is signing of his or her own free will. It is not necessary for a spouse, relative, or guardian to be present.

Which fining should the nurse expect to assess as normal skin changes in an elderly client? Select all that apply.

• wrinkles • diminished hair on scalp and pubic areas • xerosis • solar lentigo Skin changes associated with aging include the following: diminished hair on scalp and pubic areas, solar lentigo (liver spots), wrinkles, and xerosis (dryness). Dusky rubor of the left lower extremity may indicate the individual has a venous stasis problem in the affected extremity and is generally associated with "unsuccessful aging." Yellow pigmentation of the skin that may be associated with liver inflammation is generally known as jaundice.