Legal and Ethical Issues
Preventing and Controlling Infection
Health and Physical Assessment
Meeting Basic Human Needs
Fluid and Electrolyte Imbalances
100
A client asks why a diagnostic test has been ordered and the nurse replies, "I'm unsure but will find out for you." When the nurse later returns and provides an explanation, the nurse is acting under which principle?
Fidelity Rationale: Fidelity means being faithful to agreements and promises.
100
What would the nurse implement as a requirement of care specific to the client who has tuberculosis?
A private room with negative air pressure Rationale: The client with tuberculosis can spread the infection by breathing, and requires a private room and airborne precautions.
100
When using the otoscope to examine the ears of a 2-year old child, the nurse should pull the pinna in which direction?
Back and down Rationale: To adequately examine the tympanic membrane in young children, the pinna must be pulled back an down.
100
A 92-year-old client is in the hospital. The client is very hard of hearing, and the nurse needs to do the admission interview. What action is appropriate for the nurse when assessing the client?
Lower the pitch of the voice and face the client during the interview. Rationale: Speaking to the client slowly and in a lower-pitched voice while facing the client is the best means of communication.
100
A history of of what condition places a client at risk for possible hypokalemia?
Cirrhosis Rationale: In clients with cirrhosis, increased amounts of aldosterone are secreted, which leads to potassium excretion from the kidneys.
200
An individual has a seizure while walking down the street. During the seizure, a nurse from a physician's office is noticed passing by without stopping to assist. The individual sues the nurse for negligence but fails to win a judgement for which reason?
The nurse had no duty to the individual Rationale: To be guilty of negligence, the nurse must have a relationship with the client that involves a duty to provide care.
200
A client ask, "How did I get scarlet fever?" What would be the nurse's best response?
"You inhaled infected droplets in the air." Rationale: Scarlet fever is transmitted by particle droplets larger than 5 microns
200
To assess the intensity of a client's pain during a health history, the nurse could ask the client to do what?
Rate the pain on a scale of 1 to 10 Rationale: The nurse can identify the intensity of a client's pain using a pain scale.
200
The nurse is evaluating a client using a cane. What assessment made by the nurse would indicate that the client is using the cane appropriately?
Client holds the cane with the hand on the stronger side Rationale: To provide maximum support and appropriate body alignment while walking, the cane is held in the hand on the stronger side.
200
The nurse assessing a client for signs of hypocalcemia would include that this electrolyte imbalance exists after noting what finding?
Positive Trousseau's sign Rationale: Clinical manifestations of hypocalcemia include a positive Trousseau's sign, which is presence of carpopedal spasm.
300
A client is referred to a surgeon by the general practitioner. After meeting the surgeon, the client decides to find a different surgeon to continue treatment. The nurse supports the client's action, utilizing which ethical principle?
Autonomy Rationale: Autonomy is the right of individuals to take action for themselves.
300
The nurse is assisting a client who has methicillin-resistant staphylococcus aureus in collecting a clean-catch urine specimen. What protective equipment is necessary?
A gown, eye protection, and gloves Rationale: Methicillin-resistant Staphylococcus aureus requires transmission-based contact precautions.
300
The nurse performing the Rinne test during a physical examination expects to gather data that could support what nursing diagnosis?
Altered sensory/perception: auditory Rationale: The Rinne test involves the examiner using a tuning fork to compare air conduction to bone conduction related to transmission of sound.
300
The nurse is assessing a client with a mobility problem to determine an appropriate assistance device. The client's lower extremities have no paralysis, but are very weak. Upper-body strength is also reduced. The nurse should suggest which device for this client?
Four-wheeled walker Rationale: The client has bilateral weakness of the lower extremities. A four-wheeled walker provides bilateral support.
300
A client with end stage renal disease is experiencing hypermagnesemia. The nurse explains that what treatment will decrease the magnesium level most effectively?
Dialysis Rationale: Either hemodialysis or peritoneal dialysis is used to remove excess magnesium in the client with renal failure.
400
A nurse forgets to administer a client's diuretic and the client experiences an episode of pulmonary edema. The charge nurse would consider the medication error to constitute negligence because the situation contains which element?
Unintentional failure to perform a health care procedure Rationale: Negligence is the unintentional failure of an individual to perform or not perform an act that that a reasonable person would or would not do in the same or similar circumstances.
400
The nurse is preparing to irrigate a wound infected with vancomycin-resistant enterococci. What personal protective equipment (PPE) would the nurse wear?
Gloves, gown, eye protection, and a mask Rationale: An infection with vancomycin-resistant enterococci requires transmission-based contact precautions.
400
When assessing a child for strabismus, the nurse should use which eye test?
The cover-uncover test Rationale: The cover-uncover tests assesses coordination of eye muscle movement.
400
A client, admitted to the hospital for gallbladder surgery, is diagnosed as having a vitamin C deficiency. The nurse places high priority on assessing this client for which development postoperatively?
Delayed wound healing Rationale: Vitamin C is necessary for building and maintaining tissues. A deficiency of vitamin C would prolong wound healing.
400
A 10-month-old infant is admitted to the emergency department with a 102 F rectal temperature and a history of vomiting and diarrhea for 48 hours. What signs should the nurse look for related to this client's likely fluid imbalance?
Sunken eyes, lethargy, and dry, furrowed tongue Rationale: The infant's history suggests Fluid Volume Deficit and dehydration. These are reliable signs of Fluid Volume Deficit in infants.
500
An adult female ambulatory care client receiving an oral anticoagulant is given aspirin for a headache while visiting a neighbor, who is a nurse. The client subsequently has a bleeding episode because of a drug interaction. The legal nurse consultant interprets that which necessary element of malpractice is missing from this case?
Duty owed Rationale: There was no nurse-client relationship because the nurse was acting a neighbor and not in an employment capacity. Thus, there can be no duty owed.
500
The nurse would expect to institute transmission-based precautions for a client with which infection?
A draining leg wound with methicillin-resistant staphylococcus aureus Rationale: Transmission-based precautions are required for all antibiotic-resistant microorganisms regardless of their mode of transmission
500
When assessing the heart sounds of a 10-year-old, the nurse notices that the rate varies with inspiration and expiration. What action should the nurse take?
Do nothing, as this is a normal finding Rationale: An irregular heart rate that increases with inspiration and decreases with expiration is a sinus arrhythmia, which is common in children.
500
The nurse is changing the abdominal dressing of a client who is 4 days postoperative. The nurse notes a moderate amount of serosanguineous drainage, wound edge approximated, and puffy tissue protruding through the wound. What condition should the nurse suspect from these manifestations?
Evisceration Rationale: Changes in wound appearance such as increased serosanguineous drainage, edges lacking approximation, and the protruding viscera.
500
A client admitted to the hospital with a 30-pound weight gain over the past month has a fat pad at the back of the neck and moon facies. Admission laboratory results indicate decreased serum potassium and magnesium, and elevated serum chloride and sodium levels. The nurse interprets that which disorder is most consistent with these electrolyte abnormalities?
Cushing's syndrome Rationale: Cushing's syndrome causes low potassium and magnesium levels and an increase in sodium and chloride levels.
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