practice exam

A nurse-manager is preparing for annual staff performance evaluations. Which action is most appropriate for the nurse-manager to include?

Provide feedback on strengths as well as areas for improvement while formulating a plan to improve. An effective performance evaluation recognizes strengths, identifies areas for improvement, and clarifies performance expectations. Recognizing strengths increases employee morale, so limiting the evaluation to areas of improvement and goals may leave an employee feeling defeated. The nurse-manager should conduct performance evaluations privately, not in front of others. The nurse-manager should document in writing all components of a performance evaluation. Although input from staff members can be useful in preparing performance evaluations, asking other nurses to conduct performance evaluations is inappropriate. The nurse-manager is responsible for the performance of the staff.

A client has mitral stenosis and is a prospective valve recipient. The nurse is instructing the client about health maintenance prior to surgery. Inability to follow which of the following prescription would pose the greatest health hazard to this client at this time?

medication therapy Preoperatively, anticoagulants may be prescribed for the client with advanced valvular heart disease to prevent emboli. Postoperatively, all clients with mechanical valves and some clients with bioprosthesis are maintained indefinitely on anticoagulant therapy. Adhering strictly to a dosage schedule and observing specific precautions are necessary to prevent hemorrhage or thromboembolism. Some clients are maintained on lifelong antibiotic prophylaxis to prevent recurrence of rheumatic fever. Episodic prophylaxis is required to prevent infective endocarditis after dental procedures or upper respiratory, gastrointestinal, or genitourinary tract surgery. Diet modification, activity restrictions, and dental care are important; however, they do not have as much significance postoperatively as medication therapy does.

A client admitted with bacterial pneumonia develops a fever. Which health care provider order should the nurse implement first?

Draw blood cultures from two sites. Blood cultures should be obtained before antibiotic administration in order to avoid altering the culture results—this is the priority. Both acetaminophen administration and portable chest x-ray can wait until the blood cultures are obtained and the antibiotics are started.

A 20-year-old client with paranoid schizophrenia is in the 4th day of hospitalization. The client's parents visit and state to the nurse, "What did we do wrong? What caused this awful thing to happen?" Which explanation by the nurse is most accurate and therapeutic?

"You did not cause schizophrenia by doing something wrong. Schizophrenia is a brain disease." The nurse is sensitive to the parents' feeling of guilt and lack of knowledge about the etiologies of schizophrenia. The nurse reassures the parents that they are not to blame for their child's illness. The nurse then begins to educate them by explaining the biological theories of the disease in a simple, straightforward manner.Telling the parents that the cause of schizophrenia is unknown ignores the their concerns and diminishes trust in the nurse by not offering accurate information about the disorder.Stating that schizophrenia is genetic implies that the parents are to blame and offers an incomplete explanation of the disorder.Telling the parents schizophrenia is related to drug and alcohol use makes an inappropriate suggestion that the client's behavior caused the disease. Remediation:

A mother of a hospitalized infant appears anxious and displays anger with the staff. Which response by the nurse is most appropriate?

"You seem upset. Having your child hospitalized must be difficult." Acknowledging the mother's feelings and recognizing that it's difficult to cope with a hospitalized child allows the mother to express her feelings. Asking the mother if she wants to talk about her concerns only allows a yes or no response; it does not provide an opportunity for the mother to share or vent. The mother may want to speak to a chaplain, but asking does not address the issue of being fearful and angry. Additionally, that action involves the nurse delegating the problem to someone else without seeking out the root of the problem. Saying "your baby will be better soon" only gives false reassurance and does not address the mother's immediate needs.

A nurse is required to irrigate a client's nasogastric tube, a procedure the nurse has not performed before. What is the most appropriate action by the nurse?

Contact the nurse educator for an in-service and support in performing the skill. The nurse has a responsibility to recognize limitations and to seek assistance when necessary. Because the nurse has not performed this skill previously, the nurse educator is the appropriate person to provide in-service and support so the client receives safe and competent care. The other options are incorrect because they do not demonstrate expected behavior for a nurse who has identified a gap in learning or expertise.

A nurse is teaching a client with osteomalacia how to take ordered vitamin D supplements. Which adverse effects should the nurse instruct the client to report?

GI upset and metallic taste The nurse should instruct the client to report GI upset and metallic taste because these are early signs and symptoms of vitamin D toxicity. Such toxicity also may cause headache, weakness, renal insufficiency, renal calculi, hypertension, arrhythmias, muscle pain, and conjunctivitis. Dry skin, hair loss, and inflamed mucous membranes suggest vitamin A toxicity. Flushing and orthostatic hypotension (effects of vasodilation) may result from nicotinic acid and nicotinamide supplements, which are used to correct niacin deficiency. Sensory neuropathy and difficulty maintaining balance suggest pyridoxine toxicity.

A registered nurse caring for a client with generalized anxiety disorder identifies a nursing diagnosis of Anxiety. A short-term goal is established as follows: "The client will identify physical, emotional, and behavioral responses to anxiety." Which nursing interventions will help the client achieve this goal? Select all that apply.

Observe the client for overt signs of anxiety. Help the client connect anxiety with uncomfortable physical, emotional, or behavioral responses. Introduce the client to new strategies for coping with anxiety, such as relaxation techniques and exercise. The nurse should observe the client for overt signs of anxiety to assess anxiety and establish care priorities. The nurse should also help the client connect anxiety with uncomfortable physical, emotional, or behavioral responses. To modify the automatic response to stress, the client needs to connect the anxiety experience with the unpleasant symptoms. The nurse should also introduce new coping strategies, such as relaxation techniques and exercise, which can enable the client to take personal responsibility for making changes. The nurse should work with the client to identify sources of stress. The nurse should advise the client to avoid using caffeine, nicotine, and alcohol to cope with anxiety. Nicotine and caffeine are stimulants; alcohol acts as a depressant but, over time, requires increased use to achieve the desired effect, which may lead to alcohol abuse. The nurse should encourage the client to use a journal to record feelings, behaviors, stressful events, and coping strategies used to address anxiety. Documentation may help the client become aware of anxiety and the ways in which it affects overall functioning.

The nurse is planning care for an obese female client. The client experiences dribbling urine when she coughs, sneezes, and changes positions. The nurse should instruct the client to promote urinary health by encouraging which actions? Select all that apply.

Participate in a weight loss program. Perform muscle-strengthening exercises (Kegel exercises). Use adult diapers as needed. The goal is to promote health in this client who has stress incontinence. Participating in a weight loss program or support group may decrease the intra-abdominal pressure contributing to the incontinence. Participating in swimming, bicycling, or low-impact exercise is beneficial to weight loss. Kegel exercises are helpful in developing muscle control. Wearing adult diapers will absorb leaked urine and prevent excoriation. Clients with urinary stress incontinence are encouraged to avoid drinks with caffeine and alcohol. Perineal care is essential to prevent skin breakdown, but the client does not require a Foley or straight catheter at this time.

A client was admitted to the behavioral health unit with a diagnosis of severe depression. The client was started on bupropion. Forty-eight hours after initiating the drug therapy, the client has recovered from depression, is laughing, singing, and dancing in the hallway and in the sitting room. How should the nurse interpret this behavior?

The client is most likely bipolar rather than depressed, and the healthcare provider should be notified of the behavior. This behavior is often seen in clients who are bipolar when placed on an antidepressant. A mood stabilizer, such as lithium or lamotrigine, is needed to balance emotional states. The medication has affected the depression, but the client is bipolar and needs a mood stabilizer instead. These side effects occur in a person who is bipolar rather than someone suffering from depression.

Twenty-four hours after a bone marrow aspiration, the nurse is evaluating the client's postprocedure status. Which outcome is expected?

There is no bleeding at the aspiration site. After a bone marrow aspiration, the puncture site should be checked every 10 to 15 minutes for bleeding. For a short period after the procedure, bed rest may be prescribed. Signs of infection, such as redness and swelling, are not anticipated at the aspiration site. A mild analgesic may be prescribed for pain, but if the client has pain longer than 24 hours, the nurse should assess the client for internal bleeding or increased pressure at the puncture site which may be the cause of the pain and should consult the health care provider (HCP).

An adult client has bacterial conjunctivitis. What should the nurse teach the client to do? Select all that apply.

Use warm saline soaks four times per day to remove crusting. Apply topical antibiotic without touching the tip of the tube to the eye. Wash the hands after touching the eyes. Avoid touching the eyes. The client with conjunctivitis can use warm soaks to remove crusting. The nurse should teach the client to dispose of the soaks by wrapping them in a separate bag to avoid spreading bacteria. Topical antibiotics are used to treat the infection. The client should avoid contaminating the tip of the medication dispenser. Bacterial conjunctivitis requires containing the spread of the infection. The client should avoid touching the eyes. If the client does touch the eyes, the client should wash the hands after touching the eyes. The client does not need to be isolated.

A client who is likely to become a candidate for dialysis treatment tells the nurse, "I must talk to my family." Recognizing the cultural preferences and beliefs of the client, what question must the nurse first answer before disclosing health care information?

Who is responsible for making client treatment decisions? In some cultures, the family takes the responsibility for health care decisions and for protecting the client from experiencing the burden of knowing about serious health care problems. The nurse must determine who is responsible for making the health care decisions in order to disclose information to that person or group of people. The number of family members involved is not as important as the nurse knowing who the decision makers are. The appropriate information is all known treatment options. Later the discussion of the family's role in sharing the health information and treatment decision-making process with the client needs to occur.

A client visits the mental health clinic and tells the nurse that she is lethargic, experiences pain in her back, cannot concentrate, and is depressed. The nurse observes patches of hair loss on the client's scalp. Which referral should the nurse make first?

a health care provider The client is exhibiting signs of hypothyroidism, which includes hair loss, pain, fatigue, and increased sensitivity to cold. Hypothyroidism may be impacting the client's mood, ability to concentrate, physical sensations, and energy levels. Resolving potential biological causes of her symptoms takes priority over rehabilitation strategies or psychological approaches.

An infant is brought to the emergency department. The infant is limp and has central cyanosis, a heart rate of 60 beats/minute, and a respiratory rate of 12 breaths/minute. The parents state that they have an advance directive for their infant, who has a terminal illness. A nurse's initial action should be to:

ask to see a copy of the advance directive. To have information about how to proceed, the nurse must evaluate the advance directive. Until the nurse evaluates the legitimacy and content of the advance directive, it's inappropriate to administer oxygen or provide palliative care. The nurse should ask to see the advanced directive before proceeding with care; contacting the nursing supervisor isn't the most appropriate initial response.

A client with arterial insufficiency undergoes below-knee amputation of the right leg. Which action should the nurse include in the postoperative care plan?

elevating the stump for the first 24 hours Stump elevation for the first 24 hours after surgery helps reduce edema and pain by increasing venous return and decreasing venous pooling at the distal portion of the extremity. Bed rest isn't indicated and could predispose the client to complications of immobility. Heat application would be inappropriate because it promotes vasodilation, which may cause hemorrhage and increase pain. The initial pressure dressing usually remains in place for 48 to 72 hours after surgery.

When developing a series of parent classes on fetal development, the nurse should include which feature as being developed by the end of the third month (9 to 12 weeks)?

external genitalia Although sex is not easily discerned at 9 to 12 weeks, external genitalia are developed at this period of fetal development. Myelinization of the nerves begins at about 20 weeks' gestation. Brown fat stores develop at approximately 21 to 24 weeks. Air ducts and alveoli develop later in the gestational period, at approximately 25 to 28 weeks.

The nurse would expect a client with a hiatal hernia to report that the symptoms worsen when the client is:

lying down. Hiatal hernia produces symptoms of esophageal reflux as the sphincter slides up into the negative-pressure environment of the thorax. The symptoms typically occur when the client is in a recumbent position.

A client received propofol as the induction and maintenance agent for general anesthesia. What outcome of this drug should the nurse expect?

minimal nausea and vomiting Propofol, a nonbarbiturate anesthetic, causes less nausea and vomiting than other induction agents because of a direct antiemetic action. It does not cause hypertension or skeletal muscle movement, and it does not act slowly.

A client with chronic bowel inflammation reports abdominal cramping and diarrhea for the past 4 days. The nurse would anticipate which test based on the client's concerns?

occult blood and organisms Occult blood in the stool could indicate active bleeding; the stool should also be examined for microorganisms to detect early infections that could easily become systemic by spreading through the damaged mucosa. Culture and sensitivity is reflective for urine and potential infection. Parasite testing is not correct because this client has a chronic bowel problem. Fat and undigested food has no relation to the current problem.

Following an incisional approach to an abdominal hysterectomy, the nurse should assess the client for:

thrombophlebitis. Clients who have had major pelvic surgery are especially at risk for developing thrombophlebitis postoperatively. Extensive manipulation of the pelvic organs and removal of lymph glands can lead to edema, stasis, and circulatory congestion.Ascites, peripheral edema, and hypostatic pneumonia are not complications that would be specifically anticipated after pelvic surgery.