Basic Physical care (Part 2)

Reviewed by Editorial Team
The ProProfs editorial team is comprised of experienced subject matter experts. They've collectively created over 10,000 quizzes and lessons, serving over 100 million users. Our team includes in-house content moderators and subject matter experts, as well as a global network of rigorously trained contributors. All adhere to our comprehensive editorial guidelines, ensuring the delivery of high-quality content.
Learn about Our Editorial Process
| By Suarezenriquec1
S
Suarezenriquec1
Community Contributor
Quizzes Created: 12 | Total Attempts: 16,992
| Attempts: 629 | Questions: 114
Please wait...
Question 1 / 114
0 %
0/100
Score 0/100
1. A postoperative client receives a lunch tray with milk, custard, and vanilla ice cream. What is the client's current diet order?

Explanation

RATIONALE: A full-liquid diet consists of fluids and foods that are liquid at room temperature. Some examples are milk, custard, ice cream, puddings, vegetable and fruit juices, refined or strained cereals, and egg substitutes. Although milk, custard, and vanilla ice cream may be included in a dietetic exchange diet, they don't necessarily indicate that the client is following a dietetic exchange diet. A clear-liquid diet includes transparent liquids, such as apple juice, ginger ale, and chicken broth. The BRAT diet is commonly used to combat diarrhea and limits intake to bananas, rice, applesauce, toast, and dairy products.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Basic care and comfort
COGNITIVE LEVEL: Comprehension

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 989.

Submit
Please wait...
About This Quiz
Basic Physical care (Part 2) - Quiz

Physical care is the type of care given to someone who is facing a health problem or issue in order to get him or her back to working... see morecondition. The quiz below is the second in the series of tests that to see how equipped you are to offer basic care to your loved ones. Give it a try! see less

2. A client on prolonged bed rest has developed a pressure ulcer. The wound shows no signs of healing even though the client has received skin care and has been turned every 2 hours. Which factor is most likely responsible for the failure to heal?

Explanation

RATIONALE: Clients on bed rest suffer from lack of movement and a negative nitrogen balance. Therefore, inadequate protein intake impairs wound healing. Inadequate vitamin D intake and low calcium levels aren't factors in poor healing for this client. A pressure ulcer should never be massaged.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Comprehension

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p.1189.

Submit
3. A nurse is teaching a group of nursing assistants about infection-control measures. The nurse tells the group that the first line of intervention for preventing the spread of infection is:

Explanation

RATIONALE: Hand washing is the first line of intervention for preventing the spread of infection. Wearing gloves and assigning private rooms for clients can also decrease the spread of infection and should be implemented according to standard precautions. Antibiotics should be initiated when a causative organism is identified.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Application

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 708.

Submit
4. Which statement demonstrates a safe practice for taking telephone orders from a physician?

Explanation

RATIONALE: Nurses may accept telephone orders, but should do so only when absolutely necessary. To verify the information, the nurse must read back the order and clarify any questions about the order. The physician must cosign the order within 24 hours; there's no need for the physician to rewrite the order.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Application

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 255.

Submit
5. Which nursing action is essential when providing continuous enteral feeding?

Explanation

RATIONALE: Elevating the head of the bed during enteral feeding minimizes the risk of aspiration and allows the formula to flow into the client's intestines. When such elevation is contraindicated, the client should be positioned on his right side. The nurse should give enteral feedings at room temperature to minimize GI distress. Because methylene blue can cause adverse effects, it isn't a recommended enteral feeding additive.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Application

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1452.

Submit
6. A client twists his right ankle while playing basketball and seeks care for ankle pain and swelling. After the nurse applies ice to the ankle for 30 minutes, which client statement suggests that ice application has been effective?

Explanation

RATIONALE: Ice application decreases pain and swelling. Continued or increased pain, redness, and increased warmth are signs of inflammation that shouldn't occur after ice application.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Application

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1222.

Submit
7. A client's blood test results are: white blood cell (WBC) count is 1,000/μl; hemoglobin (Hb) level, 14 g/dl; hematocrit (HCT), 42%. Which goal is most important for this client?

Explanation

RATIONALE: The client's dangerously low WBC count puts him at risk for infection. Hb level and HCT are within normal limits; therefore, fluid balance, rest, and prevention of injury are inappropriate.

CLIENT NEEDS CATEGORY: Health promotion and maintenance
CLIENT NEEDS SUBCATEGORY: None
COGNITIVE LEVEL: Application

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 1061.

Submit
8. Which situation demonstrates correct principles of confidentiality?

Explanation

RATIONALE: Any health care provider must report suspected child abuse. Sharing this information doesn't violate the client's right to confidentiality. A discussion of confidential information in a public place may be overheard and is a breach of confidentiality. Any client information, whether written or electronic, is considered confidential; e-mailing it to a friend would be considered a breach of confidentiality. Nurses must discuss client's problems during change-of-shift report, but these discussions should be limited to information needed to provide safe care.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Application

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 256.

Submit
9. Policy and procedure require hand washing when caring for clients. Which statement about hand washing is true?

Explanation

RATIONALE: Even if the nurse wears gloves, she must wash her hands before and after client contact because thorough hand washing reduces the risk of cross-contamination. She shouldn't use bar soap because it's a potential carrier of bacteria. Soap dispensers are preferable, but they must be checked for bacteria. When water is unavailable, the nurse should use a liquid hand sanitizer to wash her hands.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Comprehension

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 708.

Submit
10. A nurse is assessing a client for the risk of falls. The nurse should obtain:

Explanation

RATIONALE: Assessing the client's gait and balance helps determine his risk of falls. The facility's policy on restraints isn't relevant to a risk assessment for falls. Assessing the family's psychosocial history and the client's dietary preferences are important but not as important as gait and balance in relation to the risk of falls.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Analysis

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 678.

Submit
11. To evaluate a client for hypoxia, the physician is most likely to order which laboratory test?

Explanation

RATIONALE: Red blood cell count, sputum culture, total hemoglobin, and ABG analysis all help evaluate a client with respiratory problems. However, ABG analysis is the only test that evaluates gas exchange in the lungs, providing information about the client's oxygenation status.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Comprehension

REFERENCE: Smeltzer, S.C., and Bare, B. Brunner & Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 334.

Submit
12. A client with terminal breast cancer is being cared for by a long-time friend who's a physician. The client has identified her sister as the agent in her health care power of attorney. The client loses decision-making capacity, and the sister tells the nurse, "A different physician will be caring for my sister now. I've dismissed her friend." In response, the nurse should:

Explanation

RATIONALE: A health care power of attorney transfers an individual's rights regarding health care decisions to the designated agent. It's within the power of the sister to change the physician caring for the terminally ill client. The dismissed physician has no power to interfere with the wishes of the health care power of attorney. It would be inappropriate and unprofessional of the nurse to ignore the wishes of the client's agent.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Application

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 92.

Submit
13. A client who's a member of Jehovah's Witnesses refuses a blood transfusion based on his religious beliefs and practices. His decision must be followed based on which ethical principle?

Explanation

RATIONALE: The right to refuse treatment is grounded in the ethical principle of respect for the autonomy of the individual. The client has the right to refuse treatment as long as he's competent and aware of the risks and complications associated with that refusal. The right to die is a difficult decision involving whether to initiate or withhold life-sustaining treatment for a client who is irreversibly comatose, vegetative, or suffering with end-stage terminal illness. The client may have signed an advance directive, making his wishes known. An advance directive is a document that provides guidelines for starting or continuing life-sustaining medical care, generally for a client who has a terminal disease or disability and can't indicate his own wishes. Substituted judgment is an ethical principle used when a nurse makes a decision based on what's best for an incapacitated client.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Application

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 1396.

Submit
14. After suctioning a client, a nurse should expect to find:

Explanation

RATIONALE: Clear breath sounds, which indicate that secretions have been removed, indicate effective suctioning. An above-normal respiratory rate, such as a rate of 28 breaths/minute, may indicate that the airway isn't clear of secretions and the client's respiratory rate has increased to compensate. A slightly increased heart rate, such as a rate of 104 beats/minute, may indicate health concerns unrelated to suctioning. Brisk capillary refill indicates adequate cardiovascular function and is unrelated to suctioning.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Comprehension

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1649.

Submit
15. A client complains of dyspnea. Which action by the nurse is most appropriate?

Explanation

RATIONALE: Fowler's position — the posture assumed by the client when the head of the bed is elevated 40 to 60 degrees — promotes breathing by allowing the thoracic cavity to expand. The Trendelenburg, Sims', and supine positions wouldn't facilitate breathing.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Basic care and comfort
COGNITIVE LEVEL: Application

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 870.

Submit
16. A client admitted with anorexia nervosa lost 30 lb (13.6 kg) during the previous 3 months. When planning this client's care, what should a nurse select as a priority intervention?

Explanation

RATIONALE: The nurse must first assess and plan interventions for the client's nutrition and other immediate physical needs. The nurse should consult with a dietitian to determine the client's dietary requirements, set nutritional goals, and explore ways to meet those goals. Requesting an order for physical therapy, having a chaplain visit the client, and shampooing the client's hair are also important interventions. However, they don't meet basic physical needs and aren't priority interventions at this time.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Analysis

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 61.

Submit
17. Delegation is the process of transferring work to subordinates. A nurse-manager may appropriately delegate which task?

Explanation

RATIONALE: Scheduling may be safely and appropriately delegated. Termination, disciplinary action, and salary increases shouldn't be delegated to staff, who don't have the power and authority to take such actions.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Analysis

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 116.

Submit
18. When caring for a client with a 3-cm stage I pressure ulcer on the coccyx, which action may the nurse institute independently?

Explanation

RATIONALE: The nurse may wash the area with normal saline solution and apply a protective dressing. These interventions will protect the area and are within the nurse's scope of practice. A nurse must obtain a physician's order to use a povidone-iodine wash or an antibiotic cream. Massaging with an astringent can further damage the skin.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Basic care and comfort
COGNITIVE LEVEL: Application

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 315.

Submit
19. A nurse revises the care plan for a client who has difficulty dealing with a crying neonate. Which strategy should the new care plan implement early in this mother's hospital stay?

Explanation

RATIONALE: Assessment of the mother's coping strengths and weaknesses and the presence or absence of support systems is an important aspect in the implementation process. Assessment will also help the nurse identify situations that the mother perceives as stressors. Educating the client about alternative ways of expressing feelings and about crisis hotlines and community support systems should also be part of the care plan. The nurse hasn't established that the mother is angry, so anger-management therapy may not be necessary. Proper care of a crying neonate is necessary, and assessing the mother's coping will help provide the basis for teaching the essential skills.

CLIENT NEEDS CATEGORY: Psychosocial integrity
CLIENT NEEDS SUBCATEGORY: None
COGNITIVE LEVEL: Analysis

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 198.

Submit
20. A client with severe chest pain is brought to the emergency department. He tells the nurse, "I just have a little indigestion." Which coping mechanism is the client exhibiting?

Explanation

RATIONALE: During a crisis, it's common for a client to use denial, a coping mechanism exhibited by minimizing symptoms or avoiding discussion. Anxiety is typically indicated by restlessness. A client who verbally acknowledges a problem exists isn't confused or repressing the incident.

CLIENT NEEDS CATEGORY: Psychosocial integrity
CLIENT NEEDS SUBCATEGORY: None
COGNITIVE LEVEL: Comprehension

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 963.

Submit
21. A nurse is caring for a client who required chest tube insertion for a pneumothorax. To assess for pneumothorax resolution, the nurse can anticipate that the client will require:

Explanation

RATIONALE: Chest X-ray confirms diagnosis by revealing air or fluid in the pleural space. SaO2 values may initially decrease with a pneumothorax but typically return to normal within 24 hours. ABG studies may show hypoxemia, possibly with respiratory acidosis and hypercapnia not related to a pneumothorax. Chest auscultation will determine overall lung status, but it's difficult to determine if the chest has reexpanded sufficiently.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Analysis

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1633.

Submit
22. A client complains of abdominal discomfort and nausea while receiving tube feedings. Which intervention is most appropriate for this problem?

Explanation

RATIONALE: Complaints of abdominal discomfort and nausea are common in clients receiving tube feedings. Stopping the feeding and checking for residual volume helps assess the reason for the client's nausea and discomfort. If residual volume is greater than 100 ml, hold the feeding and notify the physician. Feedings are normally given at room temperature to minimize abdominal cramping; however, this action doesn't help assess why nausea and discomfort are occurring. Elevating the head of the client's bed to at least 30 degrees prevents aspiration during feeding. Also, feeding containers are changed daily to prevent bacterial growth.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Basic care and comfort
COGNITIVE LEVEL: Application

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 992.

Submit
23. A nurse is to collect a sputum specimen from a client. The best time to collect this specimen is:

Explanation

RATIONALE: Because sputum accumulates in the lungs during sleep, the nurse should collect a sputum specimen in the morning, as soon as the client awakens. This specimen will be concentrated, increasing the likelihood of an accurate culture. Sputum specimens collected at other times during the day aren't concentrated and may not provide an accurate culture.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Knowledge

REFERENCE: Ellis, J.R., and Bentz, P.M. Modules for Basic Nursing Skills, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 288.

Submit
24. Which assessment is most supportive of the nursing diagnosis, Impaired skin integrity related to purulent wound drainage?

Explanation

RATIONALE: The nursing diagnosis indicates that the client's wound, which has purulent drainage, is infected. In response to the infection, the client's temperature would be elevated. A heart rate of 88 beats/minute, healing by primary intention, and a dry, intact dressing demonstrate normal assessment findings.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Application

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1192.

Submit
25. An obese, malnourished client has undergone abdominal surgery. While ambulating on the fourth postoperative day, she complains to the nurse that her dressing is saturated with drainage. Before this activity, the dressing was dry and intact. Which is the best initial action for the nurse to take?

Explanation

RATIONALE: The client probably has a wound evisceration or dehiscence. The first step is to assess the wound; then the nurse can implement appropriate measures. Splinting the abdomen, applying an abdominal binder, or reinforcing the existing dressing would delay treatment.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Application

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1193.

Submit
26. Which statement is a guideline to help nurses protect themselves from liability?

Explanation

RATIONALE: The nurse practice act outlines acceptable standards for nursing for a particular state. Practicing within those guidelines will protect the nurse from liability. The nurse shouldn't follow all physician's orders because physicians may not be aware of guidelines for nurses and may delegate inappropriate treatment or practice for the nurse. The client doesn't know standards of care and isn't responsible for the nurse's actions. Insurance won't prevent a liability suit, it will only assist the nurse if a suit should be filed.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Knowledge

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 99.

Submit
27. A nurse-manager notes that a staff nurse isn't working to full potential. Which strategy by the nurse-manager would best benefit the staff nurse?

Explanation

RATIONALE: The nurse-manager should meet with the staff nurse to discuss her performance and ways she can improve. Assigning the staff nurse several clients with multiple physical problems would be overwhelming, counterproductive, and unsafe because she has yet to demonstrate the priority-setting and decision-making leadership skills that this client load would require. Letting her select her own assignments or giving her fewer patients could impair the morale of other staff nurses.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Application

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 115.

Submit
28. A nurse is teaching the parents of a child with cystic fibrosis about proper nutrition. Which instruction should the nurse include?

Explanation

RATIONALE: The child should be encouraged to eat a high-calorie, high-protein diet. In cystic fibrosis, the pancreatic enzymes (lipase, trypsin, and amylase) become so thick that they plug the ducts. In the absence of these enzymes, the duodenum can't digest fat, protein, and some sugars; therefore, the child can become malnourished. A child with cystic fibrosis needs to drink plenty of fluid and take salt supplements, especially on warm days or when exercising, to help maintain hydration and adequate sodium levels. Water-soluble forms of the fat-soluble vitamins (A, D, E, and K) are essential.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Basic care and comfort
COGNITIVE LEVEL: Application

REFERENCE: Pillitteri, A. Maternal & Child Health Nursing: Care of the Childbearing and Childrearing Family, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 1271.

Submit
29. Which is a nurse's role in a situation involving domestic abuse?

Explanation

RATIONALE: The nurse must carefully and adequately document her assessment of the abused victim. The documentation must include statements from the victim, physical and psychological assessment findings, and observations relative to the abuse situation. The nurse should give the victim information about community resources, social agencies, and legal services to prevent recurrence of physical abuse. A professional nurse isn't qualified to counsel the abuser or the victim. She should refer the abuser and the victim to a professional counselor trained in dealing with domestic violence.

CLIENT NEEDS CATEGORY: Psychosocial integrity
CLIENT NEEDS SUBCATEGORY: None
COGNITIVE LEVEL: Analysis

REFERENCE: Weber J., and Kelley, J. Health Assessment in Nursing, 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 898.

Submit
30. As a nurse-manager of a medical-surgical unit reviews the month's risk-management data, she notices that a number of incident reports were completed because 6 p.m. medications were administered late. Dinner is served between 5:30 p.m. and 6 p.m. Staff take their dinner breaks between 5 p.m. and 6:30 p.m. Based on this information, which is the most appropriate action for the nurse-manager to take?

Explanation

RATIONALE: An effective nurse-manager knows that to accurately evaluate risk-management findings, she must look at the entire process and the circumstances surrounding each incident. Terminating staff without such evaluation doesn't resolve all the problem's contributing factors. She shouldn't change dinner breaks or kitchen delivery times unless she has evaluated how these factors influence medication administration.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Analysis

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 321.

Submit
31. A hospitalized client who has a living will is being fed through a nasogastric (NG) tube. During a bolus feeding, the client vomits and begins choking. Which action should the nurse take?

Explanation

RATIONALE: A living will gives information about what the client wants if he is in a terminal or permanently unconscious state. A living will doesn't apply to nonterminal events such as choking on an enteral feeding device. In this situation, the nurse should clear the client's airway. Making the client comfortable ignores the life-threatening event. Cardiopulmonary resuscitation isn't indicated. Removing the NG tube would exacerbate the situation.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Application

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 92.

Submit
32. In planning a presentation that advocates decreasing the client-to-nurse ratio from 8:1 to 6:1, a nurse should emphasize the effect on:

Explanation

RATIONALE: Client-care quality should always be the first consideration when proposing a change in care provision. Institutional resources, standards of practice, and nursing recruitment will all influence the decision but none should be as influential as client-care quality.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Knowledge

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 27.

Submit
33. Standard precautions include which measure?

Explanation

RATIONALE: To follow standard precautions, caregivers must wear gloves when there is the potential for contact with a client's body fluids; place used, uncapped needles and syringes in a puncture-resistant container; and wear goggles during procedures that are likely to generate splashes of blood or body fluids.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Comprehension

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 531.

Submit
34. An elderly client has been admitted to the medical-surgical unit from the postanesthesia care unit. While the nurse is off the floor, the client falls out of bed and fractures his right leg and right wrist. The nurse finding him states, "The side rails were down and the bed was in the high position." The client's family files legal charges against the nurse and the hospital. Which charge most accurately reflects the nurse's actions?

Explanation

RATIONALE: The position of the client's bed indicates negligence, a general term that denotes conduct lacking in due care. Collective liability stems from cooperation by several manufacturers in a wrongful activity. Comparative negligence holds the injured parties accountable for their fault in the injury. Battery involves harmful or unwarranted contact with the client.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Analysis

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 101.

Submit
35. According to Elizabeth Kübler-Ross, which stages of grief do a client or family member experience?

Explanation

RATIONALE: Denial, the avoidance of death's inevitability, is the first step of the grieving process. Anger, the most intense grief reaction, arises when people realize that a family member will die or has died. Bargaining occurs when family members attempt to stall or manipulate the outcome or death. Depression is a response to loss expressed as profound sadness or deep suffering. Acceptance, the final stage of grief, is the ability to overcome the emotion and accept what has happened.

CLIENT NEEDS CATEGORY: Psychosocial integrity
CLIENT NEEDS SUBCATEGORY: None
COGNITIVE LEVEL: Knowledge

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 987.

Submit
36. A client in a long-term care facility refuses to take his oral medications. The nurse threatens that she will apply restraints and inject the medication if he doesn't take it orally. The nurse's statement constitutes which legal tort?

Explanation

RATIONALE: 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 him time to talk, and then determine if he will take the medications. If the client still won't take the medications, the nurse should document his 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.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Comprehension

REFERENCE:Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 101.

Submit
37. When planning and prioritizing care and teaching needs for the family of a client with a new feeding tube, a nurse should consider the client's probable length of stay and remember that:

Explanation

RATIONALE: Duration of hospital stays is decreasing, and discharged clients go home with more complex needs than in the past. Teaching should begin on the day of admission. This allows time for adequate teaching and for the client and caregivers to become comfortable with any new procedures they will need to perform. Trying to teach the caregiver immediately before discharge wouldn't allow time for practice and return demonstrations. Most insurance reimbursements don't allow for lengthy hospital stays. The main responsibility for teaching clients and family members falls to the nurse, not the physician.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Analysis

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 29.

Submit
38. A nurse is using the computer when a client calls for pain medication. Which action by the nurse helps maintain computer security?

Explanation

RATIONALE: A nurse should meet a client's request for pain medication as quickly as possible after she logs out of the computer. A nurse shouldn't ask a client to wait for as long as 15 minutes for requested pain medication. If the nurse leaves the terminal without logging out, others may view confidential information or use her password. Asking a coworker to log her out isn't safe computer practice.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Application

Submit
39. A nurse is monitoring a client who is receiving moderate sedation during a breast biopsy. Which symptom should the nurse assess first?

Explanation

RATIONALE: Coarse crackles may indicate aspiration — a potentially life-threatening complication of conscious sedation. A heart rate of 84 beats/minute is within the normal range. Mild bleeding is expected at the surgical site. Poor positioning during surgery commonly causes lower back pain. Although the nurse should ultimately assess this pain, it isn't her first priority.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Analysis

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 828.

Submit
40. A nurse should question an order for a heating pad for a client who has:

Explanation

RATIONALE: Heat application increases blood flow and therefore is contraindicated in active bleeding. For the same reason, however, applying heat to a reddened abscess, an edematous lower leg, or a wound with purulent drainage promotes healing.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Analysis

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1223.

Submit
41. 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 clean the area?

Explanation

RATIONALE: The client should swab the labia minora from front to back, using one swab for each wipe. 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 doing so 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.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Comprehension

REFERENCE: Ellis, J.R., and Bentz, P.M. Modules for Basic Nursing Skills, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 286.

Submit
42. A physician orders hourly urine output measurement for a postoperative client with an indwelling catheter. The nurse records the following amounts of output for 2 consecutive hours: 8 a.m.: 50 ml; 9 a.m.: 60 ml. Based on these amounts, which action should the nurse take?

Explanation

RATIONALE: Normal urine output for an adult with an indwelling catheter is at least 30 ml/hour. Therefore, this client's output is normal. Beyond continued evaluation, no nursing action is warranted.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Basic care and comfort
COGNITIVE LEVEL: Analysis

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p.1079.

Submit
43. Which client would qualify for hospice care?

Explanation

RATIONALE: Hospices provide supportive, palliative care to terminally ill clients, such as those with late-stage AIDS, as well as their families. Hospice services wouldn't be appropriate for a client with left-sided paralysis resulting from a stroke, a client who's undergoing treatment for heroin addiction, or one who recently had coronary artery bypass surgery because these health problems aren't necessarily terminal.

CLIENT NEEDS CATEGORY: Health promotion and maintenance
CLIENT NEEDS SUBCATEGORY: None
COGNITIVE LEVEL: Comprehension

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 159.

Submit
44. A nurse is recording a client's complaint of painful urination. When documenting this symptom, the nurse should use which term?A nurse is recording a client's complaint of painful urination. When documenting this symptom, the nurse should use which term?

Explanation

RATIONALE: The nurse should document painful urination as dysuria. Oliguria refers to a decrease in the amount of urine excreted; anuria, to a urine output below 50 ml/day; and pyuria, to pus in the urine.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Basic care and comfort
COGNITIVE LEVEL: Knowledge

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed.Philadelphia: Lippincott Williams & Wilkins, 2007, p. 1084.

Submit
45. A physician has ordered a heating pad for an elderly client's lower back pain. Which item would be most important for a nurse to assess before applying the heating pad?

Explanation

RATIONALE: A client who has impaired consciousness or altered mental status is at increased risk for injury from a heating pad. When administering a heat treatment, a nurse should always check the temperature of the heating unit and examine the client's skin for redness or irritation. Risk for falls, vital signs, and nutrition level are also important assessment areas, but they aren't the priority assessment for a client using a heating pad.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Application

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1223.

Submit
46. A nurse-manager works for a nonprofit health care corporation whose revenues have significantly exceeded annual expenses. The nurse-manager has been told to anticipate which action?

Explanation

RATIONALE: In a nonprofit organization, revenue exceeding expenses is tax-exempt and is usually reinvested in the organization and used to improve services. A for-profit organization calls revenue in excess of expenses a profit and divides it as a dividend among stockholders or reinvests it in the organization.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Application

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 155.

Submit
47. A client has a blood pressure of 152/86 mm Hg. The nurse should document the client's pulse pressure as:

Explanation

RATIONALE: Pulse pressure is the difference between the systolic and diastolic pressures — in this case, 66 mm Hg.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Basic care and comfort
COGNITIVE LEVEL: Comprehension

REFERENCE: Weber, J., and Kelley, J. Health Assessment in Nursing, 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 102.

Submit
48. A nurse is reviewing a client's laboratory test results. Which electrolyte is the major cation controlling a client's extracellular fluid (ECF) osmolality?

Explanation

RATIONALE: Sodium, the major ECF cation, maintains ECF osmolality. Potassium is the major cation in intracellular fluid. Chloride is the major anion in the ECF. Calcium, found primarily in the intravascular fluid compartment of ECF, is the major cation involved in the structure and function of the teeth and bones.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Knowledge

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 920.

Submit
49. When preparing a client for a diagnostic study of the colon, the nurse teaches the client how to self-administer a prepackaged enema. Which statement by the client indicates effective teaching?

Explanation

RATIONALE: Lying on the left side allows the enema solution to flow downward by gravity into the rectum and sigmoid colon. The other options don't accomplish this goal and, therefore, are less effective in evacuating the lower bowel.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Comprehension

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1588.

Submit
50. Entering a client's room, a nurse on the maternity unit sees a mother slapping the face of a crying neonate. Which action should the nurse take in this situation?

Explanation

RATIONALE: The neonate's safety and protection is the first priority. The nurse should immediately return the neonate to the nursery and inform the physician of the neonate's abuse. By being the neonate's advocate, the nurse allows the physician to examine the neonate for injuries resulting from the incident. Social services should be notified. The neonate shouldn't remain in the room with the mother unsupervised. The nurse should follow the facility's policy and procedure for reporting suspected and actual child abuse. Although the incident may be part of the mother and neonate's revised care plan, it requires immediate intervention, not simple notification of coworkers. Confronting the mother doesn't provide for the neonate's safety.

CLIENT NEEDS CATEGORY: Psychosocial integrity
CLIENT NEEDS SUBCATEGORY: None
COGNITIVE LEVEL: Analysis

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 370.

Submit
51. A client who's scheduled for open-heart surgery in 2 days has been having circulation problems in the feet and legs. The physician orders antiembolism stockings. The nurse is teaching the client about this treatment. What is the purpose of antiembolism stockings?

Explanation

RATIONALE: Made of elastic material, antiembolism stockings are designed to reduce or prevent edema of the legs or feet by promoting venous return. They do this by increasing — not decreasing — arterial and venous blood circulation to the legs and feet. They don't maintain warmth in the legs. Blankets can be used for this purpose.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Knowledge

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 897.

Submit
52. A physician has ordered a wet-to-damp dressing for an infected pressure ulcer. The nurse knows that the primary reason for this treatment is to:

Explanation

RATIONALE: Wet-to-damp dressings keep the wound bed moist, which helps promote the growth of granulation tissue. Because dead tissue adheres to a dry dressing, wet-to-dry dressings are used for debriding wounds. Wet-to-damp dressings don't prevent the spread of infection. Although these dressings provide a soothing, cool feeling, they don't relieve pain.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Basic care and comfort
COGNITIVE LEVEL: Knowledge

REFERENCE: Smeltzer, S.C., and Bare, B. Brunner & Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1947.

Submit
53. For healing by secondary intention, a client's wound has been packed with medicated dressings. The nurse evaluates the wound. Which finding indicates wound healing?

Explanation

RATIONALE: Connective tissue develops and fills in (or approximates) the wound edges from granulation tissue. Thus, evidence of granulation tissue indicates wound healing. Red or edematous surrounding tissue and serous drainage are insufficient evidence that the wound is healing.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Basic care and comfort
COGNITIVE LEVEL: Analysis

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 1013.

Submit
54. A manager of an outpatient clinic is explaining the various health care delivery systems to a client who's interested in joining a system with a reasonable fixed capitation rate. Which organization is the client primarily interested in joining?

Explanation

RATIONALE: An HMO provides comprehensive health care services for a fixed rate of payment or capitation. A PPO pays health care expenses for members who use a provider under contract to that PPO. Managed care provides beneficiaries with various services for an established, agreed upon payment. A privately funded insurance company won't offer services for a fixed rate.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Application

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 163.

Submit
55. For the past 24 hours, a client with dry skin and dry mucous membranes has had a urine output of 600 ml and a fluid intake of 800 ml. The client's urine is dark amber. These assessments indicate which nursing diagnosis?

Explanation

RATIONALE: Dark, concentrated urine, dry mucous membranes, and a urine output of less than 30 ml/hour (720 ml/24 hours) are symptoms of dehydration or Deficient fluid volume. Decreased urine output is related to deficient fluid volume, not Impaired urinary elimination. Nothing in the scenario suggests a nutritional problem. If a fluid volume excess were present, manifestations would most likely include signs of fluid overload such as edema.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Basic care and comfort
COGNITIVE LEVEL: Analysis

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 941.

Submit
56. A nursing supervisor asks a pediatric nurse to work temporarily (float) in the intensive care unit (ICU) because there are few clients in the pediatric unit. The pediatric nurse has never worked in ICU and has no intensive care experience. Which action should this nurse take?

Explanation

RATIONALE: The pediatric nurse should notify the nursing supervisor about feeling unqualified and untrained to float in the ICU. The nursing supervisor can advise the pediatric nurse about tasks she is qualified to perform in the ICU without jeopardizing her nursing license. When the census on a unit is low, many facilities use staff to float to another unit as a cost-effective and reasonable way for managing resources. Having the ICU nurses determine what tasks the pediatric nurse can perform makes the ICU nurses responsible for the pediatirc nurse's performance. However, the nursing supervisor should make those decisions because the supervisor knows the overall needs of the facility and can, therefore, best allocate nursing resources. A nurse should never accept responsibility for a total client care assignment if she doesn't have the skills to plan and deliver care.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Application

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 100.

Submit
57. A client with heart failure must be monitored closely after starting diuretic therapy. The best indicator for the nurse to monitor is:

Explanation

RATIONALE: Heart failure typically causes fluid overload, resulting in weight gain. Therefore, weight is the best indicator of this client's status. One pound gained or lost is equivalent to 500 ml. Fluid intake and output and vital signs are less accurate indicators than weight. Urine specific gravity reflects urine concentration, indicating overhydration or dehydration. Numerous factors can influence urine specific gravity, so it isn't the most accurate indicator of the client's status.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., and Bare, B. Brunner & Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 953.

Submit
58. A nurse prepares to transfer a client from a bed to a chair. Which principle demonstrates safe body mechanics?

Explanation

RATIONALE: Rocking provides extra force when pushing or pulling. The nurse should keep any weight as close to her body as possible when lifting — not at arm's length. The nurse should keep her knees slightly bent and her feet spread apart to provide a wide base of support. Keeping the knees straight and stiff and bending at the waist and keeping the feet close together aren't examples of safe body mechanics. These positions could result in injury to the nurse or to the client.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Application

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 775.

Submit
59. A primary unit nurse tells the nurse-manager that a newly hired registered nurse needs an additional week of orientation in order to function effectively on the staff. Which action is most appropriate for the nurse-manager to take?

Explanation

RATIONALE: The nurse-manager is responsible for adequate orientation of new staff. A need for additional orientation doesn't mean that a nurse isn't competent. However, the new nurse should know what's expected of her and how soon she must fulfill those expectations. Firing the new nurse isn't the answer because she's apparently close to completing orientation and the primary nurse says she has good skills. Periodically reviewing and revising the orientation process is a good idea. However, in this case, the most appropriate course of action is to help the new nurse complete her orientation as efficiently as possible.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Analysis

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 541.

Submit
60. A client is scheduled for an appendectomy. What is the nurse's highest priority when planning preoperative teaching for this client?

Explanation

RATIONALE: The nurse should encourage the client to cough and breathe deeply as soon as possible after surgery to help prevent atelectasis and pneumonia. She shouldn't encourage the client to take food or fluids until bowel sounds are present (usually 24 hours postoperatively). Wound infection is a concern, but usually not during the first postoperative day. The nurse should assess the client's skin every 2 hours when he is made to either change position or get out of bed.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Application

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 888.

Submit
61. A nurse is caring for an elderly client with a pressure ulcer on the sacrum. When teaching the client about dietary intake, which foods should the nurse emphasize?

Explanation

RATIONALE: Although the client should eat a balanced diet, including foods from all food groups, the diet should emphasize foods that supply complete protein, such as lean meats and low-fat milk. Protein helps build and repair body tissue, which promotes healing. Legumes provide incomplete protein. Cheese contains complete protein, but it also includes fat, which should be limited to 30% or less of caloric intake. Whole grain products supply incomplete proteins and carbohydrates. Fruits and vegetables provide mainly carbohydrates.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Basic care and comfort
COGNITIVE LEVEL: Application

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 1014.

Submit
62. A client has a nursing diagnosis of Ineffective airway clearance related to poor coughing. When planning this client's care, the nurse should include which intervention?

Explanation

RATIONALE: Interventions should address the etiology of the client's problem — poor coughing. Teaching deep breathing and coughing addresses this etiology. Increasing fluids may improve the client's condition, but this intervention doesn't address poor coughing. Improving airway clearance is too vague to be considered an appropriate intervention. Suctioning isn't indicated unless other measures fail to clear the airway.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Application

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 873.

Submit
63. A client hasn't voided since before surgery, which took place 8 hours ago. Which action should the nurse take first?

Explanation

RATIONALE: Before taking any action, the nurse must assess the client's bladder area for fullness. Urine retention is a common adverse effect of anesthesia. After confirming retention, the nurse should call the physician and expect an order to catheterize the client. Telling the client to bear down and try to void is inappropriate.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Basic care and comfort
COGNITIVE LEVEL: Application

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 1084.

Submit
64. When changing a sterile surgical dressing, a nurse first must:

Explanation

RATIONALE: To prevent the spread of microorganisms, the nurse should always wash her hands before providing client care. When changing a sterile surgical dressing, the nurse also must put on sterile gloves, remove the old dressing while wearing clean gloves, open sterile packages, and moisten the dressings with sterile saline. However, these actions follow hand washing.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Knowledge

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1210.

Submit
65. A nurse will use surgical asepsis for which procedure?

Explanation

RATIONALE: Caregivers must use surgical asepsis when performing wound care or any procedure that involves entering a sterile body cavity or breaking skin integrity. To achieve surgical asepsis, objects must be sterilized or kept free of all pathogens. Because inserting an I.V. catheter disrupts skin integrity and involves entry into a sterile cavity (a vein), surgical asepsis is required. Hand washing ensures medical asepsis or clean technique to prevent the spread of infection. The GI tract isn't sterile; therefore, irrigating a nasogastric tube or a colostomy requires only clean technique.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Comprehension

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 533.

Submit
66. When assessing a client with cellulitis of the right leg, which finding should the nurse expect to observe?

Explanation

RATIONALE: Cellulitis, an inflammation of soft tissues, can extend to surrounding tissues. The skin becomes reddened, warm, swollen, and sometimes painful. The skin wouldn't be cold, pale, or necrotic.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Basic care and comfort
COGNITIVE LEVEL: Knowledge

REFERENCE: Smeltzer, S.C., and Bare, B. Brunner & Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1017.

Submit
67. A nurse is obtaining a sterile urine specimen from a client's indwelling urinary catheter. During the procedure, the nurse should:

Explanation

RATIONALE: To collect urine properly, the nurse should aspirate it from a port, using a sterile syringe and needle after cleaning the port. Opening a closed urine-drainage system, which would occur if the nurse disconnected the catheter from the tubing or opened the drainage bag, would increase the risk of urinary tract infection. Although standard precautions specify wearing gloves during contact with body fluids, the nurse need not wear sterile gloves for this procedure.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Comprehension

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1495.

Submit
68. The nurse-manager of a 20-bed coronary care unit is off duty when a staff nurse makes a serious medication error. The client, who received an overdose of medication, nearly dies. Which statement accurately reflects the nurse-manager's accountability?

Explanation

RATIONALE: The nurse-manager is accountable for what happens on the unit 24 hours per day, 7 days per week. If a serious problem occurs, the nurse-manager should be notified as soon as possible.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Analysis

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 121.

Submit
69. Nursing care for a client includes removing elastic stockings once per day. What is the rationale for this intervention?

Explanation

RATIONALE: Elastic stockings are used to promote venous return. A nurse must remove them once per day to observe the condition of the skin underneath the stockings. Applying the stockings increases blood flow to the heart. When the stockings are in place, the leg muscles can still stretch and relax, and the veins can fill with blood.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Basic care and comfort
COGNITIVE LEVEL: Comprehension

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 899.

Submit
70. A nurse gives a client the wrong medication. After assessing the client, the nurse completes an incident report. Which statement describes what will happen next?

Explanation

RATIONALE: Incident reports document unusual occurrences and deviations from care. Facilities use the internal documents to evaluate care, determine potential risks, or discover system problems that might have contributed to the error. This type of error won't result in a report to the state board of nursing or in the nurse's suspension. Some facilities do track the number of errors a nurse or a particular unit makes; the purpose of tracking errors is to provide appropriate education and to improve the nursing process.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Analysis

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 566.

Submit
71. A client who has diabetes mellitus and has sustained a large laceration on her left wrist asks the nurse, "How long will it take for my scars to disappear?" Which statement is the nurse's best response?

Explanation

RATIONALE: In a client with diabetes, wound healing will be delayed. Providing a specific time frame could give the client false information.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Application

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1189.

Submit
72. A client hasn't voided since before surgery, which took place 8 hours ago. When assessing the client, a nurse will:

Explanation

RATIONALE: Eight hours is a long time not to have voided. The kidneys typically produce 35 to 55 ml of urine in 1 hour. After 8 hours of not voiding, the bladder would be full of urine and palpable above the symphysis pubis.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Basic care and comfort
COGNITIVE LEVEL: Application

REFERENCE: Weber, J., and Kelley, J. Health Assessment in Nursing, 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 453.

Submit
73. A nurse should encourage a client with a wound to consume foods high in vitamin C because this vitamin:

Explanation

RATIONALE: The client should be encouraged to consume foods high in vitamin C because vitamin C is essential for protein synthesis, an important part of wound healing. Hemostasis is responsible for the inflammatory response and reducing edema. Hemoglobin is responsible for oxygen transport.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Basic care and comfort
COGNITIVE LEVEL: Knowledge

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1189.

Submit
74. When planning cost-effective care, a nurse should choose interventions that:

Explanation

RATIONALE: Promoting a healthy lifestyle that may prevent many costly illnesses is an effective way to cut health care costs. Interdisciplinary care should involve frequent communication and feedback among team members to promote continuity of care and decrease length of stay. Following up frequently and monitoring outcomes are important ways of decreasing costs and preventing multiple readmissions for certain diagnoses. Nurses should choose interventions that provide cost-effective care rather than the greatest reimbursement to the facility.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Analysis

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 705.

Submit
75. A client who suffered a stroke has a nursing diagnosis of Ineffective airway clearance. The goal of care for this client is to mobilize pulmonary secretions. Which intervention helps meet this goal?

Explanation

RATIONALE: Repositioning the client every 2 hours helps prevent secretions from pooling in dependent lung areas. Restricting fluids would make secretions thicker and more tenacious, thereby hindering their removal. Administering oxygen and keeping the head of the bed at a 30-degree angle might ease respirations and make them more effective but wouldn't help mobilize secretions.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Application

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 873.

Submit
76. A client is placed in isolation. Client isolation techniques attempt to break the chain of infection by interfering with the:

Explanation

RATIONALE: Client isolation techniques attempt to break the chain of infection by interfering with the transmission mode. These techniques don't affect the agent, host, or portal of entry.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Knowledge

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p.530.

Submit
77. When preparing a client with a draining vertical incision for ambulation, where should a nurse apply the thickest portion of a dressing?

Explanation

RATIONALE: When a client is ambulating, gravity causes the drainage to flow downward. Covering the base of the wound with extra dressing will contain the drainage. Applying the thickest portion of the dressing at the top, in the middle, or over the total wound won't contain the drainage.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Application

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1192.

Submit
78. A nursing assistant is caring for a client with Clostridium difficile diarrhea and asks the charge nurse, "How can I keep from catching this from the client?" The nurse reminds the nursing assistant to wash her hands and to ensure that the client is placed:

Explanation

RATIONALE: C. difficile can be transmitted from person to person by hands or waste containers such as a bedpan. A nurse who is in direct contact with the client 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 C. difficile diarrhea is not.

CLIENT NEEDS CATEGORY: Health promotion and maintenance
CLIENT NEEDS SUBCATEGORY: None
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., and Bare, B. Brunner & Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 2482.

Submit
79. A client hospitalized with pneumonia has thick, tenacious secretions. Which intervention should the nurse include when planning this client's care?

Explanation

RATIONALE: Increasing the client's intake of oral or I.V. fluids helps liquefy thick, tenacious secretions and ensures adequate hydration. Turning the client every 2 hours would help prevent pressure ulcers but wouldn't help with the secretions. Elevating the head of the bed would reduce pressure on the diaphragm and ease breathing but wouldn't help the client with secretions. Maintaining a cool room temperature wouldn't help the client with secretions.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., and Bare, B. Brunner & Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 640.

Submit
80. A nurse-manager in the office of a group of surgeons has received complaints from discharged clients about inadequate instructions for performing home care. Knowing the importance of good, timely client education, the nurse-manager should take which steps?

Explanation

RATIONALE: Every nurse who provides client care should provide client education. Nurses must work together to establish the best methods of educating clients. The most appropriate response is to contact the facility's nurse-manager, not the nursing staff. Evaluating client education in only the surgeon's office doesn't consider the entire client education process and all of the staff providing it. Client education is an important nursing responsibility and every complaint derserves attention.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Application

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 541.

Submit
81. A nurse having difficulty setting up humidified oxygen at 40% per Venturi mask doesn't know how many liters of flow she should use. Which intervention should the nurse perform to ensure that the oxygen is properly administered?

Explanation

RATIONALE: When a problem falls outside of a nurse's experience or knowledge, she should consult with a specialist in that area. A respiratory therapist is an expert at setting up oxygen delivery systems. A nurse who incorrectly follows package directions could harm a client. A nursing assistant isn't considered an expert in oxygen delivery. A conventional oxygen mask wouldn't deliver the correct rate of flow to the client.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Analysis

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 161.

Submit
82. A nurse and newly hired nursing assistant are caring for a group of clients. The nurse is administering medications and needs to know the fingerstick glucose results before administering a medication. The nurse asks the nursing assistant if she's been validated on obtaining fingerstick glucose readings. The nursing assistant says she didn't have the skill validated, but she's seen it done many times and knows she can do it. What should the nurse do?

Explanation

RATIONALE: The nurse should validate the nursing assistant's ability to perform the fingerstick glucose procedure. The nursing assistant may not perform the procedure without having her skills validated by actually performing the procedure. Providing a verbal explanation isn't sufficient. If the nurse performs the procedure on her own, she forfeits the opportunity to validate the nursing assistant's skills, and therefore underutilizes the nursing assistant.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Application

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 312.

Submit
83. A nurse is caring for a child with celiac disease. How should the nurse evaluate the effectiveness of nutritional therapy?

Explanation

RATIONALE: A gluten-free diet should eliminate fat, bulky, foul-smelling stools in a child with celiac disease. This finding indicates that the disease is controlled and the child is using nutrients effectively. Taking vital signs, measuring blood urea nitrogen and serum creatinine levels, and measuring intake and output don't indicate the effectiveness of nutritional therapy.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Basic care and comfort
COGNITIVE LEVEL: Analysis

REFERENCE: Hatfield, N. Broadribb's Introductory Pediatric Nursing, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2003, p. 261.

Submit
84. Which statement is correct regarding the Omnibus Reconciliation Act of 1986?

Explanation

RATIONALE: The federal Omnibus Reconciliation Act of 1986 mandates that all hospitals establish written protocols for identifying potential organ and tissue donors. The act sets standards organ procurement agencies must meet. The medical examiner should be notified of a potential organ or tissue donor only if the medical examiner is involved in the case. Although a facility must have the family's permission to release the donor's name and information, this stipulation isn't part of the Omnibus Reconciliation Act of 1986. Requesters for donation are health care professionals who have received special training on properly approaching family members regarding organ or tissue donation.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Comprehension

REFERENCE: Omnibus Reconciliation Act of 1986, U.S. Code 42 Sec. 1320b-8 (1986).

Submit
85. A nurse must apply a wet-to-damp dressing over an ulcer on a client's left ankle. How should the nurse proceed?

Explanation

RATIONALE: The nurse should pack the moistened fine-mesh gauze dressings into all depressions and grooves of the wound because necrotic tissue is usually more prevalent in those areas. 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 these products can prevent air circulation and hinder drying of the fine-mesh gauze.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Application

REFERENCE: Ellis, J.R., and Bentz, P.M. Modules for Basic Nursing Skills, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 753.

Submit
86. A nurse is assisting a client with lower motor neuron damage who has difficulty with urination. The nurse shows the client how to apply gentle pressure over the lower abdomen to empty the bladder. By what name does the nurse refer to this procedure?

Explanation

RATIONALE: The client performs Credé's maneuver by applying manual pressure over the lower abdomen. This procedure promotes complete emptying of the bladder in clients with lower motor neuron damage that impairs the voiding reflex. Valsalva's maneuver triggers vagal stimulation of the heart. During this maneuver, the client is instructed to take a deep breath and bear down as if defecating. Valsalva's maneuver is commonly used to help terminate atrial arrhythmias. Kegel exercises involve alternating contraction and relaxation of the perineal muscles. Leopold's maneuvers are used to determine fetal position.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Basic care and comfort
COGNITIVE LEVEL: Application

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1503.

Submit
87. A nurse implements a teaching plan for a client who's scheduled for discharge. Which client behavior best demonstrates effective teaching?

Explanation

RATIONALE: Exhibiting a positive change in behavior best demonstrates that the client understands and is complying with discharge teaching. Merely repeating what has been said, telling the nurse that the client understands, or nodding the head to indicate "yes" wouldn't demonstrate that the client has learned anything.

CLIENT NEEDS CATEGORY: Psychosocial integrity
CLIENT NEEDS SUBCATEGORY: None
COGNITIVE LEVEL: Application

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 414.

Submit
88. While assessing the incision of a client who had surgery 2 weeks ago, a nurse observes that the suture line has a shiny, light pink appearance. Which step should the nurse take next?

Explanation

RATIONALE: During the fibrinoplastic stage of healing, granulation tissue, which has a characteristic pink shiny appearance, fills in the wound. This normal occurrence requires no further action. There is no evidence of wound dehiscence or necrotic tissue. There is also no indication that the wound is open or needs to be kept moist.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Basic care and comfort
COGNITIVE LEVEL: Application

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1190.

Submit
89. A nurse is preparing to help a client with weakness in his right leg move from his bed to a chair. Where should the nurse place the chair?

Explanation

RATIONALE: The client can maintain his weight and pivot with his left foot if the chair is placed on his right side parallel to the bed. The nurse shouldn't place the chair on the client's left side or perpendicular to the bed because he won't be able to support his weight on his right leg.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Application

REFERENCE: Ellis, J.R., and Bentz, P.M. Modules for Basic Nursing Skills, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 355.

Submit
90. The managers of the physical and occupational therapy neurologic departments tell a nurse-manager of an adult neurologic rehabilitation unit that they're concerned that clients have been arriving late for therapy. In response, the nursing staff of the rehabilitation unit complains that therapy schedules don't allow sufficient time for performing nursing interventions. Which action by the nurse-manager is the best solution to this problem?

Explanation

RATIONALE: In this situation, functioning as a democratic leader is best. The nursing and therapy staffs who deal with the day-to-day problems of direct client care have the best grasp of the situation and should have autonomy to solve problems. The nurse-manager, however, should be available to help. Meeting with only the managers of physical and occupational therapy reflects an autocratic manager. Without staff input, the nurse-manager won't have the information she needs to identify the best solution. By simply telling the nursing staff to follow the therapists' schedules, the nurse-manager has abdicated responsibility for problem solving, yet the problem still exists. Determining problem-solving options without staff input is indicative of a participative manager. A participative manager asks staff members for opinions, but staff membres don't have input into actual problem solving. This lack of input may cause resentment and frustration.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Analysis

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 115.

Submit
91. A client who's dehydrated has urinary incontinence and excoriation in the perineal area. Which action would be a priority?

Explanation

RATIONALE: Because the skin, the body's first line of defense, is broken and excoriated, keeping the area clean and dry is a priority and promotes healing. Offering the urinal every 3 hours would help set a voiding schedule; however, to avoid incontinence, the urinal should be offered more often. Fluid intake of 1 L/day is insufficient for a client who has been diagnosed as dehydrated, and the fluids wouldn't aid healing. Continued incontinence as well as moist compresses would contribute to additional skin excoriation and breakdown.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Application

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 1018.

Submit
92. A client is at risk for excess fluid volume. Which nursing intervention ensures the most accurate monitoring of the client's fluid status?

Explanation

RATIONALE: Increased fluid volume leads to rapid weight gain — 2.2 lb (1 kg) for each liter of fluid retained. Weighing the client daily at the same time and in similar clothing provides more objective data than measuring fluid intake and output, which may be inaccurate because of omitted measurements such as insensible losses. Changes in vital signs are less reliable than daily weight because these changes usually are subtle during early stages of fluid retention. Weight gain is an earlier sign of excess fluid volume than crackles, which represent pulmonary edema. The nurse should plan to detect fluid accumulation before pulmonary edema occurs.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., and Bare, B. Brunner & Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 957.

Submit
93. To avoid injury while caring for a client, which principle is most important for a nurse to remember?

Explanation

RATIONALE: Bending and twisting during routine care such as bathing should be avoided because these actions may cause injury. The center of gravity is at the level of the pelvis, not the waist. The nurse should assess a client's level of consciousness and ability to cooperate because the client should help as much as he can during transfer. Tightening the abdominal muscles and tucking the pelvis actually help protect the back.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Application

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 775.

Submit
94. A client's rights to information, informed consent, and treatment refusal are addressed in the:

Explanation

RATIONALE: The Patient Care Partnership addresses the client's rights to information, informed consent, timely responses to requests for services, and treatment refusal. It's a legal document and serves as a guideline for decision making by the nurse. Standards of nursing practice, the nurse practice act, and the code for nurses contain nursing practice parameters and primarily describe use of the nursing process in providing care.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Knowledge

REFERENCE: American Hospital Association. "What to expect during your hospital stay." [Online]. Available: http://www.aha.org/aha/content/2003/pdf/pcp_english_030730.pdf. [2007, January 8].

Submit
95. A nurse who is preparing to boost a client up in bed instructs the client to use the overbed trapeze. Which risk factor for pressure ulcer development is the nurse reducing by instructing the client to move in this manner?

Explanation

RATIONALE: Friction, impaired circulation, localized pressure, and shearing forces are all risk factors of pressure ulcer development; trapeze use reduces shearing forces. Shearing forces (opposing forces that cause layers of skin to move over each other, stretching and tearing capillaries and, eventually, resulting in necrosis) can occur as clients slide down in bed or are pulled up in bed. Subcutaneous skin layers adhere to the sheets while deeper layers, muscle, and bone slide in the direction of movement. To reduce shearing forces, the nurse should instruct the client to use an overbed trapeze, place a draw sheet under the client to move him up in bed, and keep the head of the bed no higher than 30 degrees.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Basic care and comfort
COGNITIVE LEVEL: Application

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1196.

Submit
96. A nurse must irrigate a gaping abdominal incision with sterile normal saline, using a piston syringe. How should she proceed?

Explanation

RATIONALE: To wash away tissue debris and drainage effectively, the nurse should irrigate the wound until the solution becomes clear. After irrigation, the nurse should dry the area around the wound; moistening this area promotes microorganism growth and skin irritation. When the area is dry, the nurse should apply a dry, sterile dressing rather than a wet-to-damp dressing. The nurse should always instill the irrigating solution gently. Rapid or forceful instillation can damage tissues.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Application

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1237.

Submit
97. An elderly client becomes confused, dislodges his I.V. access, and attempts to remove his indwelling urinary catheter. The client's primary nurse calls the physician and receives an order for soft wrist restraints. When the client's family insists that he not be restrained, the charge nurse informs the family that the family must provide an around-the-clock attendant for the client in order to avoid restraints. The family spokesman replies, "You find the attendant; that is your responsibility." It would be most appropriate for the charge nurse to respond:

Explanation

RATIONALE: Offering the family a solution to the situation is therapeutic and can advance rapport with the family. It can also facilitate the problem-solving process, which involves the client, family, and staff. Restating that finding an attendant is the family's responsibility and saying that family members are making the situation more difficult are confrontational approaches. Such statements don't increase rapport with the family or enhance problem-solving. The staff can't renounce responsibility for the client if the family won't allow restraints.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Application

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 375.

Submit
98. A nurse has just removed an I.V. catheter from a client's arm because fluid has infiltrated the arm. The physician orders warm soaks for the area. Based on the principles of heat and cold application, the nurse should:

Explanation

RATIONALE: Because heat and cold can injure the skin, either should be applied for only a limited time. Warm compresses increase circulation and promote fluid absorption in the infiltrated area. Removing the compresses every 20 minutes for at least 15 minutes prevents injury to the skin and subsequent rebound vasoconstriction. Cold compresses, which help reduce edema, cause vasoconstriction. Keeping the area covered continuously can lead to skin breakdown.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Basic care and comfort
COGNITIVE LEVEL: Application

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1224.

Submit
99. Which scenario complies with Health Insurance Portability and Accountability Act of 1996 (HIPAA) regulations?

Explanation

RATIONALE: To provide interdisciplinary continuity of care, nurses must share relevant information during client care conferences. Nurses discussing information in the cafeteria may be overheard; this indiscretion violates HIPAA regulations. Looking up laboratory results for a neighbor is a HIPAA violation, as is discussing a client's condition with one's spouse.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Application

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 256.

Submit
100. Which intervention should a nurse use when administering oxygen by face mask to a client?

Explanation

RATIONALE: By assisting the client to the semi-Fowler's position, the nurse promotes easier chest expansion, breathing, and oxygen intake. The nurse should secure the elastic band so that the face mask fits comfortably and snugly rather than tightly, which could cause irritation. The nurse should apply the face mask from the client's nose down to the chin — not vice versa. The nurse should ensure that the connectors between the oxygen equipment and humidifier are airtight; loosened connectors can cause loss of oxygen.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Application

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 852.

Submit
101. A client is unable to take a deep breath and doesn't want to get out of bed because his chest tube is causing discomfort. To increase client adherence to the treatment plan, the nurse should:

Explanation

RATIONALE: Administering pain medication and delaying any activity until the medication takes effect will increase client adherence to the treatment plan. Explaining the purpose of the intended treatment is important but won't decrease the discomfort of the chest tube. Providing rest periods is essential but won't relieve the client's discomfort. An incentive spirometer measures deep-breathing ability, prevents atelectasis, and acts as a visual progress chart for the client. Teaching the client about incentive spirometry won't alleviate his discomfort.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Analysis

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 1191.

Submit
102. A nurse implements a health care facility's disaster plan. Which action should she perform first?

Explanation

RATIONALE: During a disaster, having a command center to provide direction and coordinate activities is crucial. Cellular phones and pagers may be essential communication tools during a disaster. Essential off-duty personnel should respond to a disaster as quickly as possible. Admitted clients should be triaged and treated in accordance with the facility's triage policy.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Application

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 688.

Submit
103. A client admitted to the hospital for chemotherapy states that he's been using a peppermint-scented candle at home to help control nausea. Which interventions would the nurse plan to promote comfort for this client?

Explanation

RATIONALE: Aromatherapy may affect the brain's limbic system, causing relaxation, evoking positive emotional memories, and decreasing the need for antiemetics. Such alternative therapies may increase a client's feeling of control over illness. Because this client associates positive feelings with the scent of peppermint, the nurse should encourage him to continue using that scent, but she should ask the client to use scented oil rather than a candle. Fire of any kind, even a candle, is a hazard in the hospital — especially when oxygen is being used. Increasing the client's nausea medication or ordering a sedative could cause dangerous adverse effects and wouldn't be best practice.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Basic care and comfort
COGNITIVE LEVEL: Analysis

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 758.

Submit
104. A severe winter storm has prevented most staff members from getting to work on a busy medical-surgical unit. One registered nurse, two licensed practical nurses, and three nursing assistants have been able to get to work. A nurse-manager must decide which nursing care delivery system (NCDS) should be implemented for the best possible client care during this staffing crisis. The nurse-manager directs the staff to implement which NCDS?

Explanation

RATIONALE: Functional nursing best uses the skills of all staff in a timely manner during this crisis. This delivery system requires the fewest staff and delegates tasks to those who can best perform them. Team nursing doesn't allow for the best use of a limited number of staff who must care for a large number of clients. Primary nursing and case management require more registered nurses than are currently available.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Analysis

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 541.

Submit
105. To follow standard precautions, the nurse should carry out which measure?

Explanation

RATIONALE: To follow standard precautions, caregivers must place used, uncapped needles and syringes in a puncture-resistant container; wear gloves when anticipating contact with a client's blood, body fluid, mucous membranes, or nonintact skin (such as when administering an I.M. injection); and wear a gown during procedures that are likely to generate splashes of blood or body fluids. Standard precautions don't call for caregivers to wear a gown or gloves when bathing a client because this activity isn't likely to cause contact with blood or body fluids.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Knowledge

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 531.

Submit
106. A charge nurse tells a new nurse, "You really need to get your skills up to speed." The statement hurts and embarrasses the new nurse. How can she best handle the situation?

Explanation

RATIONALE: The charge nurse's statement is vague; the priority issue is to gather information about what she meant. Meeting privately with the charge nurse is one way to diffuse tension in a nonthreatening manner and gather information that might have professional value for the nurse. Stating that the nurse felt hurt immediately focuses on subjective issues rather than objective concerns. Professional respect dictates inquiring about what the charge nurse meant, rather than telling her to be more specific. Discussing the situation with a coworker may make the nurse feel better but doesn't address the issue at hand.

CLIENT NEEDS CATEGORY: Psychosocial integrity
CLIENT NEEDS SUBCATEGORY: None
COGNITIVE LEVEL: Analysis

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 541.

Submit
107. The nurse-manager of an outpatient facility isn't satisfied with discharge planning policies and procedures. Knowing other managers at similar facilities regarded as the "best" in the country, which steps should the nurse-manager take as part of a continuous quality-improvement process?

Explanation

RATIONALE: Benchmarking is a good approach for the nurse-manager to take. Benchmarking is the process of comparing an organization's delivery of client care practices in one organization to those in the best health care organizations. Because the nurse-manager already has contacts at the best facilities, she's the most appropriate person to obtain the necessary information. The nurse-manager, however, shouldn't automatically change her policies and procedures to match those of the best facilities. Instead, she should evaluate the policies to determine which ones might be implemented at her facility. Then she and her staff should make appropriate recommendations for change. Asking her staff to form a task force is a good idea, but benchmarking saves time and effort and enables the nurse-manager to obtain information from excellent resources.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Application

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 345.

Submit
108. When approaching a family to discuss organ or tissue donation, a nurse should keep in mind which guideline?

Explanation

RATIONALE: The facility should offer the family an opportunity to speak with an organ procurement coordinator who is knowledgeable about organ donation and who should have exceptional interpersonal skills for dealing with grieving family members. Physician support in the process is desirable but referral to the organ procurement organization does not require a physician's consent or written order. The requestor must believe in the benefits of organ donation and support the process with a positive attitude. The possibility of speaking with an organ procurement coordinator should be introduced only after the family has been made aware of the client's condition and prognosis. Approaching a family member who believes there's still hope for recovery will likely result in a negative outcome.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Analysis

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 995.

Submit
109. A nurse is teaching a client with left leg weakness to walk with a cane. The nurse should instruct the client to proceed in which manner?

Explanation

RATIONALE: To ambulate safely, a client with a leg weakness should hold the cane in the hand opposite the weak leg 4″ to 6″ from the base of the little toe. Therefore, this client should hold the cane in his right hand. The client should hold the cane close to his body to prevent leaning and he should move the cane and the involved leg (left, in this case) simultaneously, then move the uninvolved leg.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Basic care and comfort
COGNITIVE LEVEL: Comprehension

REFERENCE: Ellis, J.R., and Bentz, P.M. Modules for Basic Nursing Skills, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 379.

Submit
110. Which situation violates the Health Insurance Portability and Accountability Act?

Explanation

RATIONALE: A nurse may not give information about a client to anyone without that client's consent. Nursing students and medical students may review client charts for the purpose of instruction and learning. The client has the right to see his chart. By remaining with the client while he reviews his chart, the nurse can explain notations that are confusing or unclear.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Analysis

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 256.

Submit
111. A nurse works on a general medical-surgical unit where nurses work on 12-client pods. Each pod is staffed by two registered nurses. When one of the nurses leaves the unit for any reason, the other nurse cares for all 12 clients. If she needs help, she can call the agency's in-house resource nurse. One evening, the remaining nurse, who was making rounds of the other nurse's clients, found medications left at bedsides and a client with a blood-draw tourniquet on his arm. In addressing the problems, the nurse should:

Explanation

RATIONALE: When a nurse discovers substandard practice by another nurse, it's always appropriate to address the situation before conveying the information to a manager or supervisor. Informing the nurse-supervisor first doesn't promote goodwill between nurses and can affect nursing care. It may be necessary to correct the problem before the nurse returns, but a written report may not be necessary if the issues can be remedied informally. If the problem persists, it may be necessary to meet jointly with a manager, but initially the problem should be addressed only by those directly involved.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Application

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 342.

Submit
112. A physician inserts a chest tube into a client to treat a pneumothorax. The tube is connected to a water-seal drainage system. The nurse can prevent chest tube air leaks by:

Explanation

RATIONALE: Air leaks commonly occur if the system isn't secure. Checking and taping all connections will prevent air leaks. The chest drainage system is kept below chest level, and the head of the bed may be elevated to promote drainage — not to prevent air leaks. Chest tubes that aren't patent may lead to tension pneumothorax but wouldn't cause an air leak.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Analysis

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1633.

Submit
113. Which option is an example of a primary preventive measure?

Explanation

RATIONALE: Primary prevention involves promoting health and helping clients achieve maximum wellness. Primary preventive measures are designed to prevent or delay the onset of specific illnesses; these measures typically include lifestyle changes such as avoiding overexposure to the sun to prevent skin cancer. Participating in a cardiac rehabilitation program is an example of a tertiary preventive measure, which attempts to prevent complications of an existing disease. Annual physical examinations and monthly breast self-examinations are examples of secondary preventive measures, which promote early detection and treatment of disease.

CLIENT NEEDS CATEGORY: Health promotion and maintenance
CLIENT NEEDS SUBCATEGORY: None
COGNITIVE LEVEL: Comprehension

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 73.

Submit
114. The nurse-manager of a home health facility includes which item in the capital budget?

Explanation

RATIONALE: Capital budgets generally include items valued at more than $500. Salaries and benefits are part of the personnel budget. Office supplies and client education materials are part of the operating budget.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Application

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 114.

Submit
View My Results

Quiz Review Timeline (Updated): Mar 22, 2023 +

Our quizzes are rigorously reviewed, monitored and continuously updated by our expert board to maintain accuracy, relevance, and timeliness.

  • Current Version
  • Mar 22, 2023
    Quiz Edited by
    ProProfs Editorial Team
  • Nov 12, 2015
    Quiz Created by
    Suarezenriquec1
Cancel
  • All
    All (114)
  • Unanswered
    Unanswered ()
  • Answered
    Answered ()
A postoperative client receives a lunch tray with milk, custard, and...
A client on prolonged bed rest has developed a pressure ulcer. The...
A nurse is teaching a group of nursing assistants about...
Which statement demonstrates a safe practice for taking telephone...
Which nursing action is essential when providing continuous enteral...
A client twists his right ankle while playing basketball and seeks...
A client's blood test results are: white blood cell (WBC) count is...
Which situation demonstrates correct principles of confidentiality?
Policy and procedure require hand washing when caring for clients....
A nurse is assessing a client for the risk of falls. The nurse should...
To evaluate a client for hypoxia, the physician is most likely to...
A client with terminal breast cancer is being cared for by a long-time...
A client who's a member of Jehovah's Witnesses refuses a blood...
After suctioning a client, a nurse should expect to find:
A client complains of dyspnea. Which action by the nurse is most...
A client admitted with anorexia nervosa lost 30 lb (13.6 kg) during...
Delegation is the process of transferring work to subordinates. A...
When caring for a client with a 3-cm stage I pressure ulcer on the...
A nurse revises the care plan for a client who has difficulty dealing...
A client with severe chest pain is brought to the emergency...
A nurse is caring for a client who required chest tube insertion for a...
A client complains of abdominal discomfort and nausea while receiving...
A nurse is to collect a sputum specimen from a client. The best time...
Which assessment is most supportive of the nursing diagnosis, Impaired...
An obese, malnourished client has undergone abdominal surgery. While...
Which statement is a guideline to help nurses protect themselves from...
A nurse-manager notes that a staff nurse isn't working to full...
A nurse is teaching the parents of a child with cystic fibrosis about...
Which is a nurse's role in a situation involving domestic abuse?
As a nurse-manager of a medical-surgical unit reviews the month's...
A hospitalized client who has a living will is being fed through a...
In planning a presentation that advocates decreasing the...
Standard precautions include which measure?
An elderly client has been admitted to the medical-surgical unit from...
According to Elizabeth Kübler-Ross, which stages of grief do a...
A client in a long-term care facility refuses to take his oral...
When planning and prioritizing care and teaching needs for the family...
A nurse is using the computer when a client calls for pain medication....
A nurse is monitoring a client who is receiving moderate sedation...
A nurse should question an order for a heating pad for a client who...
To collect a clean-catch midstream urine specimen from a female...
A physician orders hourly urine output measurement for a postoperative...
Which client would qualify for hospice care?
A nurse is recording a client's complaint of painful urination....
A physician has ordered a heating pad for an elderly client's...
A nurse-manager works for a nonprofit health care corporation whose...
A client has a blood pressure of 152/86 mm Hg. The nurse should...
A nurse is reviewing a client's laboratory test results. Which...
When preparing a client for a diagnostic study of the colon, the nurse...
Entering a client's room, a nurse on the maternity unit sees a...
A client who's scheduled for open-heart surgery in 2 days has been...
A physician has ordered a wet-to-damp dressing for an infected...
For healing by secondary intention, a client's wound has been...
A manager of an outpatient clinic is explaining the various health...
For the past 24 hours, a client with dry skin and dry mucous membranes...
A nursing supervisor asks a pediatric nurse to work temporarily...
A client with heart failure must be monitored closely after starting...
A nurse prepares to transfer a client from a bed to a chair. Which...
A primary unit nurse tells the nurse-manager that a newly hired...
A client is scheduled for an appendectomy. What is the nurse's...
A nurse is caring for an elderly client with a pressure ulcer on the...
A client has a nursing diagnosis of Ineffective airway clearance...
A client hasn't voided since before surgery, which took place 8...
When changing a sterile surgical dressing, a nurse first must:
A nurse will use surgical asepsis for which procedure?
When assessing a client with cellulitis of the right leg, which...
A nurse is obtaining a sterile urine specimen from a client's...
The nurse-manager of a 20-bed coronary care unit is off duty when a...
Nursing care for a client includes removing elastic stockings once per...
A nurse gives a client the wrong medication. After assessing the...
A client who has diabetes mellitus and has sustained a large...
A client hasn't voided since before surgery, which took place 8...
A nurse should encourage a client with a wound to consume foods high...
When planning cost-effective care, a nurse should choose interventions...
A client who suffered a stroke has a nursing diagnosis of Ineffective...
A client is placed in isolation. Client isolation techniques attempt...
When preparing a client with a draining vertical incision for...
A nursing assistant is caring for a client with Clostridium difficile...
A client hospitalized with pneumonia has thick, tenacious secretions....
A nurse-manager in the office of a group of surgeons has received...
A nurse having difficulty setting up humidified oxygen at 40% per...
A nurse and newly hired nursing assistant are caring for a group of...
A nurse is caring for a child with celiac disease. How should the...
Which statement is correct regarding the Omnibus Reconciliation Act of...
A nurse must apply a wet-to-damp dressing over an ulcer on a...
A nurse is assisting a client with lower motor neuron damage who has...
A nurse implements a teaching plan for a client who's scheduled...
While assessing the incision of a client who had surgery 2 weeks ago,...
A nurse is preparing to help a client with weakness in his right leg...
The managers of the physical and occupational therapy neurologic...
A client who's dehydrated has urinary incontinence and excoriation...
A client is at risk for excess fluid volume. Which nursing...
To avoid injury while caring for a client, which principle is most...
A client's rights to information, informed consent, and treatment...
A nurse who is preparing to boost a client up in bed instructs the...
A nurse must irrigate a gaping abdominal incision with sterile normal...
An elderly client becomes confused, dislodges his I.V. access, and...
A nurse has just removed an I.V. catheter from a client's arm...
Which scenario complies with Health Insurance Portability and...
Which intervention should a nurse use when administering oxygen by...
A client is unable to take a deep breath and doesn't want to get...
A nurse implements a health care facility's disaster plan. Which...
A client admitted to the hospital for chemotherapy states that...
A severe winter storm has prevented most staff members from getting to...
To follow standard precautions, the nurse should carry out which...
A charge nurse tells a new nurse, "You really need to get your...
The nurse-manager of an outpatient facility isn't satisfied with...
When approaching a family to discuss organ or tissue donation, a nurse...
A nurse is teaching a client with left leg weakness to walk with a...
Which situation violates the Health Insurance Portability and...
A nurse works on a general medical-surgical unit where nurses work on...
A physician inserts a chest tube into a client to treat a...
Which option is an example of a primary preventive measure?
The nurse-manager of a home health facility includes which item in the...
Alert!

Advertisement