The Interprofessional
Team
Team
A nurse is caring for a group of clients on a medical‑surgical unit. For which of the following client care needs should the nurse initiate a referral for a social worker? (Select all that apply.)
A. A client who has terminal cancer requests hospice care in the home. B. A client asks about community resources available for older adults.
C. A client states, “I would like to have my child baptized before surgery.”
D. A client requests an electric wheelchair for use after discharge. E. A client states, “I do not understand how to use a nebulizer.”
A. CORRECT: Initiate a referral for a social worker to provide information and assistance in coordinating hospice care for a client.
B. CORRECT: Initiate a referral for a social worker to provide information and assistance in coordinating care for community resources available for clients.
D. CORRECT: Initiate a referral for a social worker to assist the client in obtaining medical equipment for use after discharge
A nurse is providing discharge instructions to a client who has a prescription for oxygen use at home. Which of the following information should the nurse include? (Select all that apply.)
A. Family members who smoke must be at least 10 ft from the client when oxygen is in use.
B. Nail polish should not be used near a client who is receiving oxygen.
C. A “No Smoking” sign should be placed on the front door.
D. Cotton bedding and clothing should be replaced with items made from wool.
E. A fire extinguisher should be readily available in the home.
B. CORRECT: Remind the client to not use nail polish or other flammable materials in the home. C. CORRECT: Have the client place a “No Smoking” sign near the front door, and possibly on the client’s bedroom door.
E. CORRECT: Remind all individuals to have a fire extinguisher at home. This is especially important for a client who is receiving oxygen.
A nurse is caring for a client who is receiving enteral tube feedings due to dysphagia. Which of the following bed positions should the nurse use for safe care of this client?
A. Supine
B. Semi‑Fowler’s
C. Semi‑prone
D. Trendelenburg
B. CORRECT: In the semi‑Fowler’s position, the client lies supine with the head of the bed elevated 15° to 45° (typically 30°). This position helps prevent regurgitation and aspiration by clients who have difficulty swallowing. This is the safest position for clients receiving enteral tube feedings
A nurse is caring for a client who fell at a nursing home. The client is oriented to person, place, and time and can follow directions. Which of the following actions should the nurse take to decrease the risk of another fall? (Select all that apply.)
A. Place a belt restraint on the client when they are sitting on the bedside commode.
B. Keep the bed in its lowest position with all side rails up.
C. Make sure that the client’s call light is within reach.
D. Provide the client with nonskid footwear.
E. Complete a fall‑risk assessment.
C. CORRECT: Making sure that the call light is within reach enables the client to contact the nursing staff to ask for assistance and prevents the client from falling out of bed while reaching for the call light.
D. CORRECT: Nonskid footwear keeps the client from slipping.
E. CORRECT: A fall‑risk assessment serves as the basis for a plan of care that can then individualize for the client.
A nurse is caring for a client scheduled for abdominal surgery. The client reports being worried. Which of the following actions should the nurse take?
A. Offer information on a relaxation technique and ask the client if they are interested in trying it.
B. Request a social worker see the client to discuss meditation.
C. Attempt to use biofeedback techniques with the client.
D. Tell the client many people feel the same way before surgery and to think of something else.
A. CORRECT: It is appropriate for the nurse to recommend a noninvasive technique to facilitate coping, and to allow the client to make an informed decision about participating.
. A goal for a client who has difficulty with self‑feeding due to rheumatoid arthritis is to use adaptive devices. The nurse caring for the client should initiate a referral to which of the following members of the interprofessional care team?
A. Social worker
B. Certified nursing assistant
C. Registered dietitian
D. Occupational therapist
D. CORRECT: An occupational therapist can assist clients who have physical challenges to use adaptive devices and strategies to help with self‑care activities
A nurse educator is presenting a module on basic first aid for newly licensed home health nurses. The client who has heat stroke will have which of the following?
A. Hypotension
B. Bradycardia
C. Clammy skin
D. Bradypnea
A. CORRECT: Hypotension is a manifestation of heat stroke
A nurse is caring for a client who is sitting in a chair and asks to return to bed. Which of the following actions is the nurse’s priority at this time?
A. Obtain a walker for the client to use to transfer back to bed.
B. Call for additional staff to assist with the transfer.
C. Use a transfer belt and assist the client back into bed.
D. Determine the client’s ability to help with the transfer.
D. CORRECT: The first action that should be taken using the nursing process is to assess or collect data from the client. Determine the client’s ability to help with transfers and then proceed with a safe transfer
A nurse manager is reviewing with nurses on the unit in the care of a client who has had a seizure. Which of the following statements by a nurse requires further instruction?
A. “I will place the client on their side.”
B. “I will go to the nurses’ station for assistance.”
C. “I will note the time that the seizure begins.”
D. “I will prepare to insert an airway.”
B. CORRECT: During a seizure, stay with the client and use the call light to summon assistance.
A nurse is assessing a client as part of an admission history. The client reports drinking an herbal tea every afternoon at work to relieve stress. Tea includes which of the following ingredients?
A. Chamomile
B. Ginseng
C. Ginger
D. Echinacea
A. CORRECT: Tea can contain chamomile, which produces a calming effect, or valerian, which reduces anxiety. Attempt to gain further information to confirm the ingredients of any herbal or natural products the client can use.
. A client who is postoperative following knee arthroplasty is concerned about the adverse effects of the medication prescribed for pain management. Which of the following members of the interprofessional care team can assist the client in understanding the medication’s effects? (Select all that apply.)
A. Provider
B. Certified nursing assistant
C. Pharmacist
D. Registered nurse
E. Respiratory therapist
A. CORRECT: The provider must be knowledgeable about any medication prescribed for the client, including its actions, effects, and interactions.
C. CORRECT: A pharmacist must be knowledgeable about any medication dispensed for the client, including its actions, effects, and interactions.
D. CORRECT: A registered nurse must be knowledgeable about any medication administered, including its actions, effects, and interactions.
A home health nurse is discussing the dangers of carbon monoxide poisoning with a client. Which of the following information should the nurse include?
A. Carbon monoxide has a distinct odor.
B. Water heaters should be inspected every 5 years.
C. The lungs are damaged from carbon monoxide inhalation.
D. Carbon monoxide binds with hemoglobin in the body.
D. CORRECT: Warn the client that carbon monoxide is very dangerous because it binds with hemoglobin and ultimately reduces the oxygen supplied to the tissues in the body
A nurse is instructing a client who has COPD about using the orthopneic position to relieve shortness of breath. Which of the following statements should the nurse make?
A. “Lie on your back with our head and shoulders supported by a pillow.”
B. “Have your head turned to the side while you lie on your stomach.”
C. “Have a table beside your bed so you can sit on the bedside and rest your arms on the table.”
D. “Lie on your side with your top arm resting on the bed and your weight on your hip.”
C. CORRECT: This is an accurate description for the orthopneic position. This position allows for chest expansion and is especially beneficial for clients who have COPD.
A nurse observes smoke coming from under the door of the staff’s lounge. Which of the following actions is the nurse’s priority?
A. Extinguish the fire.
B. Activate the fire alarm.
C. Move clients who are nearby.
D. Close all open doors on the unit.
C. CORRECT: The greatest risk to this client is injury from the fire. Therefore, the priority intervention is to rescue the clients. Protect and move clients in close proximity to the fire.
A nurse is reviewing complementary and alternative therapies with a group of newly licensed nurses. Which of the following interventions are mind‑body therapies? (Select all that apply.)
A. Art therapy
B. Acupressure
C. Yoga
D. Therapeutic touch
E. Biofeedback
A. CORRECT: Art therapy is a mind‑body therapy because it allows the client to express unconscious emotions or concerns about their health.
A client who had a cerebrovascular accident has persistent problems with dysphagia. The nurse caring for the client should initiate a referral with which of the following members of the interprofessional care team?
A. Social worker
B. Certified nursing assistant
C. Occupational therapist
D. Speech‑language pathologist
D. CORRECT: A speech‑language pathologist can initiate specific therapy for clients who have difficulty with feeding due to swallowing difficulties.
A nurse educator is conducting a parenting class for new guardians of infants. Which of the following statements made by a participant indicates understanding?
A. “I will set my water heater at 130° F.”
B. “Once my baby can sit up, they should be safe in the bathtub.”
C. “I will place my baby on their stomach to sleep.”
D. “Once my infant starts to push up, I will remove the mobile from over the crib.”
D. CORRECT: The guardian should plan to remove crib toys (mobiles) from over the bed as soon as the infant begins to push up so the infant is unable to touch them.
A nurse manager is reviewing guidelines for preventing injury with staff nurses. Which of the following instructions should the nurse manager include? (Select all that apply.)
A. Request assistance when repositioning a client.
B. Avoid twisting your spine or bending at the waist.
C. Keep your knees slightly lower than your hips when sitting for long periods of time.
D. Use smooth movements when lifting and moving clients.
E. Take a break from repetitive movements every 2 to 3 hr to flex and stretch your joints and muscles.
A. CORRECT: To reduce the risk of injury, at least two staff members should reposition clients.
B. CORRECT: Twisting the spine or bending at the waist (flexion) increases the risk for injury.
D. CORRECT: Using smooth movements instead of sudden or jerky muscle movements helps prevent injury
A nurse is caring for a client who has a history of falls. Which of the following actions is the nurse’s priority?
A. Complete a fall‑risk assessment. B. Educate the client and family about fall risks.
C. Eliminate safety hazards from the client’s environment.
D. Make sure the client uses assistive aids in their possession.
A. CORRECT: The first action to take using the nursing process is to assess or collect data from the client. Therefore, the priority action is to determine the client’s fall risk. This will work as a guide in implementing appropriate safety measures
A nurse is planning to use healing intention with a client who is recovering from a lengthy illness. Which of the following is the priority action to take before attempting this particular mind‑body intervention?
A. Tell the client the goal of the therapy is to promote healing.
B. Ask whether the client is comfortable with using prayer.
C. Encourage the client participate actively for best results.
D. Instruct the client to relax during the therapy.
B. CORRECT: The first action to take using the nursing process is to assess or collect data from the client. Because people can have personal, cultural, or religious sensitivities or aversions to religious practices (prayer), the nurse must first determine that the client is comfortable with a therapy that involves prayer.
. A nurse is acquainting a group of newly licensed nurses with the roles of the various members of the health care team they will encounter on a medical‑surgical unit. When providing examples of the types of tasks certified nursing assistants (CNAs) can perform, which of the following client activities should the nurse include? (Select all that apply.)
A. Bathing
B. Ambulating
C. Toileting
D. Determining pain level
E. Measuring vital signs
A. CORRECT: It is within the range of function for a CNA to provide basic care to clients (bathing).
B. CORRECT: It is within the range of function for a CNA to provide basic care to clients, (assisting with ambulation).
C. CORRECT: It is within the range of function for a CNA to provide basic care to clients (assisting with toileting)
E. CORRECT: It is within the range of function for a CNA to provide basic care to clients (measuring and recording vital signs).
A home health nurse is discussing the dangers of food poisoning with a client. Which of the following information should the nurse include? (Select all that apply.)
A. Most food poisoning is caused by a virus.
B. Immunocompromised individuals are at increased risk for complications from food poisoning. C. Clients who are at high risk should eat or drink only pasteurized dairy products.
D. Healthy individuals usually recover from the illness in a few weeks. E. Handling raw and fresh food separately can prevent food poisoning.
B. CORRECT: Warn the client that very young, very old, immunocompromised, and pregnant individuals are at increased risk for complications from food poisoning.
C. CORRECT: Include that clients who are at high risk should follow a low‑microbial diet, which includes eating or drinking only pasteurized milk, yogurt, cheese, and other dairy products
E. CORRECT: Include interventions to prevent food poisoning (performing proper hand hygiene, cooking meat and fish to the correct temperature, handling raw and fresh food separately to avoid cross‑contamination, and refrigerating perishable items).
. A nurse educator is reviewing proper body mechanics during employee orientation. Which of the following statements should the nurse identify as an indication that an attendee understands the teaching? (Select all that apply.)
A. “My line of gravity should fall outside my base of support.”
B. “The lower my center of gravity, the more stability I have.”
C. “To broaden my base of support, I should spread my feet apart.”
D. “When I lift an object, I should hold it as close to my body as possible.”
E. “When pulling an object, I should move my front foot forward.
B. CORRECT: Being closer to the ground lowers the center of gravity, which leads to greater stability and balance.
C. CORRECT: Spreading the feet apart increases and widens the base of support.
D. CORRECT: Holding an object as close to the body as possible helps avoid displacement of the center of gravity and thus prevent injury and instability.
A nurse discovers a small paper fire in a trash can in a client’s bathroom. The client has been taken to safety and the alarm has been activated. Which of the following actions should the nurse take? A. Open the windows in the client’s room to allow smoke to escape.
B. Obtain a class C fire extinguisher to extinguish the fire.
C. Remove all electrical equipment from the client’s room.
D. Place wet towels along the base of the door to the client’s room.
D. CORRECT: Place wet towels along the base of the door to the client’s room to contain the fire and smoke in the room.
What is complimentary Alternative Medicine?
Complementary therapies are treatment approaches used in addition to or to enhance conventional medical care.