The nursing supervisor will notify the nurse-manager at home.
The nurse-manager is off duty; therefore, she need not be notified.
The nurse-manager should be informed when she returns to duty.
The nursing supervisor decides to call the off-duty nurse-manager if time permits
Measuring and recording fluid intake and output
Weighing the client daily at the same time each day
Assessing the client's vital signs every 4 hours
Checking the client's lungs for crackles during every shift
Notify the physician that the wound may be dehiscing.
Apply normal saline solution to keep the wound moist.
Do nothing because this is granulation tissue.
Prepare the client for debridement of the suture line.
Administer pain medication and delay client activity.
Tell the client why lung expansion is important.
Arrange a care schedule that includes rest periods.
Teach the client how to use an incentive spirometer.
Parallel to the bed on the right side
Perpendicular to the bed on the right side
Parallel to the bed on the left side
Parallel to the bed on either side
Receiving a portion of the revenue to improve client services on the unit
Identifying revenue as profit
Dividing revenue among stockholders as dividends
Reducing operating expenses to help the organization pay taxes on the revenue
Recapping needles after use
Wearing a gown when bathing a client
Wearing gloves when administering I.M. medication
Wearing gloves for all client contact
Tell the charge nurse she feels hurt by her statement.
Tell the charge nurse she needs to be more specific about what she means.
Discuss her feelings with a coworker in order to vent.
Ask for a private meeting to explore the charge nurse's concerns in detail.
Increasing fluids to 2,500 ml/day
Teaching the client how to deep-breathe and cough
Improving airway clearance
Suctioning the client every 2 hours
Exhibiting a positive change in behavior
Verbally repeating the instruction
Making statements indicating understanding
Exhibiting nonverbal signs such as nodding the head to indicate "yes"
At the top of the wound
In the middle of the wound
At the base of the wound
Over the total wound
The nurse stands an arm's length away from the client.
The nurse uses a rocking motion while helping the client to stand.
The nurse keeps her knees straight and stiff and bends at the waist.
The nurse keeps her feet as close together as possible.
Turning the client every 2 hours
Elevating the head of the bed 30 degrees
Encouraging increased fluid intake
Maintaining a cool room temperature
I will administer the enema while sitting on the toilet.
I will administer the enema while lying on my left side with my right knee flexed.
I will administer the enema while lying on my right side with my left knee flexed.
I will administer the enema while lying on my back with both knees flexed.
Repositioning the client every 2 hours
Restricting fluids to 1,000 ml/24 hours
Administering oxygen by nasal cannula as ordered
Keeping the head of the bed at a 30-degree angle
Irrigate continuously until the solution becomes clear.
After the irrigation, moisten the area around the wound with normal saline.
After the irrigation, apply a wet-to-damp dressing to the wound.
Rapidly instill a stream of irrigating solution into the wound.
On protective isolation.
On neutropenic precautions.
In a negative-pressure room.
On contact isolation.
Scheduling staff assignments for the next month
Terminating a nursing assistant for insubordination
Deciding on salary increases for nurses after they complete orientation
Telling a staff nurse to initiate disciplinary action against one of her peers
Keep the area covered with the warm soaks.
Remove the warm compress for at least 15 minutes after each 20-minute application.
Alternate warm compresses with cold compresses.
Question the order because heat increases edema.
Tell the primary nurse that the new nurse must finish orientation within 6 weeks because of a staffing shortage.
Meet with the new nurse and the primary nurse and help set up an additional week of orientation.
Fire the new nurse because the unit is short-staffed and needs nurses who can complete the orientation process in the normal length of time.
Schedule a staff meeting to find out if there are deficiencies or flaws in the orientation process.
Refuse to float to the ICU.
Notify the nursing supervisor that she feels unqualified and untrained for the assignment.
Report to the ICU and accept a total client assignment; ask the nurses for assistance when necessary.
Report to the ICU, tell the ICU nurses she has never worked in the ICU, and let the nurses decide what tasks she can perform.
Participating in a cardiac rehabilitation program
Having an annual physical examination
Practicing monthly breast self-examination
Avoiding overexposure to the sun
Fluid intake and output.
Urine specific gravity.
Legumes and cheese
Whole grain products
Fruits and vegetables
Lean meats and low-fat milk
Client and family teaching should take place just before discharge.
Client and family teaching begins the day of admission.
Clients may stay in the hospital as long as they choose.
A physician will provide all client and family teaching.
Keeping the chest drainage system below chest level.
Keeping the head of the bed slightly elevated.
Checking and taping all connections.
Checking patency of the chest tube.
Inform the nurse-supervisor right away.
Correct the problems and submit a written report.
Speak to the coworker when she returns to the unit.
Ask for a meeting with the coworker and a manager.
American Dietetic Association Exchange diet
Clear liquid diet
A heart rate of 88 beats/minute
Wound healing by primary intention
Oral temperature of 101° F (38.3° C)
Dry and intact wound dressing
The client should begin coughing and deep-breathing exercises as soon as he's able to follow instructions.
Surgical wound infection is most likely to occur during the first postoperative day.
The client should be encouraged to take food and fluids to prevent dehydration and malnutrition.
The client's skin should be assessed hourly.
Red blood cell count
Arterial blood gas (ABG) analysis
Right to refuse care
Keeping the perineal area clean and dry
Offering the client the urinal every 3 hours
Maintaining a fluid intake of 1 L/day
Applying moist, warm compresses to the client's groin
Splint the abdomen with a pillow and call the surgeon.
Apply an abdominal binder.
Reinforce the existing dressing with another dressing.
Lift the dressing to assess the wound.
Consult with a respiratory therapist.
Read the package directions.
Ask a nursing assistant what to do.
Use a conventional oxygen mask.
Give the feedings at room temperature.
Stop the feedings and check for residual volume.
Place the client in semi-Fowler's position while feeding.
Change the feeding container daily.
Acceptance, depression, anger, bargaining, and denial
Denial, anger, decreased interaction, depression, and mourning
Acceptance, anger, denial, and bargaining
Denial, anger, bargaining, depression, and acceptance
Gait and balance information.
The facility's restraint policy.
The family's psychosocial history.
The client's dietary preferences.
Meet with the managers of physical and occupational therapy and determine how to reschedule clients; then inform the nursing staff.
Tell the nursing staff that nurses need to determine how to transport clients to therapy according to the schedules developed by the therapists.
Meet with physical and occupational therapy managers to identify scheduling solutions.
Ask several staff nurses to work with the therapy staff to help solve the scheduling problem and offer herself as a resource.
66 mm Hg.
238 mm Hg.
86 mm Hg.
152 mm Hg.
Early in the evening.
Any time during the day.
In the morning, as soon as the client awakens.
Inform the nurses who work in the facility that client education should be implemented as soon as the client is admitted to either the hospital or the outpatient surgical center.
Review and revise the way client education is conducted in the surgeons' office.
Because none of the clients suffered any serious damage, the nurse-manager can safely ignore their complaints.
Work with the surgeons' staff and the nursing staff in the hospital and outpatient surgical center to evaluate current client education practices and make revisions as needed.
Two nurses in the cafeteria are discussing a client's condition.
The health care team is discussing a client's care during a formal care conference.
A nurse checks the computer for the laboratory results of a neighbor who has been admitted to another floor.
A nurse talks with her spouse about a client's condition.
Inform the sister that she doesn't have the authority to assign a different physician.
Ask the dismissed physician if the client ever stated that she wanted a different physician.
Abide by the wishes of the sister who holds the durable power of attorney.
Politely ignore the sister's statement and continue to call the dismissed physician for orders.
Standards of practice.
Restores the inflammatory response.
Enhances oxygen transport to tissues.
Enhances protein synthesis.
Encourage each discipline involved in care to practice independently.
Don't involve frequent client follow-up and monitoring.
Promote healthy lifestyles.
Provide the greatest reimbursement to the facility.
Assigning clients to private rooms.
Prevent the spread of the infection.
Debride the wound.
Keep the wound moist.
The physician must rewrite the order within 3 days.
The physician must cosign the order within 7 days.
A nurse must verify the order by reading it back to the physician.
Nurses aren't permitted to accept telephone orders.
Painful skin that is swollen and pale in color
Cold, red skin
Small, localized blackened area of skin
Red, swollen skin with inflammation spreading to surrounding tissues
Follow all physician's orders.
Do what the client desires even though the nurse may disagree.
Practice within the scope of the state's nurse practice act.
Obtain malpractice insurance.
Staying logged on, leaving the terminal on, and administering the medication immediately
Informing the client that he'll have to wait 15 minutes while she completes the entry
Asking a coworker to log out for her and administering the medicine right away
Logging out of the computer, then administering the pain medication
Lower back pain
Coarse crackles in both upper lobes
Heart rate of 84 beats/minute
Mild bleeding at the surgical site
Asking the physician for an order for physical therapy
Requesting that a chaplain visit the client
Consulting with a dietitian about the client's dietary needs
Asking the nursing assistant to shampoo the client's hair
Terminate the nurses responsible for failing to administer medications on time.
Decide that the staff must postpone dinner breaks until at least 7 p.m.
Decide that the kitchen staff must change the time they deliver supper trays.
Investigate when medications are given, staff and client dinner times, the number of medications that must be given at 6 p.m., and staff availability between 5 p.m. and 6 p.m.
An emergency department nurse reports suspected child abuse.
Two nurses in an elevator are discussing a client's status.
A nurse copies and e-mails client information to a friend.
During change-of-shift report, a nurse talks about a client's personal problems.
The tissue surrounding the wound is red in color.
The wound drainage is serous.
The skin around the wound is edematous.
The granulation tissue is at the wound edges.
Frequent hand washing reduces transmission of pathogens from one client to another.
Wearing gloves is a substitute for hand washing.
Bar soap, which is generally available, should be used for hand washing.
Waterless products shouldn't be used in situations in which running water is unavailable.
Hold the cane on the left side 4″ to 6″ from the base of the little toe.
Hold the cane away from the body.
Move the cane and the right leg simultaneously.
Hold the cane in the right hand.
The facility will report the incident to the state board of nursing for disciplinary action.
The incident will be documented in the nurse's personnel file.
The nurse will be suspended and, possibly, terminated from employment at the facility.
The incident report will provide a basis for promoting quality care and risk management.
Assigning the staff nurse several clients with multiple physical problems
Allowing the staff nurse to select her own assignments
Discussing the staff nurse's performance and ways she can improve
Assigning the staff nurse fewer patients than her coworkers
Contact the nurse-managers at the best facilities and compare their discharge planning policies and procedures with those of her facility.
Ask her staff nurses to investigate discharge policies and procedures at other outpatient facilities and recommend changes.
Ask the nurse-managers at the best facilities for their policies and procedures so she can adopt them.
Ask the staff nurses to form a task force to review and revise discharge policies and procedures.
Clear the client's airway.
Make the client comfortable as specified in the client's living will.
Start cardiopulmonary resuscitation.
Stop the feeding and remove the NG tube as specified in the client's living will.
Promote fluid balance
Monitoring of arterial oxygen saturation (SaO2).
Arterial blood gas (ABG) studies.
A chest X-ray.
Continue to monitor and record hourly urine output.
Notify the physician.
Irrigate the indwelling urinary catheter.
Increase the I.V. fluid infusion rate.
To increase blood flow to the heart
To observe the lower extremitiesv
To allow the leg muscles to stretch and relax
To permit veins in the legs to fill with blood
Using a povidone-iodine wash on the ulceration three times per day
Using normal saline solution to clean the ulcer and applying a protective dressing as necessary
Applying an antibiotic cream to the area three times per day
Massaging the area with an astringent every 2 hours
Proper care of a crying infant
Proper methods for dealing with stressful situations such as crying infants
Assessment of the mother's coping strengths and weaknesses and the presence or absence of support systems
The contraction phase of wound healing can take 2 to 3 years.
Wound healing is very individual but the scar should fade within 4 months.
With your history and the type and location of your injury, it's hard to say.
If you don't develop an infection, the wound should heal in 1 to 3 years.
Be unable to palpate the bladder.
Feel that the bladder is smooth.
Palpate the bladder above the symphysis pubis.
Palpate the bladder at the umbilicus.
A client with late-stage acquired immunodeficiency syndrome (AIDS)
A client with left-sided paralysis resulting from a stroke
A client who's undergoing treatment for heroin addiction
A client who had coronary artery bypass surgery 2 weeks earlier
The nurse may approach a family only with a physician's approval and written order.
The requester need not believe in the benefits of organ donation but should support the process with a positive attitude.
The requester may educate family members about brain death early in the organ donation process.
The family has an opportunity to speak with an organ procurement coordinator.
Inadequate vitamin D intake
Inadequate protein intake
Inadequate massaging of the affected area
Low calcium level
Client's risk for falls
Client's vital signs and breath sounds
Client's nutritional status
Client's level of consciousness
The right to die
Autonomy of the client
Nasogastric tube irrigation
I.V. catheter insertion
Salaries and benefits for her staff
A $1,200 computer upgrade
Client-education materials costing $300
Secure the elastic band tightly around the client's head.
Assist the client to the semi-Fowler's position if possible.
Apply the face mask from the client's chin up over the nose.
Loosen the connectors between the oxygen equipment and humidifier.
To decrease arterial blood circulation to the legs and feet
To decrease venous blood circulation from the legs and feet
To reduce or prevent edema of the legs and feet
To maintain warmth in the legs
Give the nursing assistant the glucose meter, and let her perform the fingerstick.
Ask the nursing assistant to verbally explain the procedure before allowing her to perform it.
Go with the nursing assistant into the client's room, and validate her ability to perform the procedure.
Perform the fingerstick glucose testing herself.
A reddened abscess.
An edematous lower leg.
Purulent wound drainage.
Turn off all cellular phones and pagers.
Instruct all essential off-duty personnel to report to the facility within 24 hours.
Identify a command center at which activities are coordinated.
Provide treatment for incoming clients according to time of admission.
A respiratory rate of 28 breaths/minute.
A heart rate of 104 beats/minute.
Brisk capillary refill.
Clear breath sounds.
Wearing gloves when changing a dressing
Disposing of needles in a puncture-resistant container
Wearing eye protection during tracheal suctioning
All of the above
A preferred provider organization (PPO)
A managed care organization
A health maintenance organization (HMO)
A privately funded insurance company
Telling the client she may use his scented candles
Asking the client to try using peppermint oil in place of scented candles
Asking the physician to increase the client's antinausea medication
Asking the physician to order a sedative for the client to use during chemotherapy
Impaired urinary elimination
Deficient fluid volume
Imbalanced nutrition: Less than body requirements
Excess fluid volume
Monitor vital signs every 4 hours.
Monitor the appearance, size, and number of stools.
Measure blood urea nitrogen and serum creatinine levels.
Measure intake and output.
Documenting the situation and providing support for the victim
Protecting the client's privacy by not documenting the abusing
Counseling the person committing the abuse
Counseling the victim
All families of clients who are nearing death, or who have died, must be asked about organ and tissue donation.
The medical examiner should be notified whenever donated organs or tissues may be available.
The facility may not release the donor's name without the family's permission.
Hospitals need not have designated requesters who approach families for organ and tissue donation.
Aspirate urine from the tubing port, using a sterile syringe and needle.
Disconnect the catheter from the tubing and collect urine.
Open the drainage bag and pour out some urine.
Wear sterile gloves when collecting urine.
When planning a client's discharge care, medical students discuss his home situation.
A nurse allows a nursing student to review a client's chart the day before the student will be working on the unit.
A nurse gives a client's family members a report on his progress.
A nurse gives a client his chart and stays with him while he reads the new orders.
Standards of nursing practice.
Patient Care Partnership.
Nurse practice act.
Code for nurses.
Placing the client in Trendelenburg position
Placing the client in Sims' position
Placing the client in Fowler's position
Placing the client in the supine position
By swabbing the labia minora from front to back
By cleaning the labia minora from back to front
By cleaning the labia majora from back to front
By swabbing the entire perineal area
It's your responsibility, as I have already stated to you.
We can't be responsible for the client's safety if you won't let us restrain him.
I think you're making the situation more difficult than it really is.
I recommend family members arrange to stay with the client.
Call the physician to report the client's condition.
Catheterize the client with a straight catheter.
Assess the client for bladder fullness.
Tell the client to bear down and try to void.
Portal of entry.
Elevating the head of the bed
Positioning the client on his left side
Warming the formula before administering it
Adding methylene blue to the enteral feeding to detect aspiration
Apply the saturated fine-mesh gauze dressings over the wound.
Apply an occlusive dressing over the saturated fine-mesh gauze dressings.
Cover the saturated fine-mesh gauze dressings with an elastic bandage.
Pack the moistened fine-mesh gauze dressings into all depressions and grooves of the wound.
Return the neonate to the nursery, inform the physician so he can thoroughly examine the neonate for injuries, and notify social services for assistance.
Leave the room immediately, without the neonate, and notify the nursing supervisor.
Confront the mother by asking her what she's doing and why.
Return the neonate to the nursery and inform coworkers so they can monitor the mother's behavior.
Wash her hands.
Put on sterile gloves.
Remove the old dressing while wearing clean gloves.
Open sterile packages and moisten the dressings with sterile saline solution.
Bending and twisting while providing care may cause injury.
The center of gravity is located at the waist.
A client's level of consciousness and ability to cooperate aren't important factors during transfer.
Tightening the abdominal muscles and tucking the pelvis may strain the lower back.
I need something stronger for pain relief.
My ankle looks less swollen now.
My ankle appears redder now.
My ankle feels very warm.
Encourage a high-calorie, high-protein diet.
Restrict fluids to 1,500 ml per day.
Limit salt intake to 2 g per day.
Encourage foods high in vitamin B.