Delegation
The plan of care for a diabetic patient includes all of these interventions. Which intervention should you delegate to a UAP?
A. Checking to make sure that the patient's bath water is not too hot
B. Discussing community resources for diabetic outpatient care
C. Teaching the patient to perform daily foot inspection
D. Assessing the patient's technique for drawing insulin into a syringe
Ans: A
Checking to make sure the patient's bath water is not too hot is appropriate to delegate to the UAP. The other interventions are not.
The nurse employed in an emergency department is assigned to triage clients coming to the emergency department for treatment on the evening shift. The nurse should assign priority to which client?
A. A client complaining of muscle aches, a headache, and malaise
B. A client who twisted her ankle when she fell while rollerblading
C. A client with a minor laceration on the index finger sustained while cutting an eggplant
D. A client with chest pain who states that he just ate hot wings that was made with a very spicy sauce.
Ans: D
In an emergency department, triage involves brief client assessment to classify clients according to their need for care and includes establishing priorities of care. The type of illness or injury, the severity of the problem, and the resources available govern the process. Clients with trauma, chest pain, severe respiratory distress or cardiac arrest, limb amputation, and acute neurological deficits, or who have sustained chemical splashes to the eyes, are classified as emergent and are the number 1 priority.
You are working as the triage nurse in the ED when the following four clients arrive. Which client requires the most rapid action to protect other clients in the ED from infection?
A. 3-year-old who has paroxysmal coughing and whose sibling has pertussis
B. 5-year-old who has a new pruritic rash and a possible chickenpox infection
C. 62-year-old who has a history of a methicillin-resistant Staphylococcus aureus (MRSA) abdominal wound infection
D. 74-year-old who needs tuberculosis (TB) testing after being exposed to TB during a recent international airplane flight
Ans: B
Varicella (chickenpox) is spread by airborne means and could be rapidly transmitted to other clients in the ED. The child with the rash should be quickly isolated from the other ED clients through placement in a negative-pressure room. Droplet and/ or contact precautions should be instituted for the clients with possible pertussis and MRSA infection, but this can be done after isolating the child with possible chickenpox. The client who has been exposed to TB does not place other clients at risk for infection because there are no symptoms of active TB. Focus: Prioritization
The nurse at a family practice is responsible for reviewing home safety issues with all patients. She knows that there is an increased risk of falls in which of these two groups of patients?
A. The elderly and school-age children
B. Infants and toddlers
C. Toddlers and the elderly
D. Infants and the elderly
Ans: D.
Infants and the elderly both have increased risk of falls. Nurses should educate the parents and/or caregivers of infants about safe places for sleep and play to prevent a fall. In the elderly, nurses must consider age-related factors, both physical and cognitive that can increase the risk of falling.
A nurse is preparing to transfer a client who is 72 hours post-operative to a long-term care facility. Which of the following information is not necessary for the nurse to include in the transfer report?
A. Advance directives status
B. Vital signs on day of admission
C. Medical diagnosis
D. Need for specific equipment
Ans: B
The receiving nurse and facility do not need to know admission vital signs in order to provide care or address the client’s current needs. However, provide the most current set of vital signs in the report.
A student nurse is giving a child with suspected otitis media an ear examination. Which of the following actions, if taken by the student nurse, would require correction?
A. The student nurse allows the two-year-old to sit on her mother's lap during the exam.
B. The student nurse talks with the child as she looks into her ear.
C. The student nurse applies a disposable cover to the tip of the otoscope.
D. The student nurse gently pulls the pinna of the ear up and back to straighten the ear canal.
Ans: A
The student nurse gently pulls the pinna of the ear up and back to straighten the ear canal.
The student nurse should pull the pinna down and back in a child to straighten the ear canal. It's fine to talk with the child and sit them in the mother's lap, and the application of a disposable cover is a responsible action.
A primary care provider prescribes on tablet, but the nurse accidentally administers two. After notifying the primary care provider, the nurse monitors the client carefully for untoward effects of which there are none. Is the client likely to be successful in suing the nurse for malpractice?
A. No, the client was not harmed
B. No, the nurse notified the primary care provider
C. Yes, a breach of duty exists
D. Yes, foreseeability is present
Ans: A
No, the client was not harmed. For malpractice, all elements such as duty, foreseeability causation, harm/injury and damages must be present for malpractice to be proven.
A nurse is teaching a client about breast self-examination (BSE). When should the nurse advise the client to perform BSE?
A. On the first day of the menstrual cycle
B. At the same time every month
C. Weekly, to ensure thorough examination
D. Only if a lump is suspected
Ans: B
Performing BSE at the same time every month helps women become familiar with the normal state of their breasts and detect any changes early.
A nurse is caring for a 12-month-old toddler who is hospitalized and confined to a room with contact precautions in place. Which of the following toys should the nurse recommend in order to meet the developmental needs of the client?
A. Large building block
B. Hanging crib toys
C. Modeling clay
D. Crayons and a coloring book
Ans: A
Large building blocks are age-appropriate toys for a 12-month-old toddler. A crib gym is not an age-appropriate toy for a 12-month-old toddler. The ability to stand places the toddler at risk of strangling from the strings of the toys. Modeling clay is not an age-appropriate toy for a 12-month-old toddler due to the risk of the child ingesting it. Crayons and a coloring book are not age-appropriate toys for a 12-month-old client.
You are providing nursing care for a 24-year-old female patient admitted to the unit with a diagnosis of cystitis. Which intervention should you delegate to the UAP?
A. Teaching the patient how to secure a clean-catch urine sample
B. Assessing the patient's urine for color, odor, and sediment
C. Reviewing the nursing care plan and add nursing interventions
D. Providing the patient with a clean-catch urine sample container
Ans: D
Providing the equipment that the patient needs to collect the urine sample is within the scope of practice of a UAP. Teaching, planning, and assessing all require additional education and skill, which is appropriate to the scope of practice of professional nurses.
After the respiratory therapist performs suctioning on a patient who is intubated, the RN measures vital signs for the patient. Which vital sign value should the RN be most concerned about?
A. Heart rate of 98 beats/min
B. Respiratory rate of 24 breaths/min
C. Blood pressure of 168/90 mm Hg
D. Tympanic temperature of 101.4ºF (38.6ºC)
Ans: D
Infections are always a threat to the patient receiving mechanical ventilation. The endotracheal tube bypasses the body's normal air-filtering mechanisms and provides a direct access route for bacteria or viruses to the lower part of the respiratory system.
The nurse identifies that the greatest risk for a wound infection exists for a patient with a:
A. Surgical creation of a colostomy
B. First-degree burn on the back
C. Puncture of the foot by a nail
D. Paper cut on the finger
Ans: C
C. Of all the options, puncture of the foot
by a nail has the greatest risk for a wound
infection. A nail is a soiled object that has
the potential of introducing pathogens
into a deep wound that can trap them
under the surface of the skin, a favorable
environment for multiplication. Surgery is conducted using sterile technique. In addition, preoperative preparation of the bowel helps to reduce the presence of organisms that have the potential to cause infection. There is no break in the skin in a first-degree burn; therefore, there is less of a risk for a wound infection than an example in another
option. Paper generally is not heavily soiled, and the wound edges are approximated. This is less of
a risk than an example in another option.
A 75-year-old client, hospitalized with a cerebral vascular accident (stroke), becomes disoriented at times and tries to get out of bed, but is unable to ambulate without help. What is the most appropriate safety measure?
A. Restrain the client in bed.
B. Ask a family member to stay with the client.
C. Check the client every 15 minutes.
D. Use a bed exit safety monitoring device
Ans: D
Use a bed exit safety monitoring device.
Rationale: Option D is an intervention that can allow the client to feel independent and also alert the nursing and nursing staff when the client needs assistance. It is the most realistic answer that promotes client safety. Option A can increase agitation and confusion and removes the client's independence. Option B would help but transfers the responsibility to the family member. Option C is inappropriate since the client could fall during the unobserved interval and it is not a realistic answer for the nurse.
A charge nurse on the cardiac unit observes a new graduate nurse as she suctions a patient with a tracheostomy. What action, if performed by the graduate nurse, would require intervention from the charge nurse?
A. The graduate nurse hyperoxygenates the client for three minutes before suctioning.
B. The graduate nurse withdraws the catheter and intermittently applies suction for no longer than nine seconds.
C. The graduate nurse elevates the head of the bed to Semi-Fowler's position before beginning.
D. The graduate nurse withdraws the catheter and intermittently applies suction for no longer than fifteen seconds.
Ans: D
The graduate nurse withdraws the catheter and intermittently applies suction for no longer than fifteen seconds. The nurse should suction a patient for no longer than ten seconds.
A nurse is caring for four clients who are postoperative from surgery 24 hr ago. At 1200 the nurse assesses the clients. Which of the following clients is the nurse’s priority?
A. A client who has a prescription for insulin and his premeal capillary blood glucose was 145 mg/dL and his post-meal capillary blood glucose is now 220 mg/dL
B. A client whose wound drainage at 0800 was sanguineous and now it is serosanguineous
C. A client who reports pain as 4 on a scale of 1 to 10 at 0800 now reports pain as 7
D. A client whose blood pressure at 0800 was 138/86 mm Hg and at 1200 is 96/55 mm Hg
Ans: D
A client who is postoperative is at risk for hemorrhage. A blood pressure decrease of 15 to 20 points is significant. This client is unstable; therefore, this client is the nurse’s priority.
Although the client refused the procedure, the nurse insisted and inserted a nasogastric tube in the right nostril. The administrator of the hospital decides to settle the lawsuit because the nurse is most likely to be found guilty of which of the following?
A. An unintentional tort
B. Assault
C. Invasion of Privacy
D. Battery
Ans: D
D. Battery
Rationale: Battery is the willful touching of a person without permission. Another name for an unintentional tort is malpractice. This situation is an intentional tort because the nurse executed the act on purpose.
A nurse is caring for a new mother who is concerned that her newborn's eyes cross. Which of the following statements is a therapeutic response by the nurse?
A. "I will call your primary care provider to report your concerns."
B. "I will take your baby to the nursery for further examination."
C. "This occurs because newborns lack muscle control to regulate eye movement."
D. "This is a concern, but strabismus is easily treated with patching."
Ans: C
This addresses the client’s concerns because it provides information that addresses her concerns. The eyes of newborns are structurally incomplete and muscle control is not fully developed for 3 months.
A nurse is preparing to administer the first dose of hepatitis B vaccine to a newborn. Which site is most appropriate for the injection?
A. Deltoid muscle
B. Vastus lateralis muscle
C. Gluteal muscle
D. Dorsogluteal site
Ans: B
The vastus lateralis muscle is the preferred site for intramuscular injections in newborns and infants due to its large muscle mass.
When care assignments are being made for patients with alterations related to gastrointestinal (GI) cancer, which patient would be the most appropriate to assign to an LPN/ LVN under the supervision of a team leader RN?
A. A patient with severe anemia secondary to GI bleeding
B. A patient who needs enemas and antibiotics to control GI bacteria
C. A patient who needs preoperative teaching for bowel resection surgery
D. A patient who needs central line insertion for chemotherapy
Ans: B
Administering enemas and antibiotics is within the scope of practice of LPNs/ LVNs. Although some states an facilities may allow the LPN/ LVN to administer blood, in general, administering blood, providing preoperative teaching, and assisting with central line insertion are the responsibilities of the
A few minutes after you have given an intradermal injection of an allergen to a patient who is undergoing skin testing for allergies, the patient reports feeling anxious, short of breath, and dizzy. Which action included in the emergency protocol should you take first?
A. Start oxygen at 4 L/ min using a nasal cannula.
B. Obtain IV access with a large-bore IV catheter.
C. Give epinephrine (Adrenalin) 0.3 mL intramuscularly.
D. Administer 3 mL of nebulized albuterol (Proventil) 0.083%
Ans: C
Epinephrine is the initial drug of choice for treatment of anaphylaxis. Giving epinephrine rapidly at the onset of an anaphylactic reaction may prevent or reverse cardiovascular collapse as well as airway narrowing caused by bronchospasm and inflammation. Oxygen use is also appropriate, but oxygen would be administered using a nonrebreather mask in order to achieve a fraction of inspired oxygen closer to 100%. Albuterol may also be administered to decrease airway narrowing but would not be the first therapy used for anaphylaxis. IV access will take longer to establish and should not be the first intervention. Focus: Prioritization
The nurse understands that the factor that places a patient at the greatest risk for developing
an infection is:
A. Implantation of a prosthetic device
B. Presence of an indwelling urinary catheter
C. Burns more than twenty percent of the body
D. Multiple puncture sites from laparoscopic surgery
Ans: C
A. Although wound infections can occur when
prosthetic devices are implanted, they are
surgically implanted under sterile conditions
to minimize this risk.
B. Although urinary tract infections can occur
with an indwelling urinary catheter, even
though generally it is a closed system, an
example in another option places a person at a
greater risk for infection.
C. Burns more than 20% of a person's total
body surface generally are considered
major burn injuries. When the skin is
damaged by a burn, the underlying tissue
is left unprotected and the individual is at
risk for infection. The greater the extent
and the deeper the depth of the burn, the
higher the risk for infection.
D. Laparoscopic surgery is performed using
sterile technique to minimize the risk of
infection. An example in another option places
a person at a greater risk for infection.
Which nursing intervention is the highest in priority for a client at risk for falls in a hospital setting?
A. Keep all of the side rails up.
B. Review prescribed medications.
C. Complete the "get up and go" test.
D. Place the bed in the lowest position.
Ans: D
Rationale: Placing the bed in the lowest position results in a client falling the shortest distance. The client is least likely to fall when getting out of bed is at an appropriate height. Option A can cause a fall with injury because the client may fall from a higher distance when trying to get over the rail. Option B is important to do as certain medications can increase the risk of falling. However this is not the best answer because it is N/A to all clients. Option C would help the nurse to assess a client's risk for falling but would not prevent injury.
Which of the following situations is an example of negligence?
A. The nurse observes a UAP enter the room of a patient on contact precautions wearing gloves and a gown.
B. A nurse transcribes a new medication order: Questran powder 2 oz bid with wet food or one full glass of water.
C. The UAP (Unlicensed Assistive Personnel) fills a water basin with warm water while the patient with depression combs her hair.
D. The nurse checks the distal pulses of a patient's legs two hours after they have returned from a cardiac catheterization.
Ans: D
The nurse checks the distal pulses of a patient's legs two hours after they have returned from a cardiac catheterization. The nurse should have checked the patient's distal pulse immediately after the cardiac catheterization.
The nurse in the outpatient care clinic cares for a client diagnosed with heart failure. Which of the following orders, if written by the physician, should the nurse question?
A. "Administer Lasix 40mg twice daily PO."
B. "Administer Potassium 40mEq tab once daily PO."
C. "Administer 0.9% NS solution IV at a rate of 125mL/hr."
D. "Administer Lactated Ringers solution IV at a rate of 50mL/hr."
Ans: C
"Administer 0.9% NS solution IV at a rate of 125mL/hr." The rate listed is too high for a heart failure patient, who cannot handle so much fluid on their cardiac system.
The nurse notes that an advance directive is in the client's medical record. Which of the following statements represents the best description of guidelines a nurse would follow in this case?
A. A durable power of attorney for health care is invoked only when the client has a terminal condition or is in a persistent vegetative state
B. A living will allows an appointed person to make health care decisions when the client is in an incapacitated state.
C. A living will is invoked only when the client has a terminal condition or is in a persistent vegetative state.
D. The client cannot make changes in the advance directive once the client is admitted into the hospital.
Ans: C
A living will is invoked only when the client has a terminal condition or is in a persistent vegetative state.
A living will directs the client's healthcare in the event of a terminal illness or condition. A durable power of attorney is invoked when the client is no longer able to make decisions on his or her own behalf. The client may change an advance directive at any time.
A parent of a toddler asks a nurse at a well-child visit how the child's frequent temper tantrums can best be handled. Which of the following actions should the nurse suggest to the parent?
A. Spank the child
B. Ignore the temper tantrums.
C. Tell the child that temper tantrums are not acceptable.
D. Distract the child by offering to play a game.
Ans: B
Ignoring a negative behavior is a basic concept in behavior modification. The parent should be instructed to make sure that the child is safe, and then appear to ignore the child or walk away. Without an audience, the behavior is more likely to extinguish itself quickly.
. A nurse is performing a health screening for osteoporosis. Which client is at highest risk for developing this condition?
A. A 30-year-old male who exercises regularly
B. A 45-year-old female with a high body mass index
C. A 60-year-old male who smokes
D. A 70-year-old female who is underweight
Ans: D
A 70-year-old underweight female is at highest risk for osteoporosis due to age, gender, and low body weight.
Which pediatric pain patient should be assigned to a newly-graduated RN?
A. Adolescent who has sickle cell disease and was recently weaned from morphine delivered via a patient-controlled analgesia device to an oral analgesic; he has been continually asking for an increased dose
B. Child who needs premedication before reduction of a fracture; the child has been crying and is resistant to any touch to the arm or other procedures
C. Child who is receiving palliative end-of-life care; the child is receiving narcotics around the clock to relieve suffering, but there is a progressive decrease in alertness and responsiveness
D. Child who has chronic pain and whose medication and nonpharmacologic regimen has recently been changed; the mother is anxious to see if the new regimen is successful
Ans: B
The set of circumstances is least complicated for the child with the fracture, and this would be the best patient for a new and relatively inexperienced nurse. The child is likely to have a good response to pain medication, and with gentle encouragement and pain management the anxiety will resolve. The other three children have more complex social and psychological issues related to pain management.
You are monitoring a 53-year-old client who is undergoing a treadmill stress test. Which client-finding will require the most immediate action?
A. Blood pressure of 152/ 88 mm Hg
B. Heart rate of 134 beats/ min
C. Oxygen saturation of 91%
D. Chest pain level of 3 (on a scale of 10)
Ans: D
Chest pain in a client undergoing a stress test indicates myocardial ischemia and is an indication to stop the testing to avoid ongoing ischemia, injury, or infarction. Moderate elevations in blood pressure and heart rate and slight decreases in oxygen saturation are a normal response to exercise and are expected during stress testing. Focus: Prioritization
The physician orders a wound to be packed with a wet-to-damp gauze dressing. The nurse understands that this is done primarily to:
A. Minimize the loss of protein
B. Facilitate the healing process
C. Increase resistance to infection
D. Prevent the entry of microorganisms
Ans: B
A. Wet-to-damp packing of a wound is not
done to minimize the loss of protein from a
wound. Protein loss occurs until the wound
heals.
B. Packing a wound with wet-to-damp
dressings allows epidermal cells to migrate
more rapidly across the bed of the wound
surface than dry dressings, thereby
facilitating wound healing.
C. Although packing a wound with wet-to-damp
dressings will wick exudate up and away from
the base of the wound and therefore help to
increase resistance to a wound infection, it is
not the primary reason for its use.
D. This is not the primary purpose of a
wet-to-damp gauze dressing. Dry sterile
dressings are used to prevent the entry of
microorganisms into a wound.
The nurse, at change-of-shift report, learns that one of the clients in his care has bilateral soft wrist restraints. The client is confused, is trying to get out of bed, and had pulled out the IV line, which was subsequently reinserted. Which action(s) by the nurse is appropriate? Select all that apply.
A. Document the behavior(s) that require continued use of the restraints.
B. Ensure that the restraints are tied to the side rails.
C. Provide range-of-motion exercises when the restraints are removed.
D. Orient the client.
E. Assess the tightness of the restraints.
Ans: A, C, D, E
Standards require documentation of the necessity for restraints. The implementation of range-of-motion exercises prevents joint stiffness and pain from disuse. Orienting the client helps the nurse determine the necessity of the restraint. Option B is inappropriate because it may cause injury if the side rail is lowered without untying the restraint.
An older client is admitted to the cardiac floor for new-onset atrial fibrillation. As the nurse is gathering admission history on the client, the client states, "Did you know that they can keep people alive even after they're brain dead? I never want to end up on those breathing machines." Which of the following questions should the nurse ask NEXT?
A. "Have you talked with your family about this?"
B. "I will make a note in your chart just in case."
C. "Do you have an advance directive?"
D. "Your lawyer can help you draft up papers to deal with this situation."
Ans: C
"Do you have an advance directive?"
An advance directive is a legal document that will ensure the patient's wishes are carried out, independent of what his family would like to do.
The nurse working on the diabetic specialty unit cares for four patients. A nursing assistant reports that each of the patients requires the nurse's attention. Which of the following patients, if described as detailed below by the nursing assistant, should be seen FIRST?
A. A diabetes type one patient who reported feeling weak and clammy and is now eating a simple-carbohydrate snack.
B. A diabetes type one patient who wants the nurse to change the dressing for his foot ulcer.
C. A diabetes type two patient who wants to know what to eat before she exercises.
D. A diabetes type two patient who reports headache, hot, dry skin and fruity odor to his breath.
Ans D:
A diabetes type two patient who reports headache, hot, dry skin and fruity odor to his breath.
The patient reporting hot, dry skin and fruity odor to breath shows signs of entering ketoacidosis and needs to be assessed immediately. The diabetes type one patient with low blood sugar (cool, clammy skin) is already eating a snack and should be seen second.
Nurses are bound by a variety of laws. Which description of a type of law is correct?
A. Statutory law is created by elected legislature, such as the state legislature that defines the Nurse Practice Act (NPA).
B. Regulatory law includes prevention of harm for the public and punishment for those laws that are broken.
C. Common law protects the rights of the individual within society for fair and equal treatment.
D. Criminal law creates boards that pass rules and regulations to control society.
Ans: A
A (Statutory law is created by legislature. It creates statues such as the NPA, which defines the role of the nurse and expectations of the performance of one's duties and explains what is contraindicated as guidelines for breech of those regulations.)
A nurse is educating a client who has osteoarthritis of the knee. Which of the following explanations should the nurse give to the client as part of the disease process?
A. Inflammation will resolve over time.
B. Damage to cartilage and bone can progressively worsen.
C. There will be periods of flareups and remission of symptoms.
D. Amputation may be necessary
Ans: B
As osteoarthritis progresses, bone-on-bone friction at the joint's point of contact causes degeneration of cartilage, which causes bone to erode.
A nurse is discussing health promotion strategies with a 50-year-old client. Which screening is most appropriate to recommend?
A. Annual mammogram
B. Bone density test
C. Colonoscopy every 10 years
D. Yearly prostate-specific antigen (PSA) test
Ans: C
A colonoscopy every 10 years is recommended for adults beginning at age 50 for colorectal cancer screening.
The nursing care plan for the client with dehydration includes interventions for oral health. Which interventions are within the scope of practice for an LPN/ LVN being supervised by a nurse? (Select all that apply.)
A. Reminding the client to avoid commercial mouthwashes
B. Encouraging mouth rinsing with warm saline
C. Observing the lips, tongue, and mucous membranes
D. Providing mouth care every 2 hours while the client is awake
E. Seeking a dietary consult to increase fluids on meal trays
Ans: A, B, C, D
The LPN/ LVN scope of practice and educational preparation includes oral care and routine observation. State practice acts vary as to whether LPNs/ LVNs are permitted to perform assessment. The client should be reminded to avoid most commercial mouthwashes, which contain alcohol, a drying agent. Initiating a dietary consult is within the purview of the RN or physician.
You are evaluating and assessing a patient with a diagnosis of chronic emphysema. The patient is receiving oxygen at a flow rate of 5 L/min by nasal cannula. Which finding concerns you immediately?
A. The patient has fine bibasilar crackles.
B. The patient’s respiratory rate is 8 breaths/min.
C. The patient sits up and leans over the night table.
D. The patient has a large barrel chest.
Ans: B
The oxygen flow is too high and is causing high serum oxygen level, which is decreasing the patient's respiratory drive. The oxygen flow needs to turned down.
The nurse in charge is evaluating the infection control procedures on the unit. Which finding indicates a break in technique and the need for education of staff?
A. The nurse aide is not wearing gloves when feeding an elderly client.
B. A client with active tuberculosis is asked to wear a mask when he leaves his room to go to another department for testing.
C. A nurse with open, weeping lesions of the hands puts on gloves before giving direct client care.
D. The nurse puts on a mask, a gown, and gloves before entering the room of a client on strict isolation.
Answer C.
Persons with exudative lesions or weeping dermatitis should not give direct client care or handle client-care equipment until the condition resolves.
There is no need to wear gloves when feeding a client. However, universal precautions (treating all blood and body fluids as if they are infectious) should be observed in all situations. A client with active tuberculosis should be on respiratory precautions. Having the client wear a mask when leaving his private room is appropriate. Strict isolation requires the use of mask, gown, and gloves.
A nurse is assessing a pregnant client in her third trimester. Which finding should be reported to the healthcare provider?
A. Mild edema in the feet
B. Shortness of breath when lying flat
C. Severe headache and visual disturbances
D. Occasional Braxton Hicks contractions
Ans. C
Severe headache and visual disturbances may indicate preeclampsia, which requires immediate medical attention
A nurse is caring for the client who has Ménière's disease and asks if he is allowed to ambulate independently. Which of the following responses should the nurse make?
A. "Yes, you are free to move around as you wish."
B. "No, you are on strict bedrest and must not be up."
C. "Please ring for assistance when you wish to get out of bed."
D. "We will have to get a prescription from your provider."
Ans: C
This response is appropriate. With assistance, the client can ambulate safely. Tinnitus, one-sided hearing loss, and vertigo are all manifestations of Ménière's disease that can increase the client's risk of falls when ambulating.
The charge nurse is supervising the nursing care administered on a busy medical/surgical unit. Which of the following situations, if noticed, would require immediate intervention?
A. A UAP (unlicensed assistive personnel) changes the linens on the bed while the patient with Meniere's disease ambulates to the bathroom.
B. A nurse talks with a patient's family with the patient's direct permission.
C. An LPN (licensed practical nurse) gathers all necessary supplies before entering the room of a patient who needs a sterile dressing change.
D. An RN (registered nurse) dresses in a gown and gloves before entering the room of a patient with localized herpes zoster.
Ans: A
A UAP (unlicensed assistive personnel) changes the linens on the bed while the patient with Meniere's disease ambulates to the bathroom.
The UAP should walk hand in hand with the patient with Meniere's disease. The main characteristic of the disorder is attacks of dizziness that could cause a fall and injury. It is safest to ambulate with them.
Which are the purposes of the Health Insurance Portability and Accountability Act of 1996? Select all that apply.
A. Mandate the informed consent process before procedures.
B. Protect health insurance benefits for workers who change jobs.
C. Establish standards to protect client privacy and confidentiality.
D. Protect coverage for individuals with preexisting conditions.
E. Guarantee payment to health-care facilities by Medicare.
Ans: B, C, D
Option B:
HIPAA provides for portability of insurance coverage if a person changes jobs.
Option C:
The HIPAA Privacy Rule has stipulations for how and when client information is shared.
Option D:
HIPAA prevents denial of coverage for those with preexisting conditions.
A nurse is caring for a client who is beginning to breastfeed her newborn after delivery. The new mother states, "I don't want to take anything for pain because I am breastfeeding." Which of the following statements should the nurse make?
A. "You need to take pain medications so you are more comfortable."
B. "We can time your pain medication so that you have an hour or two before the next feeding."
C. "All medications are found in breast milk to some extent."
d. "You have the option of not taking pain medication if you are concerned."
This answer does not provide an option for the client to enhance her comfort while breastfeeding her newborn.
Ans: B
This answer provides the client an option that allows for administration of pain medication but minimizes the effect it will have on the newborn while breastfeeding.
A nurse is performing a physical assessment on a pregnant client at 20 weeks gestation. Where should the nurse expect to palpate the fundus?
A. At the level of the symphysis pubis
B. Midway between the symphysis pubis and the umbilicus
C. At the level of the umbilicus
D. Midway between the umbilicus and the xiphoid process
Ans C:
At 20 weeks gestation, the fundus is typically palpated at the level of the umbilicus.
A nurse and an experienced licensed practical nurse (LPN) are caring for a group of clients. Which of the following tasks should the nurse delegate to the LPN? (Select all that apply.)
A. Obtain vital signs from a client who is 6 hr postoperative.
B. Administer a tap-water enema to a client who is preoperative.
C. Provide discharge instructions to a confused client's spouse.
D. Catheterize a client who has not voided in 8 hr.
E. Initiate a plan of care for a client who is postoperative from an appendectomy.
Ans: A, B, D
A. Obtaining vital signs from a client who is 6 hr postoperative is correct. Obtaining is a task that is appropriate to the education and skills of an LPN.
B. Administering a tap-water enema to a client who is preoperative is correct. Administering a tap-water enema is a task that is appropriate to the education and skills of an LPN.
D. Catheterizing a client who has not voided in 8 hr is correct. Urinary catheterization is a task that is appropriate to the education and skills of an LPN.
You have just finished assisting the physician with a thoracentesis for a patient with recurrent left pleural effusion caused by lung cancer. The thoracentesis removed 1800 mL of fluid. Which patient assessment information is important to report to the physician?
A. The patient starts crying and says she can’t go on with treatment much longer.
B. The patient complains of sharp, stabbing chest pain with every deep breath.
C. The patient’s blood pressure is 98/48 mm Hg and her heart rate is 114 beats/ min.
D. The patient’s dressing at the thoracentesis site has 2 cms of bright red bloody drainage.
Ans: C
Removal of large quantities of fluid from the pleural space can cause fluid to shift from the circulation into the pleural space, causing hypotension and tachycardia. The patient may need to receive IV fluids to correct this.
You are preparing to leave the room after performing oral suctioning on a client who is on contact and airborne precautions. In which order will you perform the following actions?
A. Remove N95 respirator.
B. Take off goggles.
C. Remove gloves.
D. Take off gown.
E. Perform hand hygiene.
Ans: C, B, D, A, E
This sequence will prevent contact of the contaminated gloves and gown with areas (such as your hair) that cannot be easily cleaned after client contact and stop transmission of microorganisms to you and your other clients. The correct method for donning and removal of personal protective equipment (PPE) has been standardized by agencies such as the CDC and the Occupational Safety and Health Administration.
The workmen cause an electrical fire when installing a new piece of equipment in the intensive care unit. A client is on a ventilator in the next room. The first action the nurse should take is to:
A. Attempt to extinguish the fire
B. Pull the fire alarm
C. Call the physician to obtain orders to take the client off the ventilator
D. Use an Ambu bag and remove the client from the area
The nurse's priority is to remove the client from immediate danger. Although the other actions may be appropriate, the nurse should first remove the client to a safe area.
A nurse is caring for a group of clients. Which of the following clients should the nurse refer to a social worker? (Select all that apply.)
A. A client who requires placement in an assisted living facility.
B. A client who requests to get school assignments while hospitalized on a pediatric unit.
C. A client who requests to obtain information on the adverse effects of antidepressant medication therapy.
D. A client who requests to secure an emergency notification system in the home.
E. A client who requests to receive additional instructions on breastfeeding prior to discharge.
ANS: A, B, D
A. A client who requires placement in an assisted living facility is correct. A social worker can assist in placing a client in an assisted living facility.
B. A client who requests to get school assignments while hospitalized on a pediatric unit is correct. It is within the scope of the social worker's expertise to coordinate with school systems to meet the educational needs of children who are hospitalized.
B. A client who requests to secure an emergency notification system in the home is correct. It is within the scope of the social worker's expertise to identify community resources to meet client needs after discharge.
D. client who requests to receive additional instruction on breastfeeding prior to discharge is incorrect. Instructions on breastfeeding are within the expertise of the nursing staff to complete, not a social worker.
A nurse is assessing a preschooler. Which of the following findings should indicate to the nurse a need for speech therapy? (Select all that apply.)
A. The preschooler speaks in three word sentences.
B. The preschooler talks to himself when reading.
C. The preschooler mispronounces words.
D. The preschooler stutters when speaking.
E. The preschooler speaks in a nasally tone.
Ans: C
The preschooler mispronounces words is correct. Language begins to increase with toddlers as development progresses towards two-to-three-word phrases. Mispronounced vowels and consonants occur between ages 24 and 36 months. The nurse should expect a toddler to mispronounce words.
E. Speaking in a nasally tone is correct. A child who speaks with a nasally tone might have a neurogenic speech disorder that is caused by weakened muscles of the tongue, soft palate, and face. A speech therapist can evaluate the child and determine exercises to improve the articulation, voice, pitch quality, and volume.
Which are examples of negligence? Select all that apply.
A. A nurse inadvertently giving a wrong dose of a medication
B. A nurse documenting vital signs in a medical record when they have not been taken
C. A nurse not turning and repositioning a bedridden client, resulting in the development of bedsores
D. A nurse not administering pain medications as needed for a hospice client
E. A client falling after the client has called for assistance in getting up, for which nobody responded after 25 minutes
Ans: C, D, E
Negligence is failure to use ordinary and reasonable care or to act in a responsible manner.
Option C:
A nurse failing to provide basic care that a reasonable person with similar credentials should provide is negligent.
Option D:
Not administering pain medications to a client who is in severe pain is negligent.
Option E:
A nurse is providing teaching to a client who has a new diagnosis of type 2 diabetes mellitus. The nurse should recognize that the client understands the teaching when he identifies which of the following as manifestations of hypoglycemia? (Select all that apply.)
A. Polyuria
B. Blurred vision
C. Polydipsia
D. Moist, clammy skin
E. Tachycardia
Ans: B, D, E
Blurred vision is correct. Manifestations of hypoglycemia include blurred vision.
Tachycardia is correct. Manifestations of hypoglycemia include tachycardia. Moist, clammy skin is correct. Manifestations of hypoglycemia include moist, clammy skin.
A nurse is performing a routine assessment on a 2-month-old infant. Which reflex should the nurse expect to be present?
A. Moro reflex
B. Babinski reflex
C. Stepping reflex
D. Rooting reflex
Ans: A
The Moro reflex is typically present in infants up to 4 months of age.