Basic Physical care (Part 1)

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1. A client is being discharged after abdominal surgery and colostomy formation to treat colon cancer. Which nursing action is most likely to promote continuity of care?

Explanation

RATIONALE: Many clients are discharged from acute care settings so quickly that they don't receive complete instructions. Therefore, the first priority is to arrange for colostomy care. The American Cancer Society often sponsors support groups, which are helpful when the person is ready, but contacting this organization doesn't take precedence over ensuring proper colostomy care. Requesting Meals On Wheels and asking for an occupational therapy evaluation are important, but these actions can occur later in rehabilitation.

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. 179.

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About This Quiz
Basic Physical care (Part 1) - Quiz

A nurse is a person who gives medical and other attention to a sick person. Patient safety is the cornerstone of high-quality health care. Knowledge in basic physical care is an important foundation for a nurse in training. Take the quiz below and measure how much you know so far!... see moreAll the best of luck! see less

2. A physician orders chest physiotherapy for a client with pulmonary congestion. When should the nurse plan to perform chest physiotherapy?

Explanation

RATIONALE: To avoid tiring the client or inducing vomiting, chest physiotherapy is best performed before meals. Scheduling chest physiotherapy around client or nurse convenience is inappropriate.

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. 1626.

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3. A client with burns on his groin has developed blisters. As the client is bathing, a few blisters break. The best action for the nurse to take is to:

Explanation

RATIONALE: The nurse should clean the area with a mild solution such as normal saline, and then cover it with a protective dressing. Soap and water and alcohol are too harsh. The body's first line of defense broke when the blisters opened; removing the skin exposes a larger area to the risk of infection.

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. 1190.

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4. To assess effectiveness of incentive spirometry, a nurse can use a pulse oximeter to monitor a client's:

Explanation

RATIONALE: A pulse oximeter is a noninvasive method of monitoring oxygen saturation. It doesn't measure hemoglobin, PaCO2, or PaO2 levels. Hemoglobin, the main component of the red blood cell that carries oxygen from the lungs, is measured by a simple laboratory test. Arterial blood gas analysis evaluates gas exchange in the lungs by measuring PaCO2 and PaO2.

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. 1615.

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5. A physician has ordered penicillin G potassium (Pfizerpen), I.V., for a client with a severe streptococcal infection. A nurse determines that the client may be allergic to penicillin. When considering best practice, what should the nurse's priority intervention be?

Explanation

RATIONALE: The nurse should hold the penicillin G potassium, even if the client isn't sure he's allergic to penicillin, and notify the physician so he may order a different antibiotic. Many clients can't act as their own advocates; they rely on nurses to protect their rights. Administering penicillin G potassium could cause a life-threatening reaction. Administering the medication, then watching for a reaction or notifying the pharmacist that a reaction might occur, isn't best practice. If a client is allergic to penicillin, a nurse should alert the pharmacist and label the client's chart appropriately.

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. 559.

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6. A client with fever and urinary urgency must provide a urine specimen for culture and sensitivity. The nurse should instruct the client to collect the specimen from the:

Explanation

RATIONALE: The midstream specimen is recommended because it's less likely to be contaminated with microorganisms from the external genitalia than other specimens. It isn't necessary to collect a full volume of urine for a urine culture and sensitivity.

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. 1091.

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7. A nurse has been teaching a client how to use an incentive spirometer that he must use at home for several days after discharge. Which client action indicates an accurate understanding of the technique?

Explanation

RATIONALE: When using an incentive spirometer, the client should take slow, deep breaths. This action ensures maximum ventilation, which elevates the ball (or disk) inside the spirometer. Rapid, shallow breathing doesn't allow maximum ventilation and lung expansion. The client should hold the spirometer upright; when tilted, a spirometer requires less effort to raise the ball. During spirometry, the client should sit upright — rather than lie supine — to promote maximum ventilation.

CLIENT NEEDS CATEGORY: Health promotion and maintenance
CLIENT NEEDS SUBCATEGORY: None
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. 846.

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8. The selection of a nursing care delivery system (NCDS) is critical to the success of a nursing area. Which factor is essential to the evaluation of a NCDS?

Explanation

RATIONALE: Determining who has responsibility for making decisions regarding client care is an essential element of an NCDS. Dress code, salary, and scheduling planned staff absences are important to any organization but the NCDS doesn't determine them.

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. 541.

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9. A nurse is caring for a client with a fractured hip. The client is combative, confused, and trying to pull out necessary I.V. lines and an indwelling urinary catheter. The nurse should:

Explanation

RATIONALE: In most settings, the nurse must have a physician's order before restraining a client. A client should never be left alone while the nurse summons assistance. All staff members must receive annual instruction on the use of restraints, and the nurse should be familiar with the facility's policy.

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. 680.

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10. A client is receiving a bowel preparation of magnesium citrate the evening before a scheduled colonoscopy. Which factor should the nurse consider when providing care for this client?

Explanation

RATIONALE: Bowel preparation, which usually involves laxatives and sometimes enemas, may cause severe fluid and electrolyte loss. The nurse should monitor the client for dehydration and electrolyte loss. Diarrhea is expected after bowel preparation and shouldn't be treated. Most clients eat a light meal the evening before the procedure or are ordered a clear liquid diet. Raising the side rails may increase the risk of fall for a client with frequent diarrhea.

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. 1130.

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11. A client suddenly loses consciousness. What should the nurse do first?

Explanation

RATIONALE: A nurse always should assess for responsiveness first to prevent injuries to a client who isn't in cardiac or respiratory arrest. After assessing the client, the nurse should call for assistance, open the client's airway, check for breathing, and palpate for a carotid pulse. Assessing for pupillary response would waste valuable time and is inappropriate.

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

REFERENCE: ECC Committee, Subcommittees and Task Force of the American Heart Association. "2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, Part 4: Adult Basic Life Support. Circulation 112(24 Suppl IV):IV19-IV34, December 13, 2005.

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12. A nurse has been teaching a client about a high-protein diet. The teaching is successful if the client identifies which meal as high in protein?

Explanation

RATIONALE: Beans, hamburger, and milk are all excellent sources of protein. The spaghetti-broccoli-tea choice is high in carbohydrates. The bouillon-spinach-soda choice provides liquid and sodium as well as some iron, vitamins, and carbohydrates. Chicken provides protein but the chicken-spinach-soda combination provides less protein than the beans-hamburger-milk selection.

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. 953.

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13. In a client who had major surgery 5 days ago, which assessment finding is the best indication of a wound infection?

Explanation

RATIONALE: Thick, yellow drainage is most indicative of a wound infection. Drainage is typically serosanguineous. Although an elevated temperature, pain at the incision site, and uneven wound edges may accompany an infected wound, these indicators aren't as specific as the drainage and could be related to other problems.

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. 1192.

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14. Which action must a nurse perform when cleaning the area around a Jackson-Pratt wound drain?

Explanation

RATIONALE: The nurse should move from the center outward in ever-larger circles when cleaning around a wound drain because the skin near the drain site is more contaminated than the site itself. The nurse should never remove the drain before cleaning the skin. Alcohol should never be used to clean around a drain; it may irritate the skin and, because it evaporates, has no lasting effect on bacteria. The nurse should wear sterile gloves to prevent contamination, but need not wear a mask.

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. 159.

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15. Which member of the health care team is responsible for obtaining informed consent from a client?

Explanation

RATIONALE: The physician involved with the procedure is responsible for obtaining the client's informed consent. The primary nurse or the nurse working with the physician may witness the client's signature. The social worker may not obtain informed consent.

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. 100.

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16. A staff nurse on a busy pediatric unit is an excellent role model for her colleagues. She encourages them to participate in the unit's decision-making process and helps them improve their clinical skills. This nurse is functioning effectively in which role?

Explanation

RATIONALE: A leader doesn't have formal power and authority but influences the success of a unit by being an excellent role model and by guiding, encouraging, and facilitating professional growth and development. A manager's formal power and authority within the organization are detailed in her job description. An autocrat isn't interested in guiding or encouraging staff or in being an effective role model. A manager derives her authority by virtue of her position within an organization.

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. 120.

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17. A client has left-sided paralysis. The nurse should document this condition as left-sided:

Explanation

RATIONALE: Hemiplegia refers to paralysis of one side of the body; therefore, the nurse should document that the client has left-sided hemiplegia. Monoplegia refers to paralysis of one extremity; paraplegia, to paralysis of both lower limbs; and quadriplegia, to paralysis of all four extremities and usually also the trunk.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Basic care and comfort
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. 1284.

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18. Which statement concerning informed consent is true?

Explanation

RATIONALE: Before giving informed consent, the physician performing the procedure must tell the client about the treatment, tests, alternative treatments, and the risks and benefits of each. A professional nurse involved in the informed consent process witnesses the consent and doesn't actually obtain the consent. The physician is responsible for obtaining consent. Only a minor who is married or emancipated may give informed consent. A client must be mentally competent to legally give informed consent for procedures.

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. 100.

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19. In which way does a nurse play a key role in error prevention?

Explanation

RATIONALE: The nurse must be knowledgeable about drug dosages and possible interactions when administering medications; she must follow appropriate policies to correct dosage errors or prevent potential interactions. The nurse is responsible for questioning unclear or ambiguous physician's orders and should never carry out an order with which she's uncomfortable. OSHA establishes comprehensive safety and health standards, inspects workplaces, and requires employers to eliminate safety hazards but notifying OSHA of medication errors doesn't resolve the problem. The client should be aware of his rights as a client, but that awareness doesn't play a key role in error prevention.

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. 781.

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20. A client has a soft wrist-safety device. Which assessment finding should the nurse investigate further?

Explanation

RATIONALE: A wrist-safety device on the wrist may impair circulation and restrict blood supply to body tissues. Therefore, the nurse should assess the client for signs of impaired circulation such as cool, pale fingers. A palpable radial or ulnar pulse and pink nail beds are normal findings.

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. 693.

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21. When changing the dressing on a pressure ulcer, a nurse notes necrotic tissue on the edges of the wound. Which action should the nurse anticipate that the physician will order?

Explanation

RATIONALE: Necrotic tissue prevents wound healing and must be removed. This is accomplished by debridement. Incision and drainage, culture, or irrigation won't remove necrotic tissue. Incision and drainage drain a wound abscess. A wound culture indentifies organisms growing in the wound and helps the physician determine appropriate therapy. If the wound is infected, the physician may order irrigation — usually with an antibiotic solution — to treat the infection and clean the wound.

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. 214.

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22. As a nurse helps a client ambulate, the client says, "I had trouble sleeping last night." Which action should the nurse take first?

Explanation

RATIONALE: The nurse first should determine what the client means by "trouble sleeping." The nurse lacks sufficient information to recommend warm milk or a warm shower or to make inferences about the cause of the sleep problem, such as worries or medication use.

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. 32.

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23. A scrub nurse in the operating room has which responsibility?

Explanation

RATIONALE: The scrub nurse assists the surgeon by providing appropriate surgical instruments and supplies, maintaining strict surgical asepsis and, with the circulating nurse, accounting for all gauze sponges, needles, and instruments. The circulating nurse assists the surgeon and scrub nurse, positions the client, assists with gowning and gloving, applies appropriate equipment and surgical drapes, and provides the surgeon and scrub nurse with supplies.

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. 656.

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24. Which nursing intervention is appropriate for a client with an arm restraint?

Explanation

RATIONALE: A nurse must assess the circulatory status of a restrained extremity every 2 hours to prevent circulatory impairment. To make sure the restraint is secure without compromising the circulation, the nurse should leave approximately one fingerbreadth between the restraint and the extremity. Tying a restraint to the side rail or an immovable bed part may cause client injury if the rail or bed is moved before the restraint is released. The restrained arm or leg should be flexed slightly to allow joint movement without reducing the effectiveness of the restraint.

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. 692.

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25. When following standard precautions, a nurse'sWhen following standard precautions, a nurse's primary responsibility is to: primary responsibility is to:

Explanation

RATIONALE: Standard precautions are based on the concept that all body substances are potentially infectious and that direct contact with them must be avoided. The nurse should wear gloves when contact with body substances — not unsoiled articles or intact skin — is anticipated. Because all body substances from all clients are considered potentially infectious, signs on doors are unnecessary. Gloves and gowns are inappropriate when caring for a client in respiratory isolation because they don't prevent transmission of airborne respiratory infections. The nurse should wear a mask as a barrier to such infections.

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.

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26. A client who recently immigrated to the United States from Korea is hospitalized with second- and third-degree burns. He speaks little English and has been lying quietly in bed. Ten hours after the client's admission, the nurse conducts a serial assessment and asks him whether he's in pain. He smiles and shakes his head vigorously back and forth. Which nursing action is most appropriate at this time?

Explanation

RATIONALE: The nurse should consider the possibility that the client didn't understand the question or has been conditioned culturally not to complain openly of pain. Checking vital signs and assessing for nonverbal indications of pain help the nurse determine whether the client is in pain. Accepting the client's response without question or further assessment may result in inadequate intervention. Calling the family or giving pain medication isn't warranted at this time because the client denies pain and the nurse needs to obtain more information.

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. 1375.

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27. A client is admitted to the health care facility with active tuberculosis (TB). The nurse should include which intervention in the care plan?

Explanation

RATIONALE: Because TB is transmitted by droplet nuclei from the respiratory tract, the nurse should put on a mask when entering the client's room. Occupation Safety and Health Administration standards require an individually fitted mask. Having the client wear a mask at all times would hinder sputum expectoration and respirations would make the mask moist. A nurse who doesn't anticipate contact with the client's blood or body fluids need not wear a gown or gloves when providing direct care. A client with TB should be in a room with laminar airflow, and the room's door should be shut at all times.

REFERENCE: Smeltzer, S.C., and Bare, B. Brunner & Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 645.

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28. A nurse says she's forgotten her computer password and asks to use another nurse's password to log on to the computer. Which response by the coworker demonstrates safe computer usage?

Explanation

RATIONALE: Computer passwords should never be shared. If a coworker use a nurse's password, the nurse may be held liable for anything the coworker does.

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.

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29. During assessment, a nurse measures a client's respiratory rate at 32 breaths/minute with a regular rhythm. When documenting this pattern, the nurse should use which term?

Explanation

RATIONALE: A respiratory rate of 32 breaths/minute with a regular rhythm is faster than normal and should be documented as tachypnea. Eupnea is a respiratory rate of 12 to 20 breaths/minute with a regular rhythm. Bradypnea refers to a respiratory rate below 12 breaths/minute with a regular rhythm. Apnea refers to absence of breathing.

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. 571.

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30. Which concept refers to a professional nurse's role in client advocacy?

Explanation

RATIONALE: The nurse who understands the advocacy role promotes, protects and, thereby, advocates a client's interests and rights in an effort to make the client well. The nurse recognizes that her first duty is to protect and care for the client's health and safety. True advocacy encourages and helps clients reach decisions that express their own beliefs and values. The nurse doesn't make decisions for clients but provides care for the acutely ill client with the consent of his significant other. If the client has no significant other, a health care power of attorney or the client's living will dictates what care the nurse should provide. Standards of care are the basis for providing safe, competent nursing care and set minimum criteria for proficiency on the job, enabling the nurse and others to judge the quality of care provided. Paternalism violates self-determination and advocacy by acting for another. A nurse acting as a client advocate helps clients exercise their freedom of self-determination.

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. 370.

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31. An employer establishes a physical exercise area in the workplace and encourages all employees to use it. This is an example of which level of health promotion?

Explanation

RATIONALE: Primary prevention precedes disease and applies to healthy clients. Secondary prevention focuses on clients who have health problems and are at risk for developing complications. Tertiary prevention focuses on rehabilitating clients who already have a disease or disability. Passive prevention enables clients to gain health as a result of others' activities without doing anything themselves.

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.

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32. A nurse is transferring a client from the bed to a chair. Which action should the nurse take during this client transfer?

Explanation

RATIONALE: After placing the client in high Fowler's position and moving the client to the side of the bed, the nurse should help him sit on the edge of the bed and dangle his legs. The nurse should then face the client and place the chair next to and facing the head of the bed.

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. 812.

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33. When assessing a client's incision 1 day after surgery, the nurse expects to see which feature as a sign of a local inflammatory response?

Explanation

RATIONALE: Warmth and redness are normal signs of an inflammatory response. Yellow drainage may indicate an infectious process. The nurse would expect some redness — not pallor — at the suture edges. Brown exudate is a sign of an infected wound.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Basic care and comfort
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. 1192.

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34. A physician orders supplemental oxygen for a client with a respiratory problem. Which oxygen delivery device should the nurse use to provide the highest possible oxygen concentration?

Explanation

RATIONALE: A nonrebreather mask provides the highest possible oxygen concentration — up to 95%. A nasal cannula doesn't deliver concentrations above 40%. A Venturi mask delivers precise concentrations of 24% to 44%, regardless of the client's respiratory pattern, because the same amount of room air always enters the mask opening. A simple mask delivers 2 to 10 L/minute of oxygen in uncontrollable concentrations.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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. 1630.

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35. A client with a history of heart disease is scheduled for cataract surgery when he tells the nurse that he's experiencing chest discomfort and shortness of breath. The nurse administers a nitroglycerin tablet sublingually, as ordered by the admitting physician, but fails to notify the physician, surgeon, or anesthesiologist of this development. If the client suffers a massive heart attack during surgery, the nurse could be held liable for which malpractice charge?

Explanation

RATIONALE: The nurse is responsible for assessing and monitoring clients in her care. The nurse also has a responsibility to communicate with interdisciplinary health care members, particularly if the client's status changes. In this case, the change in the client's status could influence care during surgery and influence potential surgical outcomes. The courts have recognized failure to act as a client advocate in situations in which the nurse has failed to develop and implement nursing diagnoses and has failed to exercise good judgment on a client's behalf. Failure to communicate with the client commonly refers to not adequately educating clients regarding care, procedures, or discharge instructions. Failure to protect from harm occurs when health care providers fail to protect a client who is in a vulnerable state and unable to recognize potentially harmful situations.

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. 131.

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36. Performance improvement is an important component of continuous quality improvement. Which action should an effective nurse-manager take when conducting performance evaluations?

Explanation

RATIONALE: An effective performance evaluation recognizes strengths, identifies areas for improvement, and clarifies performance expectations. The nurse-manager should conduct performance evaluations privately, not in front of others. She should document in writing all components of a performance evaluation. Although input from staff members can be useful in preparing performance evaluations, delegating all responsibility to others is inappropriate. The nurse-manager is responsible for the performance of the staff.

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.

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37. Which strategy can help make the nurse a more effective teacher?

Explanation

RATIONALE: An effective teacher always involves the client in the discussion. Using technical terms and providing detailed explanations usually confuse the client and act as barriers to learning. Using loosely structured teaching sessions permits distractions and deviations from teaching goals.

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. 413.

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38. Which action demonstrates a safe response plan in the event of fire?

Explanation

RATIONALE: Following the acronym RACE (Alerting rescue, activating the alarm, and containing and extinguishing) will help promote the safest response to a fire. Elevators should never be used during a fire. Closing fire doors helps contain a fire. The fire department must be called even if the fire is small.

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. 681.

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39. When bandaging a client's ankle, the nurse should use which technique?

Explanation

RATIONALE: The nurse uses a figure-eight technique to bandage a joint, such as an ankle, elbow, wrist, or knee. The nurse uses the circular bandaging technique to anchor a bandage; the recurrent technique to bandage a stump, hand, or scalp; and the spiral reverse bandaging technique to accommodate the increasing circumference of a body part such as when in a cast.

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. 1215.

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40. A nurse is giving nutritional counseling to the mother of a child with celiac disease. Which statement by the mother indicates understanding?

Explanation

RATIONALE: A child with celiac disease must follow a gluten-free diet. If the child eats foods containing gluten, changes in the intestinal mucosa will prevent the absorption of fats and other foods. Therefore, all foods containing wheat, rye, oats, and barley must be eliminated from the diet. Such foods as potatoes, rice, and cornstarch may be included in a gluten-free diet. Frozen and packaged foods, which may contain gluten fillers, should be avoided.

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

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

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41. Which nursing theorist addressed self-care deficits in her nursing theory?

Explanation

RATIONALE: Dorothea Orem's general theory of nursing addresses self-care deficits as the basis for nursing care. This theory posits that the nurse intervenes to reestablish the client's self-care capacity. Dorothy Johnson's behavioral systems theory views nursing as a means to reestablish balance in the client's behavioral subsystems, which have been disrupted by stress. According to Virginia Henderson's theory of nursing, the nurse focuses on the client's basic needs. In Martha Rogers' unitary human beings theory, the nurse helps the client balance the changes that occur as he constantly evolves.

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. 59.

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42. When leaving the room of a client in strict isolation, the nurse should remove which protective equipment first?

Explanation

RATIONALE: When leaving a strict-isolation room, the nurse should remove her gloves first because they're considered the most contaminated protective equipment. Removing other protective equipment before removing her gloves and washing her hands could contaminate her hair and uniform and promote pathogen transmission.

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.

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43. A nurse has custody of a client's daily Kardex and care plan so she can give a change-of-shift report. After reporting to the next shift, what steps should the nurse implement to maintain client confidentiality?

Explanation

RATIONALE: Kardexes, care plans, and other client documents contain confidential client information. The nurse should shred them or place them in a special HIPAA container for proper disposal. Regular garbage isn't secure and isn't an appropriate place to dispose of documents containing a client's name and information. Leaving the documents at the nurses' station may allow others to view them. It isn't necessary to place the nursing Kardex and care plan in the client's chart when the nurse has finished using them.

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.

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44. When placing an indwelling urinary catheter in a female client, the nurse should advance the catheter how far into the urethra?

Explanation

RATIONALE: In a female client, the nurse should advance an indwelling urinary catheter 2″ to 3″ (5 to 7.5 cm) into the urethra. In a male client, the nurse should advance the catheter 6″ to 8″.

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. 1105.

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45. Which outcome criterion would be most appropriate for a client with a nursing diagnosis of Ineffective airway clearance?

Explanation

RATIONALE: The expected outcome for a client with Ineffective airway clearance is for the lungs to be clear of secretions (or congestion) on auscultation. Congestion on X-ray, continued use of and need for oxygen, and a respiratory rate of 28 breaths/minute indicate that the client is still experiencing airway problems.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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. 873.

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46. For the past few days, a client has been having calf pain and notices that the painful calf is larger than the other one. The right calf is red, warm, achy, and tender to touch. Which question about the pain should a nurse include in the assessment?

Explanation

RATIONALE: The client's symptoms indicate deep vein thrombosis (DVT). Pointing toes toward the knee will cause discomfort in a client with DVT. Time of the day doesn't influence the pain associated with DVT. A client with intermittent claudication experiences pain that increases during activity and decreases with rest. A dependent position, not a position change, will increase venous stasis and the pain associated with DVT.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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. 1005.

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47. Which one do you like?

Explanation

RATIONALE: Clients with cancer may develop a tolerance to opioids, causing them to need higher doses to provide adequate pain relief. Although a nurse should always remain alert for adverse effects of opioids, clients may develop a tolerance for these effects. Therefore, it isn't likely that higher doses would cause respiratory depression. Administering pain medication around the clock maintains steady blood levels of opioids. Sleeping doesn't necessarily indicate pain relief, especially in a client who has chronic pain.

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. 1394.

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48. The American Nurses Association Code for Nurses includes:

Explanation

RATIONALE: The America Nurses Association wrote and published The Code of Ethics for Nurses. This code states the nurse's obligations and responsibilities to her clients. The Client's Bill of Rights outlines a client's rights. Hospital policy and procedure manuals describe each facility's best practice for performing a nursing procedure. Each state board of nursing establishes criteria for nursing licensure.

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. 70.

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49. A nurse is assigned to a client with a cardiac disorder. The nurse should question an order to monitor the client's body temperature by which route?

Explanation

RATIONALE: When caring for a client with a cardiac disorder, the nurse should avoid using the rectal route to take temperature. Using this route could stimulate the vagus nerve, possibly leading to vasodilation and bradycardia. The other options are appropriate routes for measuring the temperature of a client with a cardiac disorder.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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. 487.

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50. A nurse is evaluating a postoperative client for infection. Which sign or symptom is most indicative of infection?

Explanation

RATIONALE: Redness, warmth, and tenderness in the incision area indicate a postoperative infection. The presence of an invasive device predisposes a client to infection, but that alone doesn't indicate infection. A rectal temperature of 100° F would be a normal expectation in a postoperative client because of the inflammatory process. A normal WBC count ranges from 4,000 to 10,000/μl. This client's WBC count falls within this normal range.

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. 1192.

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51. Several day-shift nurses complain that the night-shift nurses aren't performing the daily calibration of the capillary glucose monitoring apparatus, which is their responsibility. It would be most prudent for a nurse-manager to:

Explanation

RATIONALE: When dealing with complaints, a nurse-manager should always gather data before taking action. Therefore, the nurse-manager should review the calibration documentation, then address the findings. It would be inappropriate for the nurse-manager to remind the staff of a responsibility that they may be fulfilling, arrange a meeting that could become confrontational, or counsel the charge nurse before investigating and gathering data relative to the complaint.

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. 115.

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52. A nurse must apply an elastic bandage to a client's ankle and calf. She should apply the bandage beginning at the client's:

Explanation

RATIONALE: An elastic bandage should be applied from the distal area to the proximal area. This method promotes venous return. In this case, the nurse should begin applying the bandage at the client's foot. Beginning at the ankle, lower thigh, or knee won't promote venous return.

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

REFERENCE: Ellis, J.R., and Bentz, P.M. Modules for Basic Nursing Skills, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 696.

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53. In which circumstance may the nurse legally and ethically disclose confidential information about a client?

Explanation

RATIONALE: A nurse may lawfully disclose confidential information about a client when the welfare of a person or group of people is at stake. A health care provider must inform the Department of Motor Vehicles that the taxi driver has an uncontrolled seizure disorder; disclosing the condition is in the best interest of public safety and the client's well-being. Confidentiality of HIV testing is required, but the client, who's HIV positive, should be encouraged to share the information with his family. Many state legislatures require maintaining confidentiality of HIV testing. The nurse may not disclose a diagnosis of pancreatic cancer or a pregnancy because these situations don't affect the welfare of a group of people.

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. 129.

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54. A nurse-manager of an intensive care unit (ICU) can't be held legally responsible in a court of law for which action performed by the unit's staff?

Explanation

RATIONALE: The nurse-manager is legally responsible for actions that fall within the scope of practice of the staff members who perform them. A nurse may not knowingly administer or perform tasks that will harm a client. It's within a nurse's scope of practice to refuse to carry out such orders. A nurse-manager can't be held legally responsible for the nurse's refusal in this situation. Administering medications and initiating I.V. therapy aren't within the scope of practice for nursing assistants, and a staff nurse isn't licensed to fill prescriptions.The nurse-manager can be held legally responsible for these 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. 121.

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55. A day-shift nurse gives a client an injection of pain medication. The nurse forgets to document the injection on the medication administration record (MAR). The day-shift nurse tells the evening-shift nurse that she gave the client 4 mg of morphine at 2 p.m. for postoperative pain but didn't document the injection. The evening-shift nurse puts the day-shift nurse's initials and the date and time the dose was administered in the appropriate area of the MAR. The evening-shift nurse's action is considered to be which type of documentation error?

Explanation

RATIONALE: This action is an unauthorized entry. A nurse shouldn't document for another nurse, except for an authorized entry in an emergency. Omission is a documentation error in which information is missing from the medical record. In this scenario, the day-shift nurse omitted documenting her administration of pain medication. A late entry refers to an entry made later than it should have been. The nurse should identify a necessary late entry as a "late entry" and document the reference date and time. An improper correction is an entry corrected in an improper manner, such as by erasing, using correction fluid, or obliterating the error with a marking pen. The nurse should always follow her facility's documentation guidelines.

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 810.

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56. From which direction should a nurse approach a client who is blind in the right eye?

Explanation

RATIONALE: The nurse should approach the client from the left side so that the client can be aware of the nurse's approach. Likewise, personal items should be placed on the client's left side so that he can see them easily.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Basic care and comfort
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. 2219.

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57. Which group of clients is at increased risk for developing a wound infection?

Explanation

RATIONALE: Nutrition plays an important role in wound healing. Because vitamins and protein are essential for wound healing, a malnourished client is at increased risk for developing a wound infection. Frequent pain medication allows the client to be more comfortable, and may enable him to move about more easily. Ambulation improves circulation and thus promotes better healing. A client who is 15 lb overweight isn't at increased risk for developing a wound infection.

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. 1013.

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58. When moving a client in bed, the nurse can ensure proper body mechanics by:

Explanation

RATIONALE: When moving a client in bed, the nurse should stand with her feet apart to establish a wide base of support. To reduce the amount of energy needed to move the client's weight against gravity, the nurse should slide, roll, push, or pull rather than lift the client. The nurse should flex her knees and use her arm and leg muscles instead of her back. To minimize stress, the nurse should stand as close to the client as possible.

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.1267.

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59. During a teaching session, a nurse demonstrates to a client how to change a tracheostomy dressing. Then the nurse watches as the client returns the demonstration. Which client action indicates an accurate understanding of the procedure?

Explanation

RATIONALE: To change a tracheostomy dressing effectively, the client should rinse around the clean incision site, using gauze squares moistened with normal saline. If crusts are difficult to remove, the client may use a solution of 50% hydrogen peroxide and 50% sterile saline — not full-strength hydrogen peroxide. The client shouldn't use tap water, which may contain chemicals and other harmful substances. To prevent lint or fiber aspiration and subsequent tracheal abscess, the client should use sterile dressings made of nonraveling material instead of cotton-filled gauze squares.

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. 862.

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60. A nurse is performing a sterile dressing change. Which action contaminates the sterile field?

Explanation

RATIONALE: Pouring solution onto a sterile field cloth contaminates the sterile field because moisture penetrating the cloth can carry microorganisms to the sterile field via capillary action. Holding sterile objects above the waist, leaving a 1″ edge around the sterile field, and opening the outermost flap of a sterile package away from the body maintain the sterile field.

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,

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61. During her morning assessment, a nurse notes that a client has severe dyspnea; his respirations are 34 breaths/minute and labored. Oxygen saturation is 79% on 3 L of oxygen. The nurse remembers that the client's chart includes his living will. When considering best practice, the nurse should:

Explanation

RATIONALE: A living will doesn't go into effect unless the client is unable to make his own decisions. A nurse shouldn't withhold care for an alert client unless he specifically refuses care. The nurse should give all appropriate care while also maintaining the client's right to refuse treatment. Increasing the oxygen flow rate might be an appropriate response, but it isn't the best action at this time. The family isn't responsible for determining care 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. 92.

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62. A professional negligence action requires that a client's attorney prove which elements?

Explanation

RATIONALE: Any professional negligence action must meet four demands — commonly known as the four D's — to be considered negligence and result in legal action: a duty for the health care professional to provide care to the person making the claim, a dereliction (breach) of that duty, the breach of duty resulted in damages and the damages were caused by a direct result of the negligence (causation).

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
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. 131.

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63. Which laboratory test result is the most important indicator of malnutrition in a client who has a wound?

Explanation

RATIONALE: Protein and vitamin C help build and repair injured tissue. Albumin is a major plasma protein; therefore, a client's albumin level helps gauge his nutritional status. Potassium levels indicate fluid and electrolyte status. Lymphocyte count and differential count help assess for infection.

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. 985.

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64. A nurse caring for a client with a fecal impaction should watch for:

Explanation

RATIONALE: Passage of liquid or semiliquid stools results from seepage of unformed bowel contents around the impacted stool in the rectum. Clients with fecal impaction don't pass hard, brown, formed stools because the feces can't move past the impaction. These clients typically report the urge to defecate (although they can't pass stool) and decreased appetite.

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. 1575.

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65. During a meal, a client with hepatitis B dislodges her I.V. line and bleeds onto the surface of the overbed table. It would be most appropriate for the nurse to instruct a housekeeper to clean the table with:

Explanation

RATIONALE: Blood infected with the hepatitis B virus should be removed from the table or other surfaces with bleach. Alcohol, ammonia, and acetone are less effective in destroying the hepatitis B virus.

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

REFERENCE: United States Environmental Protection Agency. "List D: EPA's Registered Antimicrobial Products Effective Against Human HIV-1 And Hepatitis B Virus." [Online]. Available: http://www.epa.gov/oppad001/list_d_hepatitisbhiv.pdf [2007, January 8].

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66. A client has a wound with a drain. When cleaning around the drain, the nurse should wipe in which direction?

Explanation

RATIONALE: When cleaning the area around the drain, the nurse should wipe in a circle around the drain, working from the center outward. The nurse wipes laterally, from the center to the opposite side, when cleaning a large horizontal wound and wipes from top to bottom when cleaning a vertical incision.

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. 159.

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67. A client, age 43, has no family history of breast cancer or other risk factors for this disease. The nurse should instruct her to have a mammogram how often?

Explanation

RATIONALE: Yearly mammograms should begin at age 40 and continue for as long as the woman is in good health. If health risks exist, such as family history, genetic tendency, or past breast cancer, more frequent examinations may be necessary.

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

REFERENCE: American Cancer Society. "American Cancer Society Guidelines for Early Detection of Cancer, 2006." [Online]. Available: http://caonline.amcancersoc.org/cgi/content/full/56/1/11. [2007, January 8].

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68. Standard precautions were designed for the care of all hospitalized clients, regardless of their diagnosis or infection status. Guidelines for standard precautions include:

Explanation

RATIONALE: Guidelines for standard precautions include disposing of sharp instruments in an impervious container. Used needles should never be recapped; they should be disposed of in a sharps container. A nurse should wear gloves whenever she anticipates contact with body fluids. For eye protection, the nurse should wear goggles approved by the Occupational Safety and Health Administration. Eyeglasses aren't an acceptable form of eye protection because they're open at the sides.

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.

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69. A physician orders a bland, full-liquid diet for a client. The nurse tells the client that his diet may include:

Explanation

RATIONALE: A bland, full-liquid diet may include fruit juices and foods from all of the food groups. On this diet, the client should avoid gastric irritants, such as coffee, tea, colas, cocoa, breads, bran (fiber), and highly seasoned foods.

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.

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70. A nurse is preparing a client for bronchoscopy. Which instruction should the nurse give to the client?

Explanation

RATIONALE: Bronchoscopy involves visualization of the trachea and bronchial tree. To prevent aspiration of stomach contents into the lungs, the nurse should instruct the client not to eat or drink anything for approximately 6 hours before the procedure. It isn't necessary for the client to avoid walking, talking, or coughing.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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. 581.

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71. A client has suffered an extensive brain injury and can't make his own treatment choices. Which written document recognized by state law directs provision of care at a time when the client can't make his own choices?

Explanation

RATIONALE: A facility refers to an advance directive, a document the client writes or completes, to provide care at a time when the client can't make his own choices. The living will and health care power of attorney are both examples of advance directives. A living will is a document which a competent adult prepares and which provides direction regarding medical care if the client becomes incapacitated. health care power of attorney is an authorization enabling any competent individual to designate someone else to exercise decision-making authority on the individual's behalf under specific circumstances. The Patient Self-Determination Act of 1990 allows clients to write advance directives.

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. 92.

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72. A newly hired charge nurse assesses the staff nurses as competent individually but ineffective and nonproductive as a team. In addressing her concern, the charge nurse should understand that the reason for such a situation is usually:

Explanation

RATIONALE: The most common reason for lack of productivity in a group of competent nurses is inadequate communication or unexpressed feelings and emotions. Unhappiness about a change in leadership, fatigue from overwork and understaffing, and failure to incorporate staff in decision making could contribute to the problematic situation, but they're less likely to be the cause of the problem.

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. 115.

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73. A nurse is assigned to care for a client with a tracheostomy tube. How can the nurse communicate with this client?

Explanation

RATIONALE: The nurse should use a nonverbal communication method, such as a magic slate, note pad and pencil, and picture boards (if the client can't write or speak English). The physician orders a tracheostomy plug when a client is being weaned off a tracheostomy; it doesn't enable the client to communicate. The call button, which should be within reach at all times for all clients, can summon attention but doesn't communicate additional information. Suctioning clears the airway but doesn't enable the client to communicate.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Basic care and comfort
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. 750.

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74. Which guidelines define and regulate what the nurse may and may not do as a professional?

Explanation

RATIONALE: Each state legislature has enacted a nurse practice act. These statutes outline the legal scope of nursing practice within a particular state. State boards of nursing oversee the statutory law. State legislatures create boards of nursing within each state; the state legislature itself doesn't regulate the scope of nursing. Facility policies govern the practice within a particular facility. Nurse practice acts set educational requirements for the nurse, distinguish between nursing practice and medical practice, and define the scope of nursing practice in that state. Standards of care, criteria that serve as a basis for evaluating the quality of nursing practice, are established by federal organizations, accreditation organizations, state organizations, and professional organizations.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
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. 123.

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75. A nurse is helping a client move up in the bed. Which action maintains good body mechanics?

Explanation

RATIONALE: When moving up in bed, the client's assistance will reduce strain on the nurse. The nurse may have to adjust the bed to a higher position, so it isn't possible to always keep the bed in a low position. However, the low position is preferred unless the client's medical condition contraindicates it. If the client folds his arms, he can't help pull or push himself up in the bed.

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. 775.

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76. When providing oral hygiene for an unconscious client, the nurse must perform which action?

Explanation

RATIONALE: An unconscious client is at risk for aspiration. To decrease this risk, the nurse should place the client in a side-lying position when performing oral hygiene. Swabbing the client's lips, teeth, and gums with lemon glycerin would promote tooth decay. Cleaning an unconscious client's tongue with gloved fingers wouldn't be effective in removing oral secretions or debris. Placing the client in semi-Fowler's position would increase the risk of aspiration.

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. 1165.

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77. A client has a tumor of the posterior pituitary gland. The nurse planning his care should include which interventions? Select all that apply.

Explanation

RATIONALE: Tumors of the pituitary gland can lead to diabetes insipidus because of a deficiency of antidiuretic hormone (ADH). Decreased ADH reduces the ability of the kidneys to concentrate urine, resulting in excessive urination, excessive thirst, and excessive fluid intake. To monitor fluid balance, the nurse should weigh the client daily, measure urine specific gravity, and monitor intake and output. The nurse should encourage fluids to keep intake equal to output and prevent dehydration. Coffee, tea, and other fluids that have a diuretic effect should be avoided.

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1446.

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78. Which action should a nurse take when making a surgical bed?

Explanation

RATIONALE: When making a surgical bed, the nurse should leave the bed in the high position when finished. After placing the top linens on the bed without touching them, the nurse should fanfold these linens to the side opposite the side from which the client will enter and place the pillow on the bedside chair. All of these actions promote transfer of the postoperative client from the stretcher to the bed. When making an occupied or unoccupied bed, the nurse should place the pillow at the head of the bed and tuck the top sheet and blanket under the bottom of the bed. When making an occupied bed, the nurse should roll the client to the far side of the bed.

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.159.

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79. A client is admitted with multiple pressure ulcers. When developing the client's diet plan, the nurse should include:

Explanation

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

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80. While performing an assessment of a 75-year-old female in the emergency department, a nurse notes many bruises in various stages of healing on the client's body. After documenting the locations of the bruises in the medical record, which step should the nurse take immediately?

Explanation

RATIONALE: The nurse should try to obtain more information from the client to complete the assessment. Without supporting information, she shouldn't assume the bruises indicate abuse, and she shouldn't notify her nursing supervisor until she has obtained additional facts. She should, however, inform the physician so he can examine the client. She should follow the facility's policy and procedure for reporting abuse. The nurse should make a report if, after the assessment, she has a strong suspicion that abuse is the cause.

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

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

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81. A nurse-manager appropriately behaves as an autocrat in which situation?

Explanation

RATIONALE: In a crisis situation, the nurse-manager should take command for the benefit of the client. Planning vacation time and evaluating procedures and client resources require staff input and are actions characteristic of a democratic or participative manager.

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. 538.

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82. The staff of an outpatient clinic has formed a task force to develop new procedures for swift, safe evacuation of the unit. The new procedures haven't been reviewed, approved, or shared with all personnel. When a nurse-manager receives word of a bomb threat, the task force members push for evacuating the unit using the new procedures. Which action should the nurse-manager take?

Explanation

RATIONALE: In an emergency such as a bomb scare, the nurse-manager must determine, without hesitation, the best action for the safety and welfare of clients and staff. Allowing staff members to do whatever they think best will cause confusion and inefficient client evacuation because no one will know how to function effectively as a team during the crisis. A staff meeting would waste valuable time.

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. 115.

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83. Nursing licensure and practice are regulated by:

Explanation

RATIONALE: Nurse practice acts regulate nursing licensure and practice. Each state has its own nurse practice act. Standards of care offer guidelines for providing care and criteria for evaluating care. Civil law protects an individual's rights and isn't associated with regulation of nursing licensure or practice. The American Nurses Association, the professional organization for registered nurses in the United States, helps make policy and establish nursing care standards.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
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.20.

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84. A nurse is assisting with a subclavian vein central line insertion when the client's oxygen saturation drops rapidly. He complains of shortness of breath and becomes tachypneic. The nurse suspects the client has developed a pneumothorax. Further assessment findings supporting the presence of a pneumothorax include:

Explanation

RATIONALE: In the case of a pneumothorax, auscultating for breath sounds will reveal absent or diminished breath sounds on the affected side. Paradoxical chest wall movements occur in flail chest conditions. Tracheal deviation occurs in a tension pneumothorax. Muffled or distant heart sounds occur in cardiac tamponade.

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

REFERENCE: Smeltzer, S.C., and Bare, B. Brunner & Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 696.

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85. A client asks to be discharged from the health care facility against medical advice (AMA). What should the nurse do first?

Explanation

RATIONALE: If a client requests a discharge AMA, the nurse should notify the physician immediately. If the physician can't convince the client to stay, the physician will ask the client to sign an AMA form, which releases the facility from legal responsibility for any medical problems the client may experience after discharge. If the physician isn't available, the nurse should discuss the AMA form with the client and obtain the client's signature. A client who refuses to sign the form shouldn't be detained because this would violate the client's rights. After the client leaves, the nurse should document the incident thoroughly and notify the physician that the client has left.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
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. 182.

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86. A community health nurse is working with disaster relief following a flood. Finding safe housing for survivors, providing support for families, organizing counseling, and securing physical care are examples of which type of prevention?

Explanation

RATIONALE: Tertiary prevention involves reducing the degree and quantity of injury, disability, and damage following a disaster or crisis. Aggregate prevention isn't a level of care prevention. Primary prevention focuses on keeping the crisis or disaster from happening. The goal of secondary prevention is to reduce the duration and intensity of the disaster or crisis.

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. 73.

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87. A client is admitted to the facility with a productive cough, night sweats, and a fever. Which action is most important in the initial care plan?

Explanation

RATIONALE: Because the client's signs and symptoms suggest a respiratory infection (possibly tuberculosis), respiratory isolation is indicated. Every 8 hours isn't frequent enough to assess the temperature of a client with a fever. Monitoring fluid intake and output may be required, but the client should first be placed in isolation. The nurse should wear gloves only for contact with mucous membranes, broken skin, blood, and other body fluids and substances.

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

REFERENCE: Smeltzer, S.C., and Bare, B. Brunner & Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 644.

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88. A nurse manages a unit that has four full-time vacant positions, and nurses volunteer to work extra shifts to cover the staffing shortages. One of the staff nurses hasn't volunteered and states, "40 hours a week of nursing is all I can manage. I won't volunteer for overtime." The nurse-manager tells an attending physician on the unit, "I'll adjust her schedule to make her wish she'd volunteered." The physician should:

Explanation

RATIONALE: It's discriminatory and punitive for the nurse-manager to alter the staff nurse's schedule. The remark is inappropriate and unprofessional, and the nurse-manager should receive counseling. The physician could choose to ignore the comment, but any provider who hears of discrimination should deal with it. If the matter can be resolved locally, reporting the nurse-manager to the labor relations board should be avoided. Institutional documentation should exist for such matters. It's inappropriate for the physician to inform the staff nurse about what was said. Such action could create difficult relations on the unit and thereby affect nursing care.

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. 143.

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89. A client with toxoplasmosis and cytomegalovirus is confused and has been dislodging his I.V. access device. He's scheduled to receive amphotericin B (Amphotec) I.V. Which action would be most appropriate for the nurse to take?

Explanation

RATIONALE: The client needs the medication to combat the protozoal infection. Because he has been dislodging the I.V. access devices, a staff member should remain with him during the infusion. Bilateral wrist restraints are a poor choice for managing this situation, and using them doesn't ensure that the client will receive the medication. Giving sedation to a confused client is risky, and it's a poor alternative to having a staff member remain with the client. Administering the drug shouldn't be delayed; appropriate nursing action allows for the drug's administration.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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. 681.

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90. A nurse is faxing client information to a nursing home. Which action should the nurse take to maintain client confidentiality?

Explanation

RATIONALE: A nurse must obtain client authorization before sending any confidential information to a nursing home or other facility. A client's name and other protected information should never appear on a fax cover sheet. It isn't necessary to read the information to the client before sending it. A physician's order doesn't give a nurse the right to send confidential information without the client's permission.

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.

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91. When teaching a client with peripheral vascular disease about foot care, a nurse should include which instruction?

Explanation

RATIONALE: The client should be instructed to avoid wearing canvas shoes. Canvas shoes cause the feet to perspire, and perspiration can cause skin irritation and breakdown. Cotton and cornstarch absorb perspiration. The client should be instructed to cut toenails straight across with nail clippers.

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. 991.

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92. A nurse is planning care for a client with hyperthyroidism. Which nursing interventions are appropriate? Select all that apply.

Explanation

RATIONALE: If the client has exophthalmos (a sign of hyperthyroidism), the conjunctivae should be moistened often with isotonic eye drops. Hyperthyroidism results in increased appetite, which can be satisfied by frequent small, well-balanced meals. The nurse should provide the client with rest periods to reduce metabolic demands. The client should be weighed daily to check for weight loss, a possible consequence of hyperthyroidism. Because metabolism is increased in hyperthyroidism, heat intolerance and excitability result. Therefore, the nurse should provide a cool and quiet environment, not a warm and busy one, to promote client comfort.

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

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1464.

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93. A nurse-manager on an oncology unit has been informed that she must determine which nursing care delivery system (NCDS) is best for efficient client care, client satisfaction, and cost reduction. Knowing that two or three registered nurses, four licensed practical nurses, and five nursing assistants are generally on duty on each shift and that the clients can easily be grouped by geographic location and client care needs, the nurse-manager and her staff appropriately decide to implement which NCDS?

Explanation

RATIONALE: Team nursing is efficient and less costly to implement than primary or case management systems. Because staff members know each other well, they can function effectively as a team. Although functional nursing is the most cost-effective, care is commonly fragmented and clients are less satisfied. Case management and primary nursing require more registered nurses than are available.

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. 117.

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94. Although living will laws vary from state to state, these statutes generally include which provisions?

Explanation

RATIONALE: Living wills include instructions on when and how to implement their provisions, witness and testator requirements, immunity from liability for anyone following the directives, documentation requirements, and under what circumstances the living will takes effect. A living will doesn't state who may uphold the declaration and it doesn't state how long it remains in effect; the assumption is that the will remains in effect indefinitely or until revised. A living will doesn't dictate what will happen to the client's valuables; this is the scope of a regular will.

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. 92.

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95. The nurse is providing dietary teaching for an elderly client. The nurse's teaching should include:

Explanation

RATIONALE: Elderly clients should drink at least eight 8-oz glasses of water each day, unless contraindicated, to help prevent constipation and dehydration. Elderly clients don't need to limit serving sizes of food and water or consume more milk and dairy products than the FDA recommends. Elderly clients should continue to follow the FDA recommendations for fats, oils, and sugars.

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

REFERENCE: United States Department of Agriculture. "Steps to a Healthier You." [Online]. Available: www.mypyramid.gov. [2007, January 8].

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96. A nurse assists in writing a community plan for responding to a bioterrorism threat or attack. When reviewing the plan, the director of emergency operations should have the nurse correct which intervention?

Explanation

RATIONALE: Clients exposed to anthrax should place contaminated clothes in a plastic bag and mark the bag "contaminated." Wearing protective clothing, instructing exposed clients to wash thoroughly, and restricting access to the exposed area are appropriate actions to take in response to a bioterrorism threat.

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. 688.

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97. Following a tonsillectomy, a client returns to the medical-surgical unit. The client is lethargic and reports having a sore throat. In which position should the nurse place the client?

Explanation

RATIONALE: Lethargy puts the posttonsillectomy client at risk for aspirating blood from the surgical wound. Therefore, placing the client in the side-lying position until he's fully awake is best. The semi-Fowler's, supine, and high-Fowler's positions don't allow for adequate oral drainage of a lethargic posttonsillectomy client and increase the risk of blood aspiration.

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

REFERENCE: Hatfield, N. Broadribb's Introductory Pediatric Nursing, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2003, p. 328.

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98. While examining a client's leg, a nurse notes an open ulceration with visible granulation tissue in the wound. Until a wound specialist can be contacted, which type of dressing should the nurse apply?

Explanation

RATIONALE: Moist sterile saline dressings support wound healing and are cost-effective. Dry sterile dressings adhere to the wound and debride the tissue when removed. Petroleum supports healing but is expensive. Povidone-iodine is used as an antiseptic cleaning agent but because it can irritate epithelial cells, it shouldn't be left on an open wound.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
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. 1947.

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99. A child with rheumatic fever complains of painful joints. Which nonpharmacologic measures should the nurse use to reduce the child's pain?

Explanation

RATIONALE: In rheumatic fever, the joints may be so sensitive that even the weight of the bed linens can cause pain. A bed cradle reduces pain by lifting the linens off the child. Moving the affected joint may increase pain; therefore, passive range-of-motion exercises aren't recommended. Massaging the joints isn't likely to relieve pain. The nurse should encourage the child to change positions at least every 2 hours to reduce the risk of skin breakdown, but this is unlikely to relieve joint pain.

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

REFERENCE: Hatfield, N. Broadribb's Introductory Pediatric Nursing, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2004, p. 383.

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100. A nurse is caring for a client with emphysema. Which nursing interventions are appropriate? Select all that apply.Reduce fluid intake to less than 2,500 ml/day.

Explanation

RATIONALE: Diaphragmatic, pursed-lip breathing strengthens respiratory muscles and enhances oxygenation in clients with emphysema. Low-flow oxygen should be administered because the client with emphysema has chronic hypercapnia and a hypoxic respiratory drive. Alternating activity with rest allows the client to perform activities without excessive distress. If the client has copious secretions and has difficulty mobilizing secretions, the nurse should teach him and his family members how to perform postural drainage and chest physiotherapy. Fluid intake should be increased to 3,000 ml/day, if not contraindicated, to liquefy secretions and facilitate their removal. The client should be placed in high Fowler's position to improve ventilation.

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

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 697.

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101. Two days after a right total knee replacement, a client rates his right-knee pain as 9 on a 10-point pain scale. A physician orders hydrocodone/APAP (Vicodin) 1 tablet by mouth every 4 to 6 hours as needed for pain. When a nurse notifies the physician of the client's pain, the physician states that one hydrocodone/APAP tablet should be sufficient and refuses to order anything stronger for pain. Which measure should the nurse select to act as an advocate for the client?

Explanation

RATIONALE: Clients must receive adequate pain relief. Allowing a client to experience a pain score of 9 out of 10 is unacceptable nursing practice. Acting as a client advocate requires a nurse to be assertive, even if this means confronting a physician. If the physician doesn't give an order for adequate pain relief, the nurse should follow the chain of command to report the physician's inaction and obtain adequate pain relief for the client. A nurse may not adjust medication frequency or dosage without a physician's 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. 48.

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102. Which task should a nurse choose to delegate to a nursing assistant? Select all that apply.

Explanation

RATIONALE: Registered nurses are responsible for all phases of the nursing process. These responsibilities include assessing a client's pain and evaluating a client's response to treatment. A nurse may delegate tasks such as taking vital signs, documenting intake and output, and performing blood glucose checks if she follows the five rights of delegation. The five rights of delegation include: right task (the task is within the delegate's scope of practice), right person (the person is competent to perform the task), right communication (the nurse gives the right directions to complete the task), right feedback (the nurse works collaboratively with the delegate), and right follow-up (the nurse follows-up on the task after it has been completed).

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.

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103. When providing discharge teaching to a client with a fractured toe, the nurse should include which instruction?

Explanation

RATIONALE: Applying ice to the injury site soon after an injury causes vasoconstriction, helping to relieve or prevent swelling and bleeding. Applying heat to the fracture site may increase swelling and bleeding. Ankle dorsiflexion has no therapeutic use after a toe fracture. It's unlikely the client would need crutches after a toe fracture.

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

REFERENCE: Smeltzer, S.C., and Bare, B. Brunner & Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 2426.

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104. Four clients injured in an automobile accident enter the emergency department at the same time. The triage nurse evaluates them immediately. The nurse should assign the highest priority to the client with the:

Explanation

RATIONALE: Emergency department triage involves giving priority to clients at highest risk for loss of life, limb, or vision. Clients with poor prognoses are given a lesser priority. The client with the maxillofacial injury and gurgling respirations needs immediate attention because of an impaired airway. The spinal cord injury client doesn't exhibit immediate airway needs. The client with the severe head injury and no blood pressure has a grave prognosis. Although the client in early labor is an urgent priority, early labor doesn't surpass airway compromise in importance.

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

REFERENCE: Smeltzer, S.C., and Bare, B. Brunner & Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 2561.

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105. To help minimize calcium loss from a hospitalized client's bones, the nurse should:

Explanation

RATIONALE: Calcium absorption diminishes with reduced physical activity because of decreased bone stimulation. Therefore, encouraging the client to increase physical activity, such as by walking in the hall, helps minimize calcium loss. Turning or repositioning the client every 2 hours wouldn't increase activity sufficiently to minimize bone loss. Providing dairy products and supplemental feedings wouldn't lessen calcium loss — even if the dairy products and feedings contained extra calcium — because the additional calcium doesn't increase bone stimulation or osteoblast activity.

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. 645.

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106. Which action is contraindicated for a client who develops a temperature of 102° F (38.9° C)?

Explanation

RATIONALE: Because a client with a fever has an increased basal metabolism rate, he needs additional calories in his diet, not fewer calories. Monitoring the client's temperature, increasing his fluid intake, and covering him with a light blanket are therapeutic interventions for a fever.

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. 972.

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107. A physician orders an intestinal tube to decompress a client's GI tract. When gathering equipment for this procedure, a nurse should obtain a:

Explanation

RATIONALE: A Miller-Abbott tube is an intestinal tube. A Sengstaken-Blakemore tube is an esophageal tube. Levin tubes and Salem sump tubes are nasogastric tubes.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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. 1175.

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108. A nurse is caring for a client who underwent surgical repair of a detached retina of the right eye. Which interventions should the nurse perform? Select all that apply.

Explanation

RATIONALE: The nurse should approach the client from the left side — the unaffected side — to avoid startling him. She should also discourage the client from bending down, deep breathing, hard coughing and sneezing, and other activities that can increase intraocular pressure. The client should be oriented to his environment to reduce the risk of injury. Stool softeners should be administered to discourage straining during defecation. The client should lie on his back or on the unaffected side to reduce intraocular pressure on the affected eye.

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

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 2068.

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109. A nurse is caring for a client with a hiatal hernia. The client complains of abdominal pain and sternal pain after eating. The pain makes it difficult for him to sleep. Which instructions should the nurse recommend when teaching this client? Select all that apply.

Explanation

RATIONALE: To reduce gastric reflux, the nurse should instruct the client to sleep with his upper body elevated; lose weight, if obese; avoid constrictive clothing, caffeine, and spicy foods; remain upright for 2 hours after eating; and eat small, frequent meals.

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

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1168.

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110. A client's attorney may file a lawsuit within which time frame?

Explanation

RATIONALE: Statute of limitations is the time period during which the injured party must file a case. Discovery rule refers to the time when the client discovers the injury. The statute of limitations typically allows clients to file a lawsuit within 2 years of discovery; however, the time may vary from state to state. Grace period refers to the contractually specified time during which payment is permitted, without penalty, beyond the due date of the debt. Alternative dispute resolution refers to any means of settling disputes outside the courtroom setting.

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. 130.

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111. A nurse-manager has decided to delegate responsibility for the review and revision of the surgical unit's client-education materials. Which statement illustrates the best method of delegation?

Explanation

RATIONALE: Delegation must be clear and precise. The nurse-manager must assign responsibility, identify the task to be accomplished, explain the necessary outcomes, and define the time frame available to complete the work. The remaining options don't clearly define the work to be done, don't clearly assign responsibility or specify desired outcomes, or establish a time frame for completion of the task.

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. 116.

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112. A nurse-manager must include which items as part of the personnel budget?

Explanation

RATIONALE: Personnel budgets include salaries, benefits, anticipated overtime costs, and potential salary increases. Any expense or single item of equipment costing more than $500 is part of the capital budget. Office supplies and videos 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.

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113. Which intervention should a nurse try first when caring for a client who exhibits signs of sleep disturbance?

Explanation

RATIONALE: The nurse should begin with the simplest interventions, such as pillows or snacks, before introducing interventions that require greater skill such as teaching relaxation techniques. Sleep medication should be avoided whenever possible. Asking the client about the quality of his sleep is appropriate if simpler interventions fail.

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. 1173.

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114. A laissez-faire nurse-manager takes which action?

Explanation

RATIONALE: Delegating a process that will affect all aspects of a nursing area shows a lack of accountability characteristic of a laissez-faire manager. Making critical decisions without staff input is characteristic of an autocratic manager. Delegating evaluation to staff who are intimately involved in a project is appropriate and characteristic of a democratic manager. Identifying potential solutions to a problem and asking staff members for their opinions of the solutions is characteristic of a participative manager.

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. 507.

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115. A nurse is developing a care plan for a client with injury to the frontal lobe of the brain. Which interventions should be part of the care plan? Select all that apply.

Explanation

RATIONALE: Damage to the frontal lobe affects personality, memory, reasoning, concentration, and motor control of speech. Therefore, the nurse needs to keep instructions simple and brief and orient the client to time, place, and person as needed. Damage to the temporal lobe, not the frontal lobe, causes hearing and speech problems. Damage to the occipital lobe causes vision disturbances. Damage to the brain stem affects vital functions.

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

REFERENCE: Smeltzer, S.C., et al. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 2131.

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