PHI-116 EXAM 2
B (Verify that the site, side, and level are marked.)
A 13-year-old is having surgery to repair a fractured left femur. As a part of the preoperative safety checklist, what should the nurse do? A- Ask the teen to point to the surgery site. B- Verify that the site, side, and level are marked. C- Ask the parents if they have signed the operative permit. D- Restate the surgery risks to the parents.
C ("For your protection, I can't keep this secret. After I notify the physician, we will need to involve your family. We want you to be safe." )
A 15-year-old adolescent confides in the nurse that he has been contemplating suicide. He says he has developed a specific plan to carry it out and pleads with the nurse not to tell anyone. What is the nurse's best response? A- "We can keep this between you and me, but promise me you won't try anything." B- "I need to protect you. I will tell your physician, but we don't need to involve your parents. We want you to be safe." C- "For your protection, I can't keep this secret. After I notify the physician, we will need to involve your family. We want you to be safe." D- "I will need to notify the local authorities of your intentions."
D (autonomy and beneficence pg 159)
A 22-year-old client with schizophrenia is refusing antipsychotic medication. The client states, "I don't like the dopey way it makes me feel. I feel like I'm walking underwater when I take it." The nurse explains to the client, "Your schizophrenia is caused by a chemical imbalance in your brain, and this medication helps fix that chemical imbalance. You need to take it so your symptoms will get better." This conversation reflects a conflict between which two types of ethical principles? A- autonomy and justice B- paternalism and veracity C- justice and nonmaleficence D- autonomy and beneficence
B (Provide one-to-one supervision of the client until detoxification treatment can begin.)
A 26-year-old is being treated for delirium due to acute alcohol intoxication. The client is restless, does not want to stay seated, and has a staggering gait. What should the nurse do first? A- Place the client in a chair with a waist restraint. B- Provide one-to-one supervision of the client until detoxification treatment can begin. C- Ask the client to sit in a chair next to the nurses' station. D- Decrease stimuli by putting the client in bed with the room door closed.
C (assess reflexes, clonus, visual disturbances, and headache.)
A 29-year-old multigravida at 37 weeks' gestation is being treated for severe preeclampsia and has magnesium sulfate infusing at 3 g/h. To maintain safety for this client, the priority intervention is to: A- maintain continuous fetal monitoring. B- encourage family members to remain at bedside. C- assess reflexes, clonus, visual disturbances, and headache. D- monitor maternal liver studies every 4 hours.
A (instituting droplet precautions)
A 3-month-old infant with meningococcal meningitis has just been admitted to the pediatric unit. Which nursing intervention has the highest priority? A- instituting droplet precautions B- administering acetaminophen C- obtaining history information from the parents D- orienting the parents to the pediatric unit
B (mumps Maternity and Pediatric Nursing, 3rd ed pg 1357)
A child in the clinic has a fever and reports a sore neck. Upon assessment the nurse finds a swollen parotid gland. The nurse suspects which infectious disease? A- Measles B- Mumps C- Whooping cough D- Scabies
B ("I am not at liberty to discuss your case with anyone except those directly involved in your care unless you authorize me to do so." pgs 29-30)
A client about to undergo gastric bypass surgery calls the nurse into the room. The client whispers to the nurse concern that friends will learn about her upcoming surgery. She pleads with the nurse to keep her surgery a secret. Which response by the nurse is best? A- "I promise I won't tell anyone." B- "I am not at liberty to discuss your case with anyone except those directly involved in your care unless you authorize me to do so." C- "I can't lie to them if they ask me." D- "I will avoid any questions."
C D E F (Admit the client to a private room, Post a "contact isolation" sign on the door, Wear a protective gown when in the client's room, Wear gloves when providing direct care.)
A client has been admitted to the hospital with draining foot lesions. What should the nurse do? Select all that apply. A- Place the client in a room with negative air pressure. B- Admit the client to a semi-private room. C- Admit the client to a private room. D- Post a "contact isolation" sign on the door. E- Wear a protective gown when in the client's room. F- Wear gloves when providing direct care.
A (The lower extremities)
A client has been diagnosed with PVD. What area of the body should the nurse focus the assessment? A- The lower extremities B- Lung sounds C- Heart rate and rhythm D- The abdominal area
D (Check on the client every 30 minutes while the restraints are on.)
A client has soft wrist restraints to prevent the client from pulling out the nasogastric tube. Which nursing intervention should be implemented while the restraints are on the client? A- Instruct the client not to move while the restraints are in place. B- Remove the restraints every 4 hours to provide skin care. C- Secure the restraints to side rails of the bed. D- Check on the client every 30 minutes while the restraints are on.
C (Beneficence pg 159)
A client is being seen in the mental health clinic because of relapse. The client has been nonadherent with the medication regimen. The nurse reinforces the advantages of taking medications. The nurse is using which ethical principle? A- Autonomy B- Justice C- Beneficence D- Veracity
A ( "A coronary artery bypass graft will benefit your heart." )
A client is scheduled for a CABG procedure. What information should the nurse provide to the client? A- "A coronary artery bypass graft will benefit your heart." B- "The CABG procedure will help identify nutritional needs." C- "A complete ablation of the biliary growth will decrease liver inflammation." D- "The CABG procedure will help increase intestinal motility and prevent constipation."
A (fidelity)
A client rings a call bell to request pain medication. Upon performing the pain assessment, the nurse informs the client that she will return with the pain medication. The nurse's promise to return with the pain medication is an example of which principle of bioethics? A- Fidelity. B- Autonomy. C- Nonmaleficence. D- Justice.
B (Interpersonal Skills)
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? A-Imaginal skills. B- Interpersonal skills. C-Instrumental skills. D-Systems skills.
D (Ensuring that the client is not permitted to use anything that would be potentially dangerous. pg 07-308 and pg 331)
A client who has experienced the recent loss of an infant child and recent immigration to the United States is admitted to the inpatient psychiatric unit with severe symptoms of depression. The client has expressed thoughts of suicide. Which is the nurse's priority intervention for this client? A- Exploring the grief and loss issues concerning the baby's death. B- Encouraging the client to express feelings of isolation following the recent immigration. C- Encouraging attendance at group cognitive-behavioral therapy on the unit. D- Ensuring that the client is not permitted to use anything that would be potentially dangerous.
B (Determine whether the client is allergic to iodine, contrast dyes, or shellfish.)
A client with a suspected brain tumor is scheduled for a computed tomography (CT) scan. What should the nurse do when preparing the client for this test? A- Immobilize the neck before the client is moved onto a stretcher. B- Determine whether the client is allergic to iodine, contrast dyes, or shellfish. C- Place a cap over the client's head. D- Administer a sedative as ordered.
A (Autonomy)
A client with esophageal cancer decides against placement of a jejunostomy tube. Which ethical principle is a nurse upholding by supporting the client's decision? A- Autonomy B- Fidelity C- Nonmaleficence D- Veracity
B (inform the client or legal guardian of their rights)
A client with metastatic brain cancer is admitted to the oncology floor. According to the Self-Determination Act of 1991 concerning the execution of an advance directive, the hospital is required to: A- decide on a treatment plan if the client can't. B- inform the client or legal guardian of their rights to execute an advance directive. C- respect individuals' moral rights. D- advise clients not to execute their advance directives because they limit treatment options.
A (The colleague had good motives but violated the principle of veracity pg 159)
A client's estranged spouse has phoned the hospital unit several times seeking information about the client's admission and status. A nurse hears a colleague tell the client, "No, your spouse has not called as far as I know." When confronted by the nurse, the colleague states, "I'm just trying to look out for the client by protecting the client from stress." How should the colleague's actions be interpreted? A- The colleague had good motives but violated the principle of veracity B- The colleague was not justified in deceiving the client and contradicted the principle of fidelity C- The colleague's actions are a justifiable example of paternalism aimed at protecting the client's best interests D- The colleague was unjustified in allowing autonomy to override beneficence
A (referral)
A community health nurse provides information to a patient with newly diagnosed multiple sclerosis for a support group at the local hospital for patients diagnosed with multiple sclerosis and their families. Providing this information is an example of which of the following? A- A referral. B- A consultation C- Conferring D- Reporting
B (Telephone the client to obtain permission to visit. pg 18)
A home care nurse is planning to visit a 60-year-old client diagnosed with heart failure for the first time. Which of the following would be most appropriate for the nurse to do? A- Contact the client to say that the nurse is coming out to visit. B- Telephone the client to obtain permission to visit. C- Ask the client if he lives alone or with someone else. D- Obtain information about the client's health insurance.
B (Avoid unattended baths for the toddler. pgs 700-701)
A home care nurse provides health education to parents regarding the care of their toddler. Which of the following precautions should the nurse suggest the parents take to protect the toddler from drowning? A- Instruct the toddler not to go near the pool. B- Avoid unattended baths for the toddler. C- Monitor the activities of the toddler. D- Allow the child to swim with friends.
C (Retrieval of information is more efficient.)
A hospital is switching to computerized charting. The nurse recognizes that one advantage to an electronic client chart is that A- No other charting method is necessary. B- Access is open to anyone. C- Retrieval of information is more efficient. D- It is less costly to maintain.
B ("I cannot give you that information due to client confidentiality." pgs 118-119)
A medical surgical client is in the radiology department. The client's cousin arrives on the medical surgical unit and asks to speak with the nurse caring for his cousin. The visitor asks the nurse to provide a brief outline of the client's illness. Which response, if given by the nurse, would demonstrate application of legal safeguard in her practice? A- "I will call the client and ask his permission." B- "I cannot give you that information due to client confidentiality." C- "Do you have any identification proving you are related to the client?" D- "I'm busy right now, but can talk later."
A (Removing dead or infected tissue to promote wound healing pg 983)
A medicalsurgical nurse is assisting a wound care nurse with the debridement of a patient's coccyx wound. What is the primary goal of these nurses' action? A- Removing dead or infected tissue to promote wound healing B- Stimulating the wound bed to promote the growth of granulation tissue C- Removing purulent drainage from the wound bed in order to accurately assess it D- Removing excess drainage and wet tissue to prevent maceration of surrounding skin
D (Surrogate decision maker.)
A mentally incapacitated client is scheduled for surgery. Considering the principle of autonomy, who should give the consent for surgery? A- Client. B- Operating surgeon. C- Attending nurse. D- Surrogate decision maker.
C (Risk for community contamination related to possible environmental pollution pg 266)
A new chemical plant is being built in the community. The nurse is concerned about the possibility of environmental pollution adversely affecting the health of the residents. What nursing diagnosis would the nurse use to address this concern? A- Knowledge deficit related to effects of chemical plant pollution B- Deficient community health related to chemical plant C- Risk for community contamination related to possible environmental pollution D- Risk for infection related to community contamination
B ( Rates pain 8/10, states nauseated for last 30 minutes.)
A nurse administered oral pain medication 1 hour ago. Which documentation by the nurse best reflects the effectiveness of the pain medication? A- States pain is not relieved, talking with family on phone. B- Rates pain 8/10, states nauseated for last 30 minutes. C- Vital signs within normal limits, sleeping. D- Rates pain higher on pain scale, notified physician.
A (Client's record and occurrence report)
A nurse administering medications accidentally gives a double dose of blood pressure medications. After ensuring the safety of the client, the nurse would document the error in which documents? A- Client's record and occurrence report B- Occurrence report and critical pathway C- Critical pathway and care plan D- Care plan and client's record
A (Contact the physician and obtain necessary orders.)
A nurse assesses a client with psychotic symptoms and determines that the client likely poses a safety threat and needs vest restraints. The client is adamantly opposed to this. What would be the best nursing action? A-Contact the physician and obtain necessary orders. B-Restrain the client with vest restraints. C- Ask a family member to come in to supervise the client. D-Apply wrist restraints instead of vest restraints.
A (1 Unit of glucose)
A nurse has administered one unit of glucose to the client as per order. What is the correct documentation of this information? A- 1 Unit of glucose B- 1 bottle of glucose C- One U of glucose D- 1U of glucose
A ("It is difficult for her to love and trust again after her losses. In this facility, she can learn to deal with her loss in a less emotionally charged environment than a foster home.")
A nurse has been caring for an adolescent client in a residential facility. The child has been through a series of foster placements since infancy with no success in any placement until the age of 7 when placed with a middle-aged single woman. The client thrived there until the woman was killed in a car accident. The client attempted suicide after her foster mother died in response to the loss and the child was placed in the residential facility. The nurse has become close to this client and wants to help her address her issues and move on with her life. Which comment to the manager demonstrates that the nurse understands the client's issues and is able to respond appropriately to the client's needs? A- "It is difficult for her to love and trust again after her losses. In this facility, she can learn to deal with her loss in a less emotionally charged environment than a foster home." B- "She just needs someone who will love her and give her the things she has missed out on in life. An adoptive family needs to be found for her as soon as possible." C- "I am not sure she can get past all the loss and rejection she has experienced. I do not think adoption will ever be a viable option for her." D- "I know her well and am familiar with her issues. I think the best chance for success for her would be if she was adopted into my family."
A (Allocation of scarce nursing resources pg. 104)
A nurse has completed 4 hours of his 8-hour shift on a medicalsurgical unit when he receives a phone call from the nursing supervisor. The nursing supervisor informs the nurse that he needs to give a report to the other two nurses on the medicalsurgical unit and immediately report to the telemetry unit to assist with staff needs on that unit. The nurse informs the supervisor that he has been busy with his patient assignment and feels this will overwhelm the nurses on the medicalsurgical unit. The supervisor informs the nurse that the need is greater on the telemetry unit. This is an example of which type of ethical problem? A-Allocation of scarce nursing resources B-Advocacy in a market-driven environment C-Conflicts concerning new technology D-Deception
A (Rescue anyone who is in immediate danger. pgs 710-711)
A nurse has smelled smoke and subsequently discovered a fire in a garbage can in a common area on the hospital unit. What is the nurse's priority action in this situation? A- Rescue anyone who is in immediate danger. B- Evacuate patients and staff. C- Activate the fire alarm on the unit. D- Attempt to extinguish the fire.
B (Restrain the client, as he is harmful to the other clients.)
A nurse in a psychiatric care unit finds that a client with psychosis has become violent and has struck another client in the unit. What action should the nurse take in this case? A- Do not restrain the client, as it is equivalent to false imprisonment. B- Restrain the client, as he is harmful to the other clients. C- Do not restrain the client, as it is equivalent to battery. D- Inform the physician and complete a comprehensive assessment.
A (Both nurses must acknowledge making the medication error.)
A nurse inadvertently transcribes a client's medication order that was written as "Ampicillin 250 mg four times a day" as "Ampicillin 2500 mg four times a day." The nurse gives two doses as transcribed to the client. Another nurse gives one dose before the pharmacist questions the reorder of the medication. What should the two nurses do in this situation? A- Both nurses must acknowledge making the medication error. B- Tell the pharmacist that the wrong quantity of medication was sent to the unit. C- Adjust the medication administration record to reflect the correct dose only. D- Only the nurse who transcribed the order should be accountable for the error.
A (Ethical Conduct pg 98)
A nurse is acting inappropriately and has an odor of alcohol. This behavior breaches which of the following? A- Ethical conduct B- Beneficence C- Fidelity D- Autonomy
C (Filling out an occurrence report and notifying the health care provider pgs 96-97)
A nurse is administering evening medications and notices that a medication was omitted during the day shift. Which of the following statements demonstrates the principle of accountability? A- Administering the medication with the other evening medications B-Telling the client that the medication will be given the following morning C-Filling out an occurrence report and notifying the health care provider D-Documenting a narrative note in the chart about the occurrence
A (A patient who is homebound and needs skilled nursing care)
A nurse is arranging for home care for patients and reviews the Medicare reimbursement requirements. Which patient meets one of these requirements? A- A patient who is homebound and needs skilled nursing care B- A patient whose rehabilitation potential is not good C- A patient whose status is stabilized D- A patient who is not making progress in expected outcomes of care
A (Those directly involved in the client's care)
A nurse is caring for a client diagnosed with myocardial infarction. A person identifying himself as the client's friend asks the nurse for the client's records, but the nurse refuses. The nurse's refusal is based on the understanding that which of the following would be entitled to access of the client's records? A- Those directly involved in the client's care B- Any family member of the client C- Close friends of the client D- Healthcare professionals of the facility
A (Use direct quotes and specific language. pg 311)
A nurse is caring for a client who was raped at gunpoint. The client does not want any photos taken of her injuries. The client also does not want the police to be informed about the incident even though state laws require reporting life-threatening injuries. Which intervention should the nurse perform to document and report the findings of the case? A- Use direct quotes and specific language. B- Obtain photos to substantiate the client's case in a court of law. C- Document only descriptions of medical interventions taken. D- Respect the client's opinion and avoid informing the police.
B (keeping the bed in the lowest possible position)
A nurse is caring for a client with a history of falls. The nurse's first priority when caring for a client at risk for falls is: A- placing the call light on the bedside table. B- keeping the bed in the lowest possible position. C- instructing the client not to get out of bed without assistance. D- keeping the bedpan available so that the client doesn't have to get out of bed.
C (mouth care)
A nurse is caring for a client with acquired immunodeficiency syndrome (AIDS). To adhere to standard precautions, the nurse should wear gloves when: A- entering the room. B- taking a blood pressure. C- providing mouth care. D- delivering the client's food tray.
D (Changes in pulse rate Focus on Nursing Pharmacology, 7th ed pg 514)
A nurse is caring for an elderly patient who is to be administered isoproterenol. Which change monitored in the patient should the nurse report immediately to the primary health care provider? A- Changes in glucose level B- Changes in appetite C- Changes in temperature D- Changes in pulse rate
D (Shared decision making pg 103)
A nurse is caring for an older adult who has cancer and is experiencing complications requiring a revision of the plan of care. The nurse sits down with the client and the family and discusses their preferences while sharing her judgments based on her expertise. Which of the following types of health care decision making does this represent? A- Ethical decision making B- Paternalistic model C- Patient sovereignty model D- Shared decision making
A (incedent report)
A nurse is documenting a variance that has occurred during the shift, and this report will be used for quality improvement to identify high-risk patterns and potentially initiate in-service programs. This is an example of which type of report? A- Incident report. B- Nurse's shift report. C- Transfer report. D- Telemedicine report.
D (Wear gloves whenever entering the patient's room. pg 545)
A nurse is in charge of patient care for a patient who has MRSA. Which of the following is an accurate guideline for using Transmission-Based Precautions when caring for this patient? A- Place the patient in a private room that has monitored negative air pressure. B- Keep visitors 3 feet from the patient. C- Use respiratory protection when entering the room. D- Wear gloves whenever entering the patient's room.
D (progress notes)
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? A- Data base B- Problem list C- Plan of care D- Progress notes
D (Allowing volunteers to return neonates to the nursery)
A nurse is orienting a new nurse to the labor and delivery unit. Which action by the new nurse regarding a neonate's security requires intervention by the preceptor? A- Affixing matching identification bands to the parents and neonate at birth B- Positioning a rooming-in neonate's bassinet toward the center of room rather than near the door to the hallway C- Affixing a security bracelet that monitors movement to a neonate D- Allowing volunteers to return neonates to the nursery
B (tell herself to "remain calm" and remember that she was trained to perform this skill. pg 453)
A nurse is preparing to enter a client's room to perform wound care. The shift report revealed that this client has a tunneling wound in the sacral area that cannot be staged. The wound was also documented as having a foul odor. The nurse is nervous because she has not performed wound care on a complex wound in the past. Using effective intrapersonal communication, this nurse should: A- inform the client that several nurses will be needed to care for this wound. B- tell herself to "remain calm" and remember that she was trained to perform this skill. C- tell the nursing assistant to gather supplies and to prepare to cleanse and dress the wound. D- ask the charge nurse to change her assignment.
B ("Current professional research indicates that this technique is critical in preventing infections.")
A nurse is presenting an in-service on the topic of preventing urinary tract infections in young girls. The nurse talks about evidence-based practice and teaching young girls to wipe from front to back. Another nurse interrupts, stating, "I haven't seen any research to justify wiping front to back. It really makes no difference." What is the most appropriate response by the nurse presenting the in-service? A- "Our community newspaper just ran an article supporting this technique." B- "Current professional research indicates that this technique is critical in preventing infections." C- "Would you like to share the basis of your comments with the group?" D- "Could you share with the group your techniques for preventing infection?"
D ("It will allow for us to see the client and possibly increase client participation in care." )
A nurse is requesting to receive change of shift report at the bedside of each client. The nurse giving the report asks about the purpose of giving report at the bedside. Which response by the nurse receiving report is most appropriate? A- "It will let me see everything that has been done and things that need to be done." B- "It makes our client feel like we care, especially if we start the day off with a clean room." C- "It will give me a better sense of what my workload will be today." D- "It will allow for us to see the client and possibly increase client participation in care."
A ("I need to inform you that your behavior is within the definition of assault.")
A nurse manager overhears a nurse caring for a client with an IV make the following statement: "If you don't stop playing with your IV, I will tie your hand to the side rail." What is the most appropriate response by the nurse manager to address this situation? A-"I need to inform you that your behavior is within the definition of assault." B-"You need to think of a more creative way to stop the client from playing with the IV." C-"You will save the client from another IV insertion by restraining the client's hand." D-"I'm sure the client knows you were joking, but it was still inappropriate to say."
A ( Identifying risks and ensuring future safety for patients)
A nurse on a night shift entered an elderly patient's room during a scheduled check and discovered the patient down on the floor beside her bed after falling when trying to ambulate to the washroom. After assessing the patient and assisting her back to bed, the nurse has completed an incident report. What is the primary purpose of this particular type of documentation? A- Identifying risks and ensuring future safety for patients B- Gauging the nurse's professional performance over time C- Protecting the nurse and the hospital from litigation D- Following up the incident with other members of the care team
C (Hold the medication until speaking with NP)
A nurse practitioner (NP) orders an antibiotic to which the client is allergic. The nurse preparing the medication notices the allergy alert and contacts the NP by phone. The NP does not return the call and the first dose is due to be given. Which of the following actions by the nurse is the best solution to this situation? A- Ask if the client is really allergic to the medication. B- Give the medication as ordered by the NP. C- Hold the medication until speaking with the NP. D- Call the pharmacist and discuss a substitution for the medication.
B (Offer a face mask to the person with the cold and use this as an opportunity for further teaching.)
A nurse preparing to discharge a child with leukemia observes a family member who has a cold sharing a meal with the child. How should the nurse approach the situation? A- Instruct family members not share food because it isn't healthful. B- Offer a face mask to the person with the cold and use this as an opportunity for further teaching. C- Tell family members to be careful to avoid the child if they're sick. D- Post isolation signs on the child's door and carefully assess the health status of all visitors.
B C D (mL, g, kg )
A nurse should recognize what as a metric system unit? (Select all that apply.) A- teaspoon B- gram C- milliliter D- kilogram E- dram
A (Assist in decision-making based on the client's best interests pg 102)
A nurse volunteers to serve on the hospital ethics committee. Which of the following indicates that the nurse knows what the purpose of an ethics committee is? A- Assist in decision-making based on the client's best interests B- Decide the care for a client who is unable to voice their opinion C- Convince the family to choose a specific decision D- Present options about the type of care
A (Calling the client information desk to find out the room number of the family member)
A nurse was informed that a family member was involved in a car accident and transported to the emergency department in the same facility. What action by the nurse best demonstrates understanding of client privacy? A- Calling the client information desk to find out the room number of the family member B- Finding the emergency medical technicians that transported the family members about the injuries C- Asking the emergency department nurse for information on the family member D- Accessing the electronic medical record of the family member to find out extent of injury
D ("You will be OK if you follow standard precautions and use protective equipment to avoid contact with blood and body fluids when providing care.")
A nurse who is 6 months pregnant is assigned to a client with a diagnosis of HIV. The nurse tells the manager that she is unable to care for the client because it would be a risk to her baby. Which of the following is the most appropriate statement by the manager? A- "I will ask that you be transferred to another unit while you are pregnant so there is no risk to you or your baby." B- "There will be no problem with this assignment if you wear a mask and gloves while providing all direct client care." C- "You can decrease the risk of exposure to the virus if the client uses disposable plates and utensils when eating." D- "You will be OK if you follow standard precautions and use protective equipment to avoid contact with blood and body fluids when providing care."
D (Remain in the operating room suite until another nurse arrives to take that assignment.)
A nurse working in the operating room is assigned to the suite where therapeutic abortions are to be performed throughout the day. The nurse feels that participation in these procedures conflicts with personal religious beliefs. What should the nurse do after notifying the operating room supervisor? A- Continue working in the suite because that is the assignment for the shift. B- Complete a work refusal form and leave the surgical suite immediately. C- Contact the local right-to-life association and inform them of the procedures. D- Remain in the operating room suite until another nurse arrives to take that assignment.
B (Parents allowing a child to decide not to have an intravenous line inserted pgs 93-94)
A nursing faculty is discussing laissez-faire values with students. Which of the following is an example of those values? A- Teaching children right from wrong B- Parents allowing a child to decide not to have an intravenous line inserted C- Modeling healthy behaviors for teenagers D- Telling a child an injection will feel like a pinch
C (fidelity pg 159)
A nursing student is initiating a relationship with an assigned client. After meeting and spending approximately 20 minutes talking with the client, the student makes arrangements to visit again after lunch. After lunch, fellow classmates invite the student to go to the gym with them and a group of clients to play volleyball. The student starts to go with them but then remembers the promise to meet with the client. The student decides to forgo volleyball and talk with the client. The student's decision reflects which ethical principle? A- autonomy B- beneficence C- fidelity D- veracity
D (performing a preoperative surgical scrub for at least 3 to 5 minutes.)
A parent of a 9-year-old-child scheduled to have surgery expresses concern about the potential for postoperative infection. A nurse provides the parent with information about the measures taken to maintain surgical asepsis. Typical surgical asepsis involves: A- using sterile surgical scrubs. B- preoperative cleansing of jewelry worn by the surgical team. C- applying bandages to cover any wounds surgical team members have. D- performing a preoperative surgical scrub for at least 3 to 5 minutes.
B (Assess the patient's hemoglobin and platelets. lol-omg K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. pg 944-945)
A patient with AML has pale mucous membranes and bruises on his legs. What is the primary nursing intervention? A- Assess the patient's skin. B- Assess the patient's hemoglobin and platelets. C- Assess the patient's pulses and blood pressure. D- Check the patient's history.
B ("It is important for us to know how much and how often you drink to help prevent surgical complications." Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. pg 409)
A patient with a history of alcoholism and scheduled for an urgent surgery asks the nurse, "Why is everyone so concerned about how much I drink?" What is the best response by the nurse? A- "The amount of alcohol you drink will determine the amount of pain medication you will need postoperatively." B- "It is important for us to know how much and how often you drink to help prevent surgical complications." C- "It is a required screening question for all patients having surgery." D- "We can have counselors available after surgery; if it is determined you need help for your drinking."
A (Inform the physician that a written order is needed.)
A physician is in a hurry to leave the unit and tells the nurse to give a morphine 2 mg IV every 4 hours as needed for pain. What action by the nurse is appropriate? A- Inform the physician that a written order is needed. B- Read back the order and write the order in the client's record. C- Call the pharmacy to have the ordered entered in the electronic record. D- Add the new order to the medication administration record.
B (fainting)
A primiparous client who gave birth vaginally 8 hours ago desires to take a shower. The nurse anticipates remaining nearby the client to assess for which problem? A- fatigue B- fainting C- diuresis D- hygiene needs
D (justice pg 159)
A psychiatric nursing class is discussing current trends in mental health care. A student voices the opinion that there should be equitable access to mental health care and resources for those who live in rural areas, for those without health insurance, and for those with very little income. The student nurse's opinion most closely reflects which ethical principle? A- nonmaleficence B- paternalism C- veracity D- justice
A (Make sure that you have smoke detectors in your house and that they're in working order." pg 693 )
A school nurse is conducting a safety seminar with 6th-grade students. Which of the following teaching points is most important? A- "Make sure that you have smoke detectors in your house and that they're in working order." B- "If your clothes should catch on fire, go to an open area as quickly as possible." C- "Make sure that your family's microwave oven was made after 1999, otherwise it may be a fire risk." D- "A wood-burning fireplace is a major fire risk, and it shouldn't be used unless necessary."
A ( "It helps determine our staffing requirements.")
A student nurse asks why completing an acuity report is important. What is the best response by the nurse? A- "It helps determine our staffing requirements." B- "It determines if a client needs to be transferred to a different unit." C- "It?s the beginning step in determining the plan of care for the client." D- "It provides the pharmacy with the newest physician orders."
C (Drink coffee)
A teenage girl has been diagnosed with a urinary tract infection. The nurse recognizes the need for teaching when the teenager states: A- "I will not take bubble baths." B- "I will drink plenty of water." C- "I can drink coffee." D- "I can drink cranberry juice."
A (an institutional ethics committee pg 52)
A terminally ill 15-year-old tells the nurse that she wants to stop all treatments and go home despite her parents' directives to provide extraordinary means to keep their child alive. What is the best resource available to this nurse to help solve this dilemma? A- An institutional ethics committee B- The local Joint Commission on Accreditation of Healthcare Organizations (JCAHO) branch C- The American Association of Nurses D- A nurse mentor
A (have the right to copy their health records)
According to the Health Insurance Portability and Accountability Act (HIPAA) passed in 1996, patients: A- have the right to copy their health records. B- need to obtain legal representation to update their health records. C- can be punished for violating guidelines. D- are required to obtain health record information through their insurance company.
D (Use the call system to request assistance.)
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? A- Tell the client that his spouse is probably under a lot of stress. B- Instruct the client to stop pounding on the overbed table. C- Call facility security to control the situation. D- Use the call system to request assistance.
A (4days)
All people who have household or face-to-face contact with the patient diagnosed with smallpox after the fever begins should be vaccinated within what timeframe to prevent infection and death? A- 4 days B- 1 week C- 10 days D- 2 weeks
D (Explain the reason why information cannot be disclosed.)
An 18-year-old client is being treated for a sexually transmitted infection. The parent of the client comes to the clinic demanding information regarding the care provided since the child is covered on the parent's insurance. What response by the nurse is most appropriate? A- Verify the insurance coverage before giving information. B- Refer the parent to the physician providing care. C- Mediate a meeting between the parent and client. D- Explain the reason why information cannot be disclosed.
B (Use a nightlight in the bathroom.)
An alert and oriented elderly client is admitted to the hospital for treatment of cellulitis of the left shoulder after an arthroscopy. Which fall prevention strategy is most appropriate for this client? A- Keep all the lights on in the room at all times. B- Use a nightlight in the bathroom. C- Keep all four side rails up at all times. D- Place the client in a room with a camera monitor.
C (Deficient knowledge)
An elderly client is diagnosed with pulmonary tuberculosis. Upset and tearful, he asks the nurse how long he must be separated from his family. Which nursing diagnosis is most appropriate for this client? A- Anxiety B- Social isolation C- Deficient knowledge (disease process and treatment regimen) D- Impaired social interaction
C (private room)
An infant is being admitted to the hospital with dehydration secondary to viral gastroenteritis. Which room assignment is the most appropriate for this infant? A- a semiprivate room with an 8-year-old child who has had an appendectomy B- a semiprivate room with a 10-year-old child with a closed head injury C- a private room D- a semiprivate room with a 4-year-old child with leukemia
B (falls Focus on Nursing Pharmacology, 7th ed pg 1275)
An older adult who lives in a long-term care facility has recently begun taking losartan (Cozaar) for the treatment of hypertension. The nurse who provides care for this resident should recognize that this change in the resident's medication regimen make create a risk for: A- constipation. B- falls. C- xerostomia (dry mouth). D- depression.
A (Malignant hyperthermia Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. pg 435)
During a procedure, a client's temperature begins to rise rapidly. This is likely the result of which of the following complications? A- Malignant hyperthermia B- Hypothermia C- Infection D- Fluid volume excess
B (Calling the physician to request an oral pain medication)
For a hospitalized client, the physician orders morphine, 4 mg I.V., every 2 hours as needed for pain. However, the client refuses to take injections. Which nursing action is most appropriate? A- Administering the medication as ordered B- Calling the physician to request an oral pain medication C- Withholding the medication until the client understands its importance D- Explaining that no other medication can be given until the client receives the pain medication
A ("Wash your hands thoroughly, and let your breasts dry after each feeding." Maternity and Pediatric Nursing, 3rd ed pg 218)
How should the nurse counsel a postpartum client on how to prevent mastitis? A- "Wash your hands thoroughly, and let your breasts dry after each feeding." B- "If you notice that your breast is warm, hard, or red, stop feeding on that side and pump from that breast instead." C- "Be sure to keep your breasts covered when you are not feeding or pumping." D- "Sterilize your bottles and pump equipment after each use."
A B D E (Identification of neonates, infants, toddlers, children, and adolescents at all times / The facility's physical layout / Available resources to obtain and maintain the security plan / Methods for educating all staff regarding the security plan)
In developing a security plan for a pediatric unit, a nurse must consider which factors? Select all that apply. A- Identification of neonates, infants, toddlers, children, and adolescents at all times B- The facility's physical layout C- The climate in which the hospital is located D- Available resources to obtain and maintain the security plan E- Methods for educating all staff regarding the security plan
A (Integrity pg. 108)
In the delivery of care, the nurse acts in accordance with nursing standards and the code of ethics and reports a medication error that she has made. The nurse is most clearly demonstrating which of the following professional values? A- Integrity B- Altruism C-Social justice D-Human dignity
D (It provides quick access to abnormal findings.)
Nurses at a health care facility maintain client records using a method of documentation known as charting by exception. Which of the following is a benefit of this method of documentation? A- It documents assessments on separate forms. B- It records progress under problems, intervention, and evaluation. C- It provides and refers to client's problem by a number. D- It provides quick access to abnormal findings.
C ( to protect the safety of the public Psychiatric-Mental Health Nursing, 7th ed. Chapter 9: Legal and Ethical Issues, p. 159.)
Professional regulations and laws that govern nursing practice are in place for what reason? A- To limit the number of nurses in practice B- To ensure that practicing nurses have strong interpersonal skills C- To protect the safety of the public D- To ensure that enough new nurses are always available
C ("Neither intelligence nor personality normally decline because of aging." pgs. 425 - 426)
The charge nurse in an extended-care facility knows that the new nurse understands ageism when she says which of the following? A-"Most older adults are lonely." B-"Older adults have incontinence." C-"Neither intelligence nor personality normally decline because of aging." D-"Older adults don't mind how they look."
A (Subjective data should be included when documenting.)
The charge nurse is reviewing SOAP format documentation with a newly hired nurse. What information should the charge nurse discuss? A- Subjective data should be included when documenting. B- Objective data is what the client states about the problem. C- The plan includes interventions, evaluation, and response. D- Abnormal laboratory values are common items that are documented.
A (The decision should be made in light of consequences.)
The children of a 78-year-old female client with a recent diagnosis of early-stage Alzheimer's disease are attempting to convince their mother to move into an assisted living facility, a move to which the client is vehemently opposed. Both the client and her children have expressed to the nurse how they are entrenched in their position. Which of the following statements expresses a utilitarian approach to this dilemma? A-The decision should be made in light of consequences. B-The client's autonomy and independence are the priority considerations. C-Benefits and burdens should be evenly distributed between the children and the client. --D-The client has a right to self-determination that is the ultimate priority.
A (Ensuring any complementary therapies are safe when combined with his prescribed therapy.)
The children of an elderly male client who has suffered an ischemic stroke have informed the nurse that an herbalist will be coming to their father's bedside tomorrow to make recommendations for his care. Which of the following considerations should the nurse prioritize in light of the practitioner's planned visit? A- Ensuring any complementary therapies are safe when combined with his prescribed therapy. B- Identifying whether the family would prefer to pursue alternative or conventional treatment for their father. C- Ensuring that the care team does not impose their beliefs on the family or the complementary practitioner. D- Taking measures to prevent cultural conflict when the practitioner comers to the hospital.
C (Remove the entire sterile field from use. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed pg 426)
The circulating nurse is unsure if proper technique was followed when placing an object in the sterile field during a surgical procedure. What is the best action by the nurse? A- Remove the item from the sterile field. B- Mark the patient's chart for future review of infections. C- Remove the entire sterile field from use. D- Ask another nurse to review the technique used.
B (teaching the client about the disease and its treatment )
The client with tuberculosis is to be discharged home with nursing follow-up. Which aspect of nursing care will have the highest priority? A- offering the client emotional support B- teaching the client about the disease and its treatment C- coordinating various agency services D- assessing the client's environment for sanitation
A ("Has the child ever eaten shellfish before now?" Maternity and Pediatric Nursing, 3rd ed. Integrity/Integumentary Disorder, p. 1752.)
The nurse admits a 10-year-old who has just eaten lobster and has hives over much of the body. In collecting data regarding this child, which question should the nurse ask the caregiver first? A- "Has the child ever eaten shellfish before now?" B- "Is your child allergic to peanuts or other foods?" C- "Does anyone in your family have any food allergies?" D- "Have you ever given your child antihistamines?"
C (Administer oxygen pg 1404)
The nurse caring for a client on the medical-surgical unit collects the following data during head-to-toe assessment; mid-sternal chest pain, nausea, and pulse oximetry (SpO2) of 86%. The nurse would next implement which priority nursing intervention for this client who is experiencing these symptoms? A- Administer morphine B- Administer sublingual nitroglycerin C- Administer oxygen D- Notify health care provider
B D ( With the client's permission, the nurse explained the client's diagnosis to the client's spouse. The nurse removed the client from the emergency department waiting room into a private area to collect assessment data. pgs 118 and 119)
The nurse educator provides an educational session to the nursing staff on protection of a client's privacy. Which circumstances, identified by the staff, would indicate to the educator that the teaching was effective? Select all that apply. A- During a bed bath, the nurse exposed the client's upper torso while washing the client's face. B- With the client's permission, the nurse explained the client's diagnosis to the client's spouse. C- The nurse questioned the client about her social life even though it did not affect care planning. D- The nurse removed the client from the emergency department waiting room into a private area to collect assessment data. E- Because the facility is a teaching facility, the nurse allowed the nursing student to take the client's picture for his care plan.
D (Complete the hospital identification procedure with mother and infant.)
The nurse from the nursery is bringing a newborn to a mother's room. The nurse took care of the mother yesterday and knows the mother and baby well. The nurse should implement which action to ensure the safest transition of the infant to the mother? A- Assess whether the mother is able to ambulate to care for the infant. B- Ask the mother if there is anything else she needs for the care of her baby. C- Check the crib to determine if there are enough diapers and formula. D- Complete the hospital identification procedure with mother and infant.
A (Remind the nursing assistant about the client's right to privacy.)
The nurse hears a nursing assistant discussing a client's allergic reaction to a medication with another nursing assistant in the cafeteria. What is the highest priority nursing action? A- Remind the nursing assistant about the client's right to privacy. B- Report the nursing assistant to the nurse manager. C- Notify the client relations department about the breech of privacy. D- Document the nursing assistant?s conversation.
A (Contact the pharmacist immediately to check the order and the barcode label for accuracy.)
The nurse in the emergency department is administering a prescription for 20 mg intravenous furosemide, which is to be given immediately. The nurse scans the client's identification band and the medication barcode. The medication administration system does not verify that furosemide is prescribed for this client; however, the furosemide is prepared in the accurate unit dose for intravenous infusion. What should the nurse do next? A- Contact the pharmacist immediately to check the order and the barcode label for accuracy. B- Administer the medication now, knowing the medication is labeled and the client is identified. C- Report the problem to the information technology team to have the barcode system recalibrated. D- Ask another nurse to verify the medication and the client so the medication can be given now.
A (The client overdosed on pills 2 years earlier Psychiatric-Mental Health Nursing, 7th ed. pg 326)
The nurse is assessing a client who has presented to the emergency department in emotional distress. What client data represents the greatest risk for suicide? A- The client overdosed on pills 2 years earlier B- The client states, "Everything just seems really dark right now." C- The client has been treated with a variety of antidepressants over the years. D- The client sits silently after being asked several of the assessment questions
D (hopeless stage Maternity and Pediatric Nursing pg 305)
The nurse is aware of three different phases in the cycle of violence. Which is not one of those phases? A- honeymoon phase B- tension-building phase C- battering incident D- hopeless stage
D (has a known history of sexually transmitted disease.)
The nurse is caring for a client recently diagnosed with hepatitis C. In reviewing the client's history, what information will be most helpful as the nurse develops a teaching plan? The client: A- has a history of exercise-induced asthma. B- is a scientist and is frequently exposed to multiple chemicals. C- traveled to Central America recently and ate uncooked vegetables. D- has a known history of sexually transmitted disease.
D (The principle of autonomy pg 375)
The nurse is caring for a client who just learned of his terminal diagnosis. After the physician leaves, the nurse remains to answer further questions so that the client can make an informed decision about further treatment. By providing all available information, the nurse is promoting which ethical principle? A- The principle of justice B- The principle of nonmaleficence C- The principle of fidelity D- The principle of autonomy
A (Hinduism Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed pg 101)
The nurse is caring for a patient who states that his religion prohibits him from eating meat. The nurse inquires if the patient practices which of the following religions? A- Hinduism B- Seventh-day Adventism C- Judaism D- Islam
C (Assess the patient for a cough reflex. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed pg 487)
The nurse is caring for a patient with recurrent hemoptysis who has undergone a bronchoscopy. Immediately following the procedure, the nurse should complete which of the following? A- Ensure the patient remains moderately sedated to decrease anxiety. B- Offer the patient ice chips. C- Assess the patient for a cough reflex. D- Instruct the patient that bed rest must be maintained for 2 hours.
A (Maintain a tidy environment around the child. )
The nurse is caring for a toddler who is visually impaired. What is the most important action for the nurse to take to ensure the safety of the child? A- Maintain a tidy environment around the child. B- Request that the parents stay with the child. C- Use visual aids to facilitate communication. D- Avoid startling the child by limiting excess noise.
C (Patient's verbalization of feelings of loss Textbook of Medical-Surgical Nursing, 13th ed pg 90)
The nurse is developing a plan of care to assist a patient in coping with a right leg-below-the-knee amputation (BKA). Which of the following interventions should the nurse include? A- Subjective appraisal of event by patient B- Establishment of nurse-determined goals C- Patient's verbalization of feelings of loss D- Discouragement of complementary medicine
C (2130)
The nurse is documenting an assessment that was completed at 9:30 pm. The facility uses military time for documentation. What entry should the nurse make for the time care was given? A- 0930 B- 930 pm C- 2130 D- 1930
B (The patient placed the load close to the body. K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. pg 1134)
The nurse is educating a patient with lower back pain on proper lifting techniques. The nurse would document what behavior as evidence the education was effective? A- The patient reached over head with arms fully extended. B- The patient placed the load close to the body. C- The patient used a narrow base of support. D- The patient bent at the hips and tightened the abdominal muscles.
C (25 degrees Textbook of Medical-Surgical Nursing, 13th ed pg 157)
The nurse is evaluating whether or not a patient's walker is the right height for the patient. While the patient's hands are on the hand grip, the nurse assesses the patient's elbows. The nurse determines that the walker is at the right height when the patient's elbows are in which of the following positions? A- 0 degree flexion B- 15 degree flexion C- 25 degree flexion D- 45 degree flexion
B (The nurse meets with nurses or other health care professionals to discuss some aspect of patient care.)
The nurse is finding it difficult to plan and implement care for a patient and decides to have a nursing care conference. What action would the nurse take to facilitate this process? A- The nurse consults with someone in order to exchange ideas or seek information, advice, or instructions. B- The nurse meets with nurses or other health care professionals to discuss some aspect of patient care. C- The nurse, along with other nurses, visits patients with similar problems individually at each patient's bedside in order to plan nursing care. D- The nurse sends or directs someone to take action in a specific nursing care problem.
B (Screening for HIV Maternity and Pediatric Nursing, 3rd ed pg 1859)
The nurse is instructing a group of women of childbearing age about human immunodeficiency virus (HIV) during pregnancy. What would be a priority recommendation in this setting? A- Screening for sexually transmitted infections (STIs) B- Screening for HIV C- Prophylactic treatment for HIV D- Proper nutrition
C (Valuing pgs 95-96)
The nurse is managing the care of a terminally ill client whose spouse insists that all measures be continued. The nurse speaks to the spouse about obtaining a hospice consult. This is an example of "ethical" what? A- Accountability B- Sensibility C- Valuing D- Discernment
A B C (Discussion of pertinent information, The client's agreement to the plan of care, Freedom from coercion)
The nurse is obtaining informed consent from a client. To adhere to ethical and legal standards, the nurse must ensure that the informed consent consists of which of the following? Select all that apply. A- Discussion of pertinent information B- The client's agreement to the plan of care C- Freedom from coercion D- Caregiver preference and opinion E- Verification from next of kin
D (Contact the health care provider (HCP) who prescribed the medication.)
The nurse is planning care for a client with severe postoperative pain. There is a prescription for morphine written as "10 mg MSO4" on the medical record. What should the nurse do first? A- Obtain an intravenous infusion system. B- Prepare the medication for administration. C- Contact the pharmacy department. D- Contact the health care provider (HCP) who prescribed the medication.
D (The use of a condom is advised for sexual intercourse.)
The nurse is preparing a community education program about preventing hepatitis B infection. Which information should be incorporated into the teaching plan? A- Hepatitis B is relatively uncommon among college students. B- Frequent ingestion of alcohol can predispose an individual to development of hepatitis B. C- Good personal hygiene habits are most effective at preventing the spread of hepatitis B. D- The use of a condom is advised for sexual intercourse.
A (Genital herpes)
The nurse is presenting a community lecture about STIs. She emphasizes that some STIs are easily cured with early and adequate treatment. Which of the following is not among these easily treated diseases? A- Genital herpes B- Chlamydia C- Gonorrhea D- Syphilis
D ("I will respect your wishes and keep your information confidential. I do wish you would reconsider though") (Page 356)
The nurse is seeing a client who is going to be married in a month. This client has a history of Huntington disease in her family. The genetic testing has come back, and the client has just been told she carries the gene for Huntington disease and will develop the disease when she gets older. The client asks the nurse if this information is confidential and if it will remain that way. The nurse explains to the client that her family should be told and so should her fiancé. The client forcefully tells the nurse "no." She is not going to tell either her family or her fiancé. What is the nurse's best response? A-"I am ethically bound to tell your family and your fiancé." B-"Your information will remain confidential until the geneticist reviews everything. Then he will have to tell your family." C-"Have you thought about what this disease will do to the person you are going to marry and any children you may have?" D-"I will respect your wishes and keep your information confidential. I do wish you would reconsider though"
A ("PPE should be used when you risk exposure to blood or bodily fluids.")
The nurse manager of a surgical unit observes a nurse providing colostomy care to a client without using any personal protective equipment (PPE). What is the most appropriate response by the nurse manager in relation to the use of PPE? A- "PPE should be used when you risk exposure to blood or bodily fluids." B- "If you're not using PPE, you need to be careful not to touch any of the drainage." C- "You should be aware that PPE is used when caring for any client in the hospital." D- "In the future, have the physician write an order for PPE for clients with colostomies."
A (Safety pg 62)
The nurse performs an assessment of the client and the family to have a better understanding of client and family needs. Which of the following is an individual need? A- Safety B- Education C- Socialization D- Political
B (Intradermal Textbook of Medical-Surgical Nursing, 13th ed pg 1033)
The nurse working in an allergy clinic is preparing to administer skin testing to a patient. Which of the following routes is the safest for the nurse to use to administer the solution? A- Intramuscular B- Intradermal C- Subcutaneous D- Intravenous
A (Incentivizing health care workers to utilize hand hygiene pg 540)
The nurse working with the hospital's infection control team is attempting to decrease the transmission of health care-associated pathogens. Which of the following will be most effective? A- Incentivizing health care workers to utilize hand hygiene B- Revising the facility's infection control protocols C- Encouraging visitors to adhere to isolation precautions D- Limiting visitors to family members over the age of 18
A ("You are free to move onto the stretcher without assistance, but I will supervise for your safety." pgs 1071-1072)
The nursing assistant is preparing to help the patient make a lateral transfer from the bed to a stretcher. The patient informs the nurse that he is able to move onto the stretcher without her help. What is the nurse's best response? A- "You are free to move onto the stretcher without assistance, but I will supervise for your safety." B- "I can only allow you to transfer without assistance based upon a physician's order, so I will now help you." C- "You cannot transfer without my help because you need a friction-reducing device to prevent harm to your skin." D- "That is fine if you want to transfer without my help, so ring your call bell after you have transferred and are ready to go."
A (Invasion of privacy pgs 118-119)
The nursing student talks with the student's family about an AIDS client from the clinical experience. Which tort has the student committed? A-Invasion of privacy B-Fraud C-Assault D-Slander
A ("When the vesicles and pustules have crusted." )
The parent of a child diagnosed with chickenpox asks when the child can go to play group again. What is the best response by the nurse? A- "When the vesicles and pustules have crusted." B- "Two days after the rash appears." C- "When the fever disappears." D- "When the rash is changing into vesicles, and pustules appear."
C (communication)
What ensures continuity of care? A- Reassessment B- Critical thinking C- Communication D- Integration
C (penicillin Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. pg 1036)
What is the most common cause of anaphylaxis? A- Opioids B-NSAIDs C- Penicillin D- Radiocontrast agent
C (Providing prompt recognition of the potential or actual threat to safety pgs 704-705)
What is the primary role of the nurse in the care of clients that experience domestic violence? A- Calling the police B- Identifying health education and counseling measures for the family C- Providing prompt recognition of the potential or actual threat to safety D- Serving as a witness in court
A (Joint Commission on Accreditation of Healthcare Organizations)
What organization audits charts regularly? A- Joint Commission on Accreditation of Healthcare Organizations B- National League for Nursing C- American Nurses Association D- Sigma Theta Tau International
B (stays with the patient pg 97)
What would be an example of the nurse practicing fidelity? The nurse: A- Regulates visitors B- Stays with the patient during his or her death as promised C- Withholds information as requested D- Provides continuity of care
C (The patient should be placed in a private room when possible. )
When a hospitalized patient is in contact precautions, which of the following responses is necessary? A- The patient's door should be closed. B- Masks are worn when caring for the patient. C- The patient should be placed in a private room when possible. D- The patient should be in a room with negative air pressure.
C (Rinse her eyes with water, report the incident, and go to Employee Health.)
When a nurse removes an I.V. from an client with acquired immunodeficiency syndrome (AIDS), blood splashes into her eyes. What should the nurse do next? A- Rinse her eyes with water, record the incident on the client's chart, and see Employee Health. B- Wash her hands, complete an incident report, and see a physician as soon as possible. C- Rinse her eyes with water, report the incident, and go to Employee Health. D- Rinse her eyes, contact Employee Health and document their findings.
A (limiting abbreviations to those approved for use by the institution. )
When documenting the care of a patient, the nurse is aware of the need to use abbreviations conscientiously and safely. This includes: A- limiting abbreviations to those approved for use by the institution. B- using only abbreviations whose meaning is self-evident to an educated health professional. C- ensuring that abbreviations are understandable to patients who may seek access to their health records. D- using only those abbreviations that are defined in full at another location in the patient's chart.
B (SOAP)
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? A- Focus charting B- SOAP charting C- PIE charting D- Narrative charting
B (educating the public on common sources of lead)
When teaching parent workshops about measures to prevent lead poisoning in children, which preventive measure should the nurse include as the most effective? A- condemning of old housing developments B- educating the public on common sources of lead C- educating the public on the importance of good nutrition D- keeping pregnant women out of old homes that are being remodeled
A ( Nutritional consult)
Which consultation or referral by the nurse is most appropriate for a client who is obese and demonstrates poor wound healing? A- Nutritional consult B- Social services consult C- Pulmonologist referral D- Podiatry referral
A (nonmaleficence pg 159)
Which ethical principle focuses on the duty to do no harm? A- Nonmaleficence B- Autonomy C- Justice D- Beneficence
A (Justice pg 159)
Which ethical principles become an issue in mental health when a segment of a population does not have access to health care? A- justice B- nonmaleficence C- fidelity D- veracity
A (The nurse provides information over the phone to the patient's family member who lives in a neighboring state.)
Which example may illustrate a breach of confidentiality and security of patient information? A- The nurse provides information over the phone to the patient's family member who lives in a neighboring state. B- The nurse provides information to a professional caregiver involved in the care of the patient. C- The nurse informs a colleague that she should not be discussing patient information in the hospital cafeteria. D- The nurse accesses patient information on the computer at the nurse's station then logs off before answering a patient's call bell.
C (Ephedra Focus on Nursing Pharmacology, 7th ed pg 505)
Which herbs has been removed from most weight-loss medications due to potential legal liability? A- Gingko B- Ginseng C- Ephedra D- Rose hips
D ("Take rest periods during the day.")
Which instruction should a nurse include in an injury-prevention plan for a pregnant client? A- "Wear your seat belt across your tummy." B- "Position the steering wheel toward your abdomen." C- "It's OK to start learning a new sport during your pregnancy." D- "Take rest periods during the day."
C (Arm restraints while asleep )
Which item in the care plan for a toddler with a seizure disorder should a nurse revise? A- Padded side rails B- Oxygen mask and bag system at bedside C- Arm restraints while asleep D- Cardiorespiratory monitoring
A (A patient has asked a nurse if he can read the documentation that his physician wrote in his chart)
Which of the following clinical situations is addressed by the provisions of the Health Insurance Portability and Accountability Act (HIPAA)? A- A patient has asked a nurse if he can read the documentation that his physician wrote in his chart. B- A patient wishes to appeal her insurance company's refusal to reimburse for a diagnostic test. C- A patient has asked for a second opinion regarding treatment options for her diagnosis of ovarian cancer. D- A patient who resides in Indiana has required hospitalization during a vacation in Hawaii.
A (A patient has asked a nurse if he can read the documentation that his physician wrote in his chart. pg 343)
Which of the following clinical situations is addressed by the provisions of the Health Insurance Portability and Accountability Act (HIPAA)? A- A patient has asked a nurse if he can read the documentation that his physician wrote in his chart. B- A patient wishes to appeal her insurance company's refusal to reimburse for a diagnostic test. C- A patient has asked for a second opinion regarding treatment options for her diagnosis of ovarian cancer. D- A patient who resides in Indiana has required hospitalization during a vacation in Hawaii.
D (Question the client regarding the type and intensity of symptoms to provide a baseline evaluation. Focus on Nursing Pharmacology, 7th ed Chapt. 58)
Which of the following is an important assessment for the nurse to make before administering a laxative? A- Once a medication is ordered by the physician, it is unnecessary to make any additional assessments before administering the medication. B- An abdominal circumference measurement is an important assessment for the nurse to make in order to evaluate medication effectiveness. C- It is imperative to ask clients whether they are expecting any visitors because the effects of the medication may hinder visitation. D- Question the client regarding the type and intensity of symptoms to provide a baseline evaluation.
A (gloves pg 572)
Which of the following pieces of personal protective equipment should be removed first? A- Gloves B- Respirator C- Gown D- Goggles
A (A nurse performs handwashing each time she removes a pair of gloves. pg 542)
Which of the following practices is a correct application of infection control practices? A- A nurse performs handwashing each time she removes a pair of gloves. B- A nurse dons a pair of gloves prior to any patient contact. C- A nurse uses an alcohol-based handrub each time that his hands are visibly soiled. D- A nurse ensures that she rinses her hands thoroughly after the application of an alcohol-based handrub.
B (Toddlers Maternity and Pediatric Nursing, 3rd ed pg 1,419)
Which of these age groups has the highest actual rate of death from drowning? A- Infants B- Toddlers C- Preschool children D- School-aged children
A (Leave the catheter in place as a marker and attempt to insert a new sterile catheter directly above the misplaced catheter. pg 1318)
You are attempting to insert a urinary catheter into a female patient's bladder and realize the catheter has been inserted into the vagina. Which of the following actions is most appropriate? A- Leave the catheter in place as a marker and attempt to insert a new sterile catheter directly above the misplaced catheter. B- Immediately remove the catheter from the vagina, contact the primary care provider and anticipate an order for prophylactic antibiotics. C- Ask the patient to bear down until the catheter is expelled. D- Remove the catheter from the vagina and attempt to insert it into the bladder.
