PrepU Passpoint Basic Physical Care
The nurse is gathering data from a group of clients during clinic visits. Which client does the nurse determine is at the greatest risk for the development of type 2 diabetes?
48-year old client that had gestational diabetes with her second child Explanation: One of the risk factors for the development of type 2 diabetes is having gestational diabetes or giving birth to a child over 9 lb (4 kg). Exercising regularly is not a risk factor and can be a preventative measure for healthy living. Regular physical activity lowers the risk factor significantly. Having a myocardial infarction does not increase the risk factors for the development of type 2 diabetes. A hemoglobin AIC of 4.8 is within normal range. A range of 5.7-6.4 indicates the client may be in a prediabetic state.
The licensed practical nurse removes a client's nasogastric (NG) tube according to the physician's order. The nurse should watch for which complication after removing an NG tube?
Abdominal distention Explanation: After removing an NG tube, the nurse should assess the client for such complications as abdominal distention, nausea, and vomiting. Flatulence indicates that gas from the small intestine is passing through the colon. Constipation isn't a complication associated with removing an NG tube. Bowel sounds occur when peristalsis is present, which indicates that the GI tract is functioning.
To collect a clean-catch midstream urine specimen from a female client, the nurse instructs her to clean the area at the external urinary meatus with an antiseptic. How should the client do this?
By swabbing the labia minora from front to back Explanation: The client should swab the labia minora from front to back, using one swab for each wipe, because this technique cleans from the area of least contamination to the area of greatest contamination. The labia minora shouldn't be cleaned from back to front because this increases the risk of contamination. The labia majora should be cleaned with soap and water from front to back — not back to front. Before swabbing the labia minora with an antiseptic, the client should wash the perineal area with soap and water.
A client, age 43, has no family history of breast cancer or other risk factors for this disease. The nurse should instruct her to have a mammogram how often?
Once per year Explanation: The American Cancer Society (Canadian Cancer Society) recommends having a mammogram every year starting at age 40. Women at increased risk (those with a family history, genetic tendency, or history of breast cancer) should talk to their physicians about beginning screening earlier than age 40.
A client was admitted to the coronary care unit (CCU) two days ago with an acute myocardial infarction. Which action would breach client confidentiality?
The emergency department (ED) nurse calls up the latest electrocardiogram results to check the client's progress. Explanation: The ED nurse is no longer directly involved with the client's care, and has no legal right to information about the client's present condition. Anyone directly involved in their care (such as the telemetry nurse and the on-call provider) has the right to information about the client's condition. Because this client asked the nurse to update their spouse, doing so doesn't breach confidentiality.
A client has been admitted to the hospital with heart failure. On entering the room, the nurse notices that the client is having difficulty breathing. Which position would be most appropriate to help the client's breathing?
high Fowler position Explanation: High Fowler's position facilitates adequate lung expansion by helping gravity to pull the organs away from the chest and by decreasing venous return to the heart. Placing the client flat in bed with the feet elevated, in semi-Fowler's position, or on the side promotes venous return to an already overloaded heart and restricts lung expansion.
When inserting a urinary catheter on a male client, which action should the nurse take to facilitate the insertion?
instruct the client to breathe deeply Explanation: Breathing deeply relaxes the urinary sphincter, making urinary catheter insertion easier. Initiating a stream of urine (urinating) interferes with catheter insertion. Moving the client to the side of the bed or holding the penis does not ease insertion, and doing so may contaminate the sterile field.
A nurse must obtain the blood pressure of a client in airborne isolation. Which method is best to prevent transmission of infection to other clients by the equipment?
leave the equipment in the room for use only with that client Explanation: Leaving equipment in the room for use only with that client is appropriate to avoid organism transmission by inanimate objects. Disposing of equipment after each use prevents the transmission of organisms but isn't cost-effective. Wearing gloves protects the nurse, not other clients. Using equipment for other clients spreads infectious organisms among clients.
When assessing if a procedural risk to a client is justified, the ethical principle underlying the dilemma is known as what?
nonmaleficence Explanation: Nonmaleficence is the principle of creating no harm. It refers to preventing or minimizing harm to an individual. The other options do not represent the situation presented in the question.
A nurse is caring for a confused, older adult client. Which action should the nurse prioritize for this client's care?
promoting safety by protecting from injury Explanation: The nurse's first responsibility is always to protect the client from injury. Determining the cause of the confusion and protecting the older adult client's neurologic status from deterioration are the primary care provider's responsibilities. Encouraging the client to participate in ADLs is a nursing intervention, but it is not the most important consideration.
The nurse is caring for a client after abdominal surgery. When reinforcing education for coughing and deep breathing, what should the nurse include?
splint the incision, take a deep breath, and then cough Explanation: Splinting the incision with a pillow will protect the incision while the client coughs. Taking a deep breath will help open the alveoli, which promotes oxygen exchange and prevents atelectasis. Coughing and deep-breathing exercises are best accomplished in a sitting or semi-sitting position. Expectoration of secretions will be facilitated in a sitting position, as will splinting and taking deep breaths.
A client asks a nurse if a large enteric-coated tablet can be cut in half. What is the best response by the nurse?
"Cutting the medication in half alters the medication's absorption." Explanation: Dividing an enteric-coated tablet destroys the enteric barrier, allowing stomach secretions to act on the medication and alter its absorption.
During a meal, a client with hepatitis B dislodges her intravenous line and bleeds on the surface of the over-the-bed table. Which item would it be most appropriate for the nurse to instruct a housekeeper to clean the table with?
Bleach Explanation: Blood infected with the hepatitis B virus should be removed from the table or other surfaces with bleach. Alcohol, ammonia, and acetone are less effective in destroying the hepatitis B virus.
A nurse's coworker tells the nurse, "I am not going to get this year's flu vaccination. Last year I felt sick right after I got it." What is the nurse's best response?
"Reducing your own risk of getting influenza ultimately benefits your clients." Explanation: Framing the issue in terms of benefiting clients is likely more effective than making a declaration about professional responsibility. Influenza vaccinations do not confer 100% protection against the disease.
The nurse is working on an ethics committee that is reviewing client-nurse interactions. Which nursing action indicates negligence?
A nurse forgot to remove the tourniquet after phlebotomy, resulting in tissue injury. Explanation: Negligence is the unintentional failure of a nurse to perform or not perform an act or behave in a way a reasonable nurse would not. Additionally, for a nursing action to be considered negligent, there must be client injury. A reasonable nurse would have removed the tourniquet after obtaining blood, therefore, the unintentional act harmed the client and constitutes negligence. Although the nurse failed to complete a fall risk assessment within an appropriate time frame, there was no client injury; therefore, it is not considered a negligent action. Crushing medication and giving it is intentional and may be within the facility's policy and therefore not negligence. Administering a generic drug instead of a brand-name drug per the pharmacist's orders constitutes no error.
The nurse is caring for a client with a fever of 103°F (39°C) due to a respiratory infection. The client states, "I am freezing and I have a terrible headache!" What is the appropriate nursing action?
Administer acetaminophen as prescribed. Explanation: Acetaminophen will help to reduce the fever and relieve the pain of the headache. Placing the client into a cool bath will increase shivering which increases the metabolic rate and causes increase in fever. Applying extra blankets will increase the body temperature. The respiratory infection may be viral. The client has the right to pain relief from the headache.
A client arrives in the emergency department with hives and redness after a bee sting stating, "I can't breathe! I am going to die." What action is anticipated by the nurse?
Administer an injection of epinephrine stat. Explanation: Symptoms of hives and redness at the bee sting site coupled with a progression of symptoms including respiratory difficulty and an impending feeling of doom indicate anaphylaxis. Emergency treatment of anaphylaxis is an injection of epinephrine. Bronchodilators may help but are not the primary treatment. Beta-adrenergic blockers are not indicated in the management of anaphylaxis because they may cause bronchospasm. Having the client in high Fowler's position is appropriate but not emergency treatment.
A child is brought to the emergency department with life-threatening bleeding that needs immediate intervention. The child's parents cannot be reached to give consent. The nurse continues to assist with the child's care based on which understanding about consent?
Consent is not needed in a life-threatening situation. Explanation: Although parents have full responsibility for the child and are required to give informed consent (either verbal or written) whenever possible, the law is clear that in an emergency, life-threatening situation, or a situation in there is the possibility of permanent injury, consent is implied. A neighbor, close family friend, or health care provider cannot legally sign consent. Treatment should not be delayed in an emergency to obtain consent.
A nurse is preparing to administer an intramuscular (IM) injection. Immediately after administering the injection, what is the nurse's first action?
Discard the uncapped needle in a puncture-proof container. Explanation: To reduce the risk of an unintentional needle stick, the nurse should never recap a needle. An uncapped needle should be discarded in a puncture-proof, leak-proof container. A used needle should never be placed in a garbage can or medical waste container that is not puncture-proof and leak-proof. A needle should never be broken or bent before it is discarded because this increases the risk of a needle stick.
The nurse is assisting a healthcare provider in debriding a necrotic skin wound. The healthcare provider is using a plastic basin to collect the bloody supplies. When cleaning the area on completion of debridement, which nursing action is done after placing the supplies in a hazardous material bag?
Dispose of the plastic basin. Explanation: The plastic basin would be disposed of. Hot water causes the protein materials to stick to the basin. The basin does not need to be disinfected. An antiseptic is used to limit bacteria on the skin. Plastic emesis basins are disposable. The nurse would obtain a new one for the room.
For healing by second intention, a client's wound has been packed with medicated dressings. When evaluating the wound, which finding indicates that healing is taking place?
Granulation tissue is forming at the wound edges. Explanation: Connective tissue develops and fills in (or approximates) the wound edges from granulation tissue. Thus, evidence of granulation tissue indicates wound healing. The other options — red or edematous surrounding tissue and serous drainage — are insufficient evidence that the wound is healing.
The nurse has answered the telephone at the nurses' station, and the individual on the line states that there is bomb in the healthcare facility. What is the nurse's best response?
Keep the individual on the line in order to gather more information about the details of the threat. Explanation: If a bomb threat is received, the nurse should keep the caller on the line and talking as long as possible in order to gather information about the location of the bomb and a description of the bomb and the caller. The threat must be reported promptly, but the nurse should not hang up in order to do this.
To verify the placement of a nasogastric feeding tube, what action should the nurse perform?
Obtain a chest X-ray. Explanation: The gold standard for identification of placement of a nasogastric feeding tube is a chest X-ray. The cessation of reflex gagging that occurs during placement indicates the oropharynx is no longer being stimulated. Exact measurement of the distance between the nares and the stomach is impossible prior to insertion but should be estimated and marked. Instillation of any fluid prior to checking appropriate placement may induce aspiration pneumonia.
A licensed practical nurse (LPN) hears the facility code that indicates an infant has been abducted from the nursery. Which action should the LPN take?
Report to an exit and be alert for anyone carrying packages. Explanation: The LPN should report to an exit and be alert for anyone carrying packages. The abductor could conceal an infant in a package to remove it from the facility. Going to the nursery to ask what happened interferes with the nursery investigation and prevents the LPN from securing an exit. The facility should have a policy in which a hospital security officer is responsible for notifying the police when necessary; it isn't appropriate for the LPN to do so. It isn't necessary for the LPN to document the names of visitors visiting the medical-surgical floor.
The care plan for an older adult client who has had a stroke and is paraplegic indicates that the client should be turned at least every 2 hours. What outcome does the nurse hope to achieve with this intervention?
The client will not develop skin breakdown, pneumonia, and urinary tract infections (UTIs). Explanation: Immobility can lead to severe physiological problems such as skin breakdown, pressure ulcers, pneumonia, and UTIs. Therefore, frequent turning helps to minimize the effects of immobility. Immobility doesn't necessarily mean there's lack of stimuli. Although venous stasis can occur with immobility, heart failure doesn't develop as a result of venous stasis. Turning the client may improve how the client feels, but this isn't the primary rationale for this intervention.
Nurse researchers have proposed a study to examine the efficacy of a new wound care product. Which aspect of the methodology demonstrates that the nurses are attempting to maintain the ethical principle of nonmaleficence?
The nurses are taking every responsible measure to ensure that no participants experience impaired wound healing as a result of the study intervention. Explanation: The principle of nonmaleficence dictates that nurses avoid causing harm. In this study, this may appear in the form of taking measures to ensure that the intervention will not cause more harm than good. The principle of justice addresses the distribution of risks and benefits and the informed consent process demonstrates that autonomy is being protected. Preliminary indications of the therapeutic value of the intervention show a respect for the principle of beneficence.
The nurse finds the family member of a client in the nutrition room standing in a puddle of water holding the microwave door, shaking. What should the nurse do first?
Unplug the microwave. Explanation: For the safety of the nurse and to prevent further injury to the client, the first action is to unplug the microwave. Pulling the client from the pool without removing the source of the electricity endangers the nurse as well. The emergency response system can be activated after the source of electricity is unplugged. Vital signs can be obtained after all the other activities are done. The priority here is the safety of the nurse and the client.
The licensed practical nurse (LPN) is caring for a group of clients on a medical-surgical floor. Which client should the nurse attend to first?
a client whose lower leg is red and swollen Explanation: The LPN should first attend to the client whose lower leg is red and swollen. This client may have deep vein thrombosis caused by immobility, which should be investigated further. An apical pulse rate of 80 beats/minute is within normal limits. The LPN should address the clients' concerns about going home and receiving the breakfast tray; however, those concerns don't take priority.
Which theory of ethics most highly prioritizes the nurse's relationship with clients and the nurse's character in the practice of ethical nursing?
care-based ethics Explanation: Central to the care-based approach to ethics is the nurse's relationships with clients and the nurse's "being," or character and identity. Deontology, utilitarianism, and principle-based ethics each prioritize goals and principles that exist beyond the particularities of the nurse-client relationship.
A physician has ordered penicillin G potassium I.V., for a client with a severe streptococcal infection. A nurse determines that the client may be allergic to penicillin. When considering best practice, what should the nurse's priority intervention be?
holding the penicillin G potassium and notifying the physician that the client may have an allergy to penicillin Explanation: The nurse should hold the penicillin G potassium, even if the client isn't sure they are allergic to penicillin, and notify the physician so a different antibiotic may be ordered. Many clients can't act as their own advocates; they rely on nurses to protect their rights. An allergy to penicillin G potassium is suspected, but not confirmed. Administering penicillin G potassium could cause a life-threatening reaction. Administering the medication, then watching for a reaction or notifying the pharmacist that a reaction might occur, isn't best practice. If a client is allergic to penicillin, a nurse should alert the pharmacist and label the client's chart appropriately.
Which nursing intervention is appropriate for a client with an arm restraint?
monitoring circulatory status every 2 hours Explanation: A nurse must assess the circulatory status of a restrained extremity every 2 hours to prevent circulatory impairment. To make sure the restraint is secure without compromising the circulation, the nurse should leave approximately one fingerbreadth between the restraint and the extremity. Tying a restraint to the side rail or an immovable bed part may cause client injury if the rail or bed is moved before the restraint is released. The restrained arm or leg should be flexed slightly to allow joint movement without reducing the effectiveness of the restraint.
A hospital safety officer is evaluating nurses' responses to potential safety hazards. Which employee actions are appropriate for the situation? Select all that apply.
taking small steps with feet shoulder length apart when walking on wet surfaces removing clients from the area where a fire is reported using tongs to place a dislodged radioactive device in a lead container Explanation: There are a number of situations that could compromise safety where an appropriate response will minimize risk. People should not walk under ladders, move unidentified objects during a bomb threat, or directly touch radiation sources. Clients should be safe before an employee starts to fight a fire. Wet conditions make footing slippery, so if it is necessary to walk on a wet surface the person should use a wide base of support and take small steps.
The nurse is collecting data on a client who appears to miss portions of what is being asked by the nurse. The client's family member tells the nurse that the client has a hearing aid, but will not wear it. The client states, "It worked when I first got it, but now it's a nuisance because I can't hear anything with it." The nurse asks which question to gain a better understanding of the client's concern?
"Have you checked the battery to make sure it works?" Explanation: The client stated the hearing aid no longer works, so the nurse needs to determine if there is a problem; asking about the battery is appropriate. Before contacting the medical equipment company, the client should check the battery first. Even if the hearing aid is ill-fitted, it still should work, so the battery needs to be checked. The hearing aid was working, so the client did give it an opportunity to work.
After a surgical procedure, the health care provider orders a clear-liquid diet for a client. The nurse advises the unlicensed assistive personnel (UAP) to check the client's food tray for which of the following allowable items? Select all that apply.
apple juice, chicken broth, and gelatin ginger ale, jello, and a fruitless popsicle Explanation: A clear-liquid diet may include apple juice, broth, gelatin, and other transparent liquid foods or beverages. Orange juice, farina, coffee, pineapple juice, milk, and custard are all included in a full-liquid diet. A bran muffin is appropriate for a high-fiber diet.
Which scenario requires the licensed practical nurse (LPN) to notify the registered nurse (RN) immediately?
Apical pulse rate of 90 beats/minute with a radial pulse rate of 70 beats/minute Explanation: The LPN should immediately report an apical pulse rate of 90 beats/minute associated with a radial pulse rate of 70 beats/minute, which indicates a pulse deficit of 20 beats/minute. This finding signifies an irregular heartbeat that might lead to a decrease in cardiac output. Regarding the other answer options, the decrease in BP is a positive finding and doesn't need to be reported immediately; the LPN can assess pain and administer pain medications as prescribed; and the LPN can provide the family with an estimated discharge time without consulting the RN.
A client recovering from a stroke has slid down in bed and needs to be repositioned. Which action should the nurse take to ensure safety for both the client and the nurse?
Ask for assistance from the lift team. Explanation: A safe and effective approach to client repositioning is the use of a lift team. When using a team, a group of care providers share the weight of the client, reducing the risk of personal injury, and providing a safe method of repositioning the client. Rolling the client side to side is not a correct action to reposition a client in bed. The bed should be flat when repositioning a client. Raising the head of the bed will cause the client to slide further down in the bed. Any attempts at repositioning will be difficult because of the client's angle in the bed. Standing at the head of the bed and sliding the client toward the pillow is also not an appropriate method to reposition a client in bed.
A client with cancer-related pain has been prescribed a narcotic analgesic to be given around the clock. The client is competent and has been actively involved in decisions regarding care. What should the nurse do if the client refuses the next dose of analgesia?
Document the client's choice and re-assess pain in 1 hour. Explanation: A client has the right to choose whether to take medication. The nurse should assess the client's pain regularly and educate the client that taking the medication before the pain gets out of control will be a better pain management plan. The other options do not reflect an understanding of the client's right to choice including the refusal of pain medication.
The nurse is teaching the parents of a child with cystic fibrosis about proper nutrition. Which of the following instructions should the nurse include?
Encourage a high-calorie, high-protein diet. Explanation: The child should eat a high-calorie, high-protein diet. In cystic fibrosis, the enzymes from the pancreas (lipase, trypsin, and amylase) become so thick that the ducts become plugged. Without these enzymes, the duodenum isn't able to digest fat, protein, and some sugars; therefore, the child can become malnourished. Because fats aren't easily tolerated, they may need to be restricted. The child with cystic fibrosis needs to drink plenty of fluid and take salt supplements, especially on warm days or when exercising. Water- soluble forms of the fat-soluble vitamins (A, D, E, and K) are necessary because the inability to absorb fats results in a deficiency of these vitamins. Clients with cystic fibrosis don't have a problem absorbing water-soluble vitamins such as vitamin B.
An obese, malnourished client has undergone abdominal surgery. While ambulating on the fourth postoperative day, she states, "My dressing is very wet with drainage." Before this activity, the dressing was dry and intact. Which is the best initial action for the nurse to take?
Lift up the dressing to check the wound. Explanation: The client most likely has a wound dehiscence or evisceration. The first step is to check the wound; then the nurse can implement appropriate measures. Splinting the abdomen, applying an abdominal binder, or reinforcing the existing dressing would delay treatment.
The nurse must apply a wet-to-dry dressing over an ulcer on a client's left ankle. How should the nurse proceed?
Lightly pack the moistened fine-mesh gauze dressings into all depressions and grooves of the wound. Explanation: The nurse should lightly pack the moistened fine-mesh gauze dressings into all depressions and grooves of the wound because necrotic tissue usually is more prevalent in those areas. Wound packing facilitates wound healing. The nurse should wring out excess moisture from saturated fine-mesh gauze dressings because saturated dressings won't dry properly. The nurse shouldn't apply an occlusive dressing or elastic bandage because they can prevent air circulation and hinder drying of the fine-mesh gauze.
A nurse is providing home care to a client who has failing vision. The nurse is concerned about the client's safety. Which action should the nurse take to help reduce the client's risk of a fall?
Request that the family have handrails installed on the stairs, in hallways, and in bathrooms. Explanation: For a client with failing vision, handrails can help the client to navigate the environment and provide physical support to enhance stability. Close arrangement of furniture creates dangerous obstacles that could precipitate falls on sharp, hard objects. A medical identification bracelet provides the client with no protection in the event of a fall. Blinking lights that indicate a ringing doorbell or telephone are useful for clients who are hearing impaired.
A client in a long-term care facility refuses to take oral medications. The nurse threatens to apply restraints and inject the medication if the client doesn't take it orally. The nurse's statement constitutes which legal tort?
assault Explanation: Assault occurs when a person puts another person in fear of harmful or threatening contact. Battery is offensive contact with another's body. If the nurse actually carried out the threat, battery would also apply. Negligence involves actions that don't meet the standard of care. The client has the legal right to refuse care. In this situation, the nurse should try to calm the client, allow the client time to talk, and then determine if the client will take the medications. If the client still won't take the medications, the nurse should document this refusal, note the medications involved, and notify the physician and nursing supervisor. The nurse should follow the facility's policy related to clients refusing care.
Which guidelines define and regulate what the nurse may and may not do as a professional?
nurse practice act Explanation: Each state legislature has enacted a nurse practice act. These statutes outline the legal scope of nursing practice within a particular state. State boards of nursing oversee the statutory law. State legislatures create boards of nursing within each state; the state legislature itself doesn't regulate the scope of nursing. Facility policies govern the practice within a particular facility. Nurse practice acts set educational requirements for the nurse, distinguish between nursing practice and medical practice, and define the scope of nursing practice in that state. Standards of care, criteria that serve as a basis for evaluating the quality of nursing practice, are established by federal organizations, accreditation organizations, state organizations, and professional organizations.
A certified nursing assistant (CNA) is caring for a client with Clostridium difficile diarrhea and asks the nurse, "How can I keep from catching this from the client?" The nurse reminds the CNA to wash her hands and to ensure that the client is placed:
on contact isolation. Explanation: C. difficile can be transmitted from person to person by hands or waste containers such as a bedpan. When in direct contact with the client, the nurse should practice contact isolation, which includes wearing gloves and a gown. Protective isolation is used to protect a client who is immunocompromised, which isn't evident in this case. Neutropenic precautions are for clients with an absolute neutrophil count of 1,000/μl or less; this isn't evident in this case. A negative-pressure room is used when the organism is spread by the airborne route, which isn't true of C. difficile diarrhea.
A train accident sends a large number of injured passengers to the hospital. The hospital's disaster plan is put into effect. Which nursing action would best serve the hospital in this disaster situation?
perform duties as outlined in the disaster plan Explanation: Before a disaster occurs, the nurse should know how the hospital's disaster plan works and what he or she will be required to do. During a disaster, the charge nurse will assign staff to areas where they are needed; therefore, a nurse could be required to perform tasks outside of the usual duties. This practice is permitted if the nurse has the knowledge, skill, and comfort level to perform the assigned tasks. However, the nurse should never perform medical procedures outside of the scope of practice as outlined in the state's Nurse Practice Act.
A nurse is caring for a client who is recovering from an illness requiring prolonged bed rest. Based on the nursing documentation provided, which procedure would the nurse implement next?
performing active range-of-motion exercises of the legs Explanation: Active range-of-motion exercises involve moving the client's joints through their full range of motion; they require some muscle strength and endurance. The client should have received passive range-of-motion exercises since admission to maintain joint flexibility and should have been taught isometric exercises to build strength and endurance for transfers and ambulation. Walking to the bathroom would be unsafe without the ability to first dangle the legs over the bedside and transfer from bed to chair.
The nurse is providing care for a client who has had a stroke. Since the onset of symptoms, the client has been experiencing left-sided hemianopsia. Which nursing interventions would be appropriate? Select all that apply.
place the client's belongings on the right side of the bed stand on the right side of the bed when providing care Explanation: Hemianopsia is a condition in which the client has lost half of the visual field. It is most often associated with stroke. In this case, the stroke has affected the client's left side; therefore, placing belongings on the right side of the bed will enable the client to best see them. Standing on the right side of the bed when providing care will ensure the client is able to see the nurse. Approaching the client from the left side is counterproductive because the client would not be able to adequately see the nurse. Using an eye patch or dimming the lights will not help with treating or managing the condition.
