Nursing Process
Which step in the nursing process would involve promoting a safe environment for the client?
A. Planning
B. Diagnosis
C. Assessment
D. Implementation
The nurse promotes a safe environment during the implementation stage of the nursing process. During the planning stage, the nurse develops an individualized care plan for the client. The plan contains strategies and alternatives to achieve specific outcomes. During the diagnosis stage, the nurse analyzes the assessment data to determine the health care issues. The nurse collects comprehensive data pertinent to the client’s health and situation during the assessment stage.
Which health care team member is responsible for providing intravenous medication therapy to a client?
A. Registered nurse (RN)
B. Nursing manager
C. Patient-care associate (PCA)
D. Unlicensed nursing personnel (UNP)
The RN is responsible for providing intravenous medications to clients. The RN has knowledge of medication administration via all routes. Nursing managers are able to provide intravenous medications but may not be available at all times. PCAs are unlicensed professionals and are unable to provide intravenous medications. UNP are not eligible to provide medications to clients; they can provide assistance in monitoring clients.
The nurse is changing the soiled bed linens of a client with a wound that is draining serosanguinous exudate. Which personal protective equipment (PPE) would the nurse wear?
A. Mask
B. Clean gloves
C. Sterile gloves
D. Shoe covers
Clean gloves protect the hands and wrists from microorganisms in the linens. Clean gloves are the first line of defense in preventing the spread of infection. Mask, sterile gloves, and shoe covers are not required for this situation.
Which statement describes the function of the dermis?
A. Provides cells for wound healing
B. Assists in retention of body heat
C. Acts as mechanical shock absorber
D. Inhibits proliferation of microorganisms
The dermis is present between the epidermis and subcutaneous layers and has such functions as giving the skin its flexibility and strength and providing cells for wound healing. Subcutaneous tissue is the innermost layer of the skin that helps in retention of body heat and acts as a mechanical shock absorber. Epidermis is the outermost layer of skin that inhibits the proliferation of microorganisms.
The nurse speaking in support of the best interest of a vulnerable client reflects which nursing duty?
A. Caring.
B. Veracity.
C. Advocacy.
D. Confidentiality.
The nurse has a professional duty to advocate for a client by promoting what is best for the client. This is accomplished by ensuring that the client’s needs are met and by protecting the client’s rights. Caring is a behavioral characteristic of the nurse. Veracity relates to the habitual observance of truth, fact, and accuracy. Confidentiality is an ethical principle and legal right that the nurse will hold secret all information relating to the client unless the client gives consent to permit disclosure.
The nurse is interviewing a client for admission to the hospital. Which phase of the nursing process is being used in this situation?
A. Planning
B. Evaluation
C. Assessment
D. Diagnosis
Assessment involves taking the history of and verbally interviewing the client. Planning is the phase of the nursing process that includes the development of a written document of expected outcomes. Evaluation is the phase of the process when the care plan is modified and updated. Diagnosis involves the documentation and validation of health care needs and priorities via verbal discussion with the client.
Which information would the nurse provide an older adult and caregivers regarding medication safety? Select all that apply.
A. Use a pill organizer.
B. Read all medication labels.
C. Place pills in unlabeled bottles.
D. Review medications with pharmacist.
E. Empty medicine cabinet every 2 years.
The nurse would instruct the client and caregivers regarding medication safety. This includes using a pill organizer or calendar to remember doses and days to take medications. The nurse would also emphasize the importance of reading all medication labels for possible warnings. The client should review medications with the pharmacist or health care provider. Pills should never be placed in unlabeled bottles because this can lead to confusion about which medication it is. The medicine cabinet should be emptied at least every year for expired medications and old prescriptions.
Which category of isolation would the nurse implement for a client who is positive for Clostridium difficile?
A. Airborne precautions
B. Droplet precautions
C. Contact precautions
D. Protective environment
Contact precautions should be used for direct client or environmental contact with blood or body fluids from an infected client. This includes colonization of infection with multidrug-resistant organisms (MDROs) such as methicillin-resistant Staphylococcus aureus (MRSA), stool infected with Clostridium difficile, draining wounds where secretions are not contained, or scabies. Airborne precautions are used for infected droplets smaller than 5 mcg, such as measles, chickenpox (varicella), or pulmonary tuberculosis (TB). Droplet precautions are used for droplets larger than 5 mcg and when within 3 feet (0.9 m) of the client, such as streptococcal pharyngitis, mumps, and influenza. Protective environment focuses on clients with a compromised immune system to protect them from incoming pathogens.
The nurse is preparing to initiate antibiotic therapy for a client who developed an incisional infection. Which task would the nurse ensure has been completed before starting the first dose of intravenous antibiotics?
A. Red blood cell count
B. Wound culture
C. Knee x-ray
D. Urinalysis
A wound culture always should be completed before the first dose of antibiotic. A wound culture is obtained to determine the organism that is growing. A broad spectrum antibiotic often is given first; after the organism has been identified an organism-specific antibiotic can be given. There is no indication that a red blood cell count is needed; however, a white blood cell count would be beneficial. A urinalysis is not needed, because data gathered during the assessment indicate an incisional infection. At the early stage of the infection, there is no need to obtain a knee x-ray.
Which characteristic indicates that nursing is a profession?
A. Nurses are trained to perform specific tasks.
B. Nurses are required to follow a code of ethics.
C. Nurses are required to have a collection of specific skills.
D. Nurses are required to have a collection of specific skills .
Nursing is a profession because it follows a code of ethics, in which philosophical ideals of right and wrong defines the principles the nurse uses to care for the clients. Nursing is not just a collection of specific skills performed by a trained individual. The nurse is expected to act professionally by administering quality client-centered care in a safe, conscientious, and knowledgeable manner. Nursing is a profession because nurses have autonomy in decision-making and practice in accordance with the state and federal laws and regulations. Nursing is a profession because its members must not only possess basic nursing education but extended education to explore new methods of health care.
Which step of the nursing process is directly affected if the nurse does not make a nursing diagnosis?
A. Planning
B. Evaluation
C. Assessment
D. Implementation
The planning phase of the nursing process is directly affected if the nurse does not make a nursing diagnosis. The nurse cannot plan or interpret correctly if the client’s problems are not clear. The evaluation phase of the nursing process is not directly affected by the nursing diagnosis. A nursing diagnosis is based on an accurate assessment. The nurse must obtain and document a comprehensive assessment. In the absence of a nursing diagnosis, the nurse cannot implement appropriate nursing interventions. The implementation phase is directly affected if there is no plan of care.
The health care provider prescribes 1000 mL of total parenteral nutrition (TPN) to be administered in 12 hours. Based on this prescription, how many milliliters of solution will be administered per hour? Round final answer to the whole number.
83 mL/h is the correct calculation. 1000 mL of solution divided by 12 hours equals 83.3 mL/h.
Which evaluation method is the most effective way for the nurse to evaluate the teachers’ knowledge of hand-washing techniques after a program for teachers about infection-control and hand-washing techniques?
A. Observe the teachers lecture the children about hand hygiene.
B. Administer an objectively written final examination to the teachers.
C. Have the teachers share their knowledge of hand washing.
D. Watch the teachers demonstrate infection-control techniques.
The best way to evaluate learning is by feedback demonstration of precautions related to infection control, such as hand-washing techniques. This method is observable and must meet objective criteria. Although observing a lecture, giving a written examination, or sharing what has been learned in a seminar are all evaluation techniques that may be used, none of these methods are as objective and definitive as observing an actual psychomotor demonstration of techniques.
Which intervention could result in further tissue necrosis when the registered nurse (RN) delegates the tasks of caring for a client with pressure ulcers?
A. Cleaning of the wound by the RN
B. Performing irrigation of the wound by the patient care associate (PCA)
C. Administering of oral analgesics by the licensed practical nurse (LPN)
D. Repositioning the client every 1 to 2 hours by the licensed practical nurse (LPN)
The PCA is not authorized to irrigate the wound because improper technique can lead to tissue damage. The RN is qualified to perform wound care; therefore cleaning the wound is not likely to lead to tissue necrosis. Pressure ulcers are associated with pain. The LPN administering oral analgesics may relieve the pain, but it will not cause tissue necrosis. Having the LPN reposition the client every 1 to 2 hours will minimize the risk of tissue necrosis due to pressure ulcers.
Which statement would be appropriate to include in a lecture for nursing students related to ethics and legal principles?
A. Beneficence emphasizes promoting good, actively seeking benefit, and ensuring the client’s well-being.
B. After the nurse has delegated a task or activity, the unlicensed assistive personnel (UAP) is accountable for the task or activity.
C. Social justice is an obligation to protect a client as an advocate when a client is not capable of self-determination.
D. There is a universal list that all states use that describes tasks that can be safely delegated and assigned to nursing team members.
Beneficence is the ethical principle that emphasizes promoting good, actively seeking benefit, and ensuring the client’s well-being. The nurse is always accountable for the task or activity that is delegated. Social justice refers to equality, the idea that all clients should be treated with fairness and equity. Each state designates which tasks may be safely delegated and assigned to nursing team members; there is no universal list that all states use to describe tasks that can be delegated.
he nurse asks an unlicensed assistive personnel (UAP) to provide an ice pack to a client. Which nursing function does this represent?
A. Delegation
B. Implementation
C. Case management
D. Interprofessional teamwork
Delegation is the assignment of a nursing task to someone else who is able or qualified to perform the task. Implementation is a part of the nursing process where the nurse carries out the care plan for a client. Case management is the collaborative effort of care planning and advocacy to make sure that a client’s and family’s needs are met. The interprofessional team is made up of professionals from several different disciplines who work together in the provision of care to the client.
A health care provider prescribes guaifenesin 300 mg four times a day. The dosage strength is 200 mg/5 mL. How many milliliters will the nurse administer for each dose? Record your answer using one decimal place.
7.5 mL
Which action would the nurse take first after learning that sputum cultures for a client with a chronic cough were positive for tuberculosis?
A. Place the client on airborne precautions.
B. Notify the client’s health care provider.
C. Auscultate the client’s breath sounds.
D. Notify the public health department.
The initial action by the nurse after learning that a client has active tuberculosis would be to assure the safety of other clients, visitors, and staff by implementing airborne precautions. The health care provider would be notified, but this can be done after airborne precautions are started because implementation of infection control measures does not require a prescription by the health care provider. The nurse would plan to check the client’s lung sounds, but this can be done after airborne precautions, including the use of an N95 mask by the nurse when assessing the client. The public health department will need to be notified so that contacts of the client can be tested and treated, but this can be done any time during the client’s hospitalization.
Which stage would the nurse document for a client with a pressure injury that has exposed bone and tendons?
A. Stage I
B. Stage II
C. Stage III
D. Stage IV
A stage IV pressure injury involves full-thickness tissue loss and the tendons, bones, or muscles are exposed. In stage I, the skin is intact and there is a nonblanchable redness at a localized area, usually over a bony prominence. In stage II, there is a partial-thickness loss of the dermis manifesting as a shallow open ulcer with a red-pink wound bed, without slough. In stage III, full-thickness tissue is lost.
A client decides to have hospice care rather than an extensive surgical procedure. Which ethical principle does the client's behavior illustrate?
A. Justice
B. Veracity
C. Autonomy
D. Beneficence
The client is exhibiting the freedom to make a personal decision, and this reflects the concept of autonomy. Justice refers to fairness. Veracity refers to truthfulness. Beneficence refers to implementing actions that benefit others.
Which phrase defines assessment?
A. Coordinating care delivery
B. Analyzing assessment data to determine diagnoses or issues
C. Collecting comprehensive data pertinent to the client’s health and/or situation
D. A registered nurse provides consultation to influence an identified plan
Assessment is the process of collection of comprehensive data pertinent to the client’s health and/or situation. Coordination of care refers to delivering care to the client. Diagnosis refers to analyzing the assessment data to determine the diagnoses or issues. Consultation is the process where a registered nurse discusses with other health care providers to influence the identified plan, enhance the abilities of other caregivers, and effect change.
During a 12-hour shift, a client has a 6-oz (180-mL) cup of tea and 360 mL of water. The client vomits 100 mL, and the instilled intravenous (IV) fluids equaled the urinary output. Which fluid balance would the nurse record for the 12-hour period?
The correct calculation is 440 mL. The client’s intake was 180 mL of tea and 360 mL of water for a total fluid intake of 540 mL; the client vomited 100 mL, which, when subtracted from 540 mL, leaves 440 mL.
Which nursing interventions require the nurse to wear gloves? Select all that apply. One, some, or all responses may be correct.
A. Giving a back rub
B. Emptying a portable wound drainage system
C. Interviewing a client in the emergency department
D. Obtaining the blood pressure of a client who is positive for human immunodeficiency virus (HIV)
PPE should be used because the nurse may be exposed to blood and fluid that are contained in the portable wound drainage system. PPE is not required for a back rub; there is no indication that the nurse is in contact with bodily secretions. PPE is not necessary when conducting an interview because it is unlikely that the nurse will come into contact with the client’s body fluids. PPE is not necessary when obtaining the blood pressure of a client, even if the client is HIV positive.
Which technology would the nurse use to reduce chronic ulcers by removing fluids from the wound?
A. Electrical stimulation
B. Topical growth factors
C. Hyperbaric oxygen therapy
D. Negative pressure wound therapy
Negative pressure wound therapy is a new technology used to reduce chronic ulcers by removing fluids from the wound and enhancing granulation. Electrical stimulation is done by the application of low-voltage current to a wound area to increase blood vessel growth and promote granulation. Topical growth factors are the normal body substances that stimulate cell movement and growth. Hyperbaric oxygen therapy is the administration of oxygen under pressure, raising the tissue oxygen concentration.
Which ethical principle is violated when the nurse forgets to give a painkiller to a client as promised?
A. Justice
B. Fidelity
C. Veracity
D. Nonmaleficence
Fidelity involves being loyal by keeping promises, doing what is expected, performing duties, and being trustworthy. Justice refers to fair treatment and fair distribution of resources. Veracity involves being truthful to the client. Nonmaleficence refers to acting in ways that prevent harm or risk of it.