Basic Physical care (Part 1)

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  • 1/115 Questions

    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?

    • Notifying the American Cancer Society of the client's diagnosis
    • Requesting Meals On Wheels to provide adequate nutritional intake
    • Referring the client to a home health nurse for follow-up visits to provide colostomy care
    • Asking an occupational therapist to evaluate the client at home
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About This 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! All the best of luck!

Basic Physical care (Part 1) - Quiz

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  • 2. 

    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:

    • Remove the raised skin because the blister has already broken.

    • Wash the area with soap and water to disinfect it.

    • Apply a weakened alcohol solution to clean the area.

    • Clean the area with normal saline solution and cover it with a protective dressing.

    Correct Answer
    A. Clean the area with normal saline solution and cover it with a protective dressing.
    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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  • 3. 

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

    • After meals

    • Before meals

    • When the client has time

    • When the nurse has time

    Correct Answer
    A. Before meals
    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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  • 4. 

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

    • Oxygen saturation.

    • Hemoglobin level.

    • Partial pressure of carbon dioxide (PaCO2).

    • Partial pressure of oxygen (PaO2).

    Correct Answer
    A. Oxygen saturation.
    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?

    • Administering the penicillin G potassium as ordered

    • Administering the penicillin G potassium and staying alert for any reaction

    • Holding the penicillin G potassium and notifying the physician that the client may have an allergy to penicillin

    • Administering the penicillin G potassium but notifying the pharmacist that the client might experience an allergic reaction

    Correct Answer
    A. Holding the penicillin G potassium and notifying the physician that the client may have an allergy to penicillin
    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:

    • First stream of urine from the bladder.

    • Middle stream of urine from the bladder.

    • Final stream of urine from the bladder.

    • Full volume of urine from the bladder.

    Correct Answer
    A. Middle stream of urine from the bladder.
    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?

    • The client takes slow, deep breaths to elevate the spirometer ball.

    • The client takes rapid, shallow breaths to elevate the ball.

    • The client tilts the spirometer down when using it.

    • The client uses the device while lying supine.

    Correct Answer
    A. The client takes slow, deep breaths to elevate the spirometer ball.
    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?

    • Determining how planned absences such as vacation time will be scheduled so that all staff are treated fairly

    • Identifying who will be responsible for making client care decisions

    • Deciding what type of dress code will be implemented

    • Identifying salary ranges for various types of staff

    Correct Answer
    A. Identifying who will be responsible for making client care decisions
    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:

    • Leave the client and get help.

    • Obtain a physician's order to restrain the client.

    • Read the facility's policy on restraints.

    • Order soft restraints from the storeroom.

    Correct Answer
    A. Obtain a physician's order to restrain the client.
    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 suddenly loses consciousness. What should the nurse do first?

    • Call for assistance.

    • Assess for responsiveness.

    • Palpate for a carotid pulse.

    • Assess for pupillary response.

    Correct Answer
    A. Assess for responsiveness.
    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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  • 11. 

    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?

    • Baked beans, hamburger, and milk

    • Spaghetti with cream sauce, broccoli, and tea

    • Bouillon, spinach, and soda

    • Chicken cutlet, spinach, and soda

    Correct Answer
    A. Baked beans, hamburger, and milk
    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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  • 12. 

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

    • Complaints of deep, sharp incisional pain

    • Evidence of uneven wound edges

    • Thick, yellow wound drainage

    • Oral temperature of 100.6° F (38.1° C)

    Correct Answer
    A. Thick, yellow wound drainage
    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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  • 13. 

    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?

    • Manager

    • Autocrat

    • Leader

    • Authority

    Correct Answer
    A. Leader
    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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  • 14. 

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

    • Clean from the center outward in a circular motion.

    • Remove the drain before cleaning the skin.

    • Clean briskly around the site with alcohol.

    • Wear sterile gloves and a mask.

    Correct Answer
    A. Clean from the center outward in a circular motion.
    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?

    • The primary nurse

    • The physician involved with the procedure

    • The nurse working with the physician

    • The social worker

    Correct Answer
    A. The physician involved with the procedure
    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. 

    Which statement concerning informed consent is true?

    • Minors may give informed consent.

    • The professional nurse and physician must each obtain informed consent.

    • The client must be fully informed regarding treatment, tests, alternative treatments, and the risks and benefits of each.

    • Mentally incompetent clients may legally give informed consent.

    Correct Answer
    A. The client must be fully informed regarding treatment, tests, alternative treatments, and the risks and benefits of each.
    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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  • 17. 

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

    • Monoplegia.

    • Hemiplegia.

    • Paraplegia.

    • Quadriplegia.

    Correct Answer
    A. Hemiplegia.
    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. 

    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?

    • Antidiarrheal medication should be given if the client has more than two loose stools.

    • Eating large meals should be encouraged to prevent weight loss.

    • The client may require fluid and electrolyte replacement.

    • Side rails should be raised at all times.

    Correct Answer
    A. The client may require fluid and electrolyte replacement.
    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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  • 19. 

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

    • Applying the restraint loosely to prevent pressure on the skin

    • Tying the restraint to the side rail

    • Positioning the restrained arm in full extension

    • Monitoring circulatory status every 2 hours

    Correct Answer
    A. Monitoring circulatory status every 2 hours
    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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  • 20. 

    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?

    • Incision and drainage

    • Culture

    • Debridement

    • Irrigation

    Correct Answer
    A. Debridement
    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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  • 21. 

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

    • Recommending warm milk or a warm shower at bedtime

    • Gathering more information about the client's sleep problem

    • Determining whether the client is worried about something

    • Finding out whether the client is taking medication that may impede sleep

    Correct Answer
    A. Gathering more information about the client's sleep problem
    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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  • 22. 

    A scrub nurse in the operating room has which responsibility?

    • Positioning the client

    • Assisting with gowning and gloving

    • Handing surgical instruments to the surgeon

    • Applying surgical drapes

    Correct Answer
    A. Handing surgical instruments to the surgeon
    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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  • 23. 

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

    • Identifying incorrect dosages or potential interactions of ordered medications

    • Never questioning a physician's order because the physician is ultimately responsible for the client outcome

    • Notifying the Occupational Safety and Health Administration (OSHA) of workplace violations

    • Informing the client of the Patient's Bill of Rights

    Correct Answer
    A. Identifying incorrect dosages or potential interactions of ordered medications
    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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  • 24. 

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

    • A palpable radial pulse

    • A palpable ulnar pulse

    • Cool, pale fingers

    • Pink nail beds

    Correct Answer
    A. Cool, pale fingers
    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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  • 25. 

    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?

    • Documenting that the client is resting quietly and denies pain

    • Calling a family member to obtain information about the client

    • Giving the client the ordered as-needed pain medication

    • Checking vital signs and assessing for nonverbal indications of pain

    Correct Answer
    A. Checking vital signs and assessing for nonverbal indications of pain
    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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  • 26. 

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

    • Wear gloves for all client contact.

    • Consider all body substances potentially infectious.

    • Place a body substance isolation sign on the client's door.

    • Wear gloves and a gown if the client is in respiratory isolation.

    Correct Answer
    A. Consider all body substances potentially infectious.
    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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  • 27. 

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

    • Putting on an individually fitted mask when entering the client's room

    • Instructing the client to wear a mask at all times

    • Wearing a gown and gloves when providing direct care

    • Keeping the door to the client's room open to observe the client

    Correct Answer
    A. Putting on an individually fitted mask when entering the client's room
    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?

    • Telling the nurse that she may use the password

    • Telling the nurse to ask someone else for her password

    • Writing down the password so the nurse won't forget it

    • Telling the nurse that she may not use the password

    Correct Answer
    A. Telling the nurse that she may not use the password
    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?

    • Eupnea

    • Bradypnea

    • Apnea

    • Tachypnea

    Correct Answer
    A. Tachypnea
    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. 

    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?

    • Primary prevention

    • Secondary prevention

    • Tertiary prevention

    • Passive prevention

    Correct Answer
    A. Primary prevention
    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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  • 31. 

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

    • The nurse makes decisions for clients who can't make decisions for themselves.

    • The nurse follows the basic standards of care and hospital policies and procedures for providing client care.

    • The nurse promotes and protects the client's interests and rights.

    • The nurse adopts a paternalistic approach to client care.

    Correct Answer
    A. The nurse promotes and protects the client's interests and rights.
    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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  • 32. 

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

    • Position the head of the bed flat.

    • Help the client dangle his legs.

    • Stand behind the client.

    • Place the chair facing away from the bed.

    Correct Answer
    A. Help the client dangle his legs.
    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. 

    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?

    • Nasal cannula

    • Venturi mask

    • Simple mask

    • Nonrebreather mask

    Correct Answer
    A. Nonrebreather mask
    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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  • 34. 

    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?

    • Clear, yellow drainage

    • Redness and warmth

    • Pallor around sutures

    • Brown exudate at incision edges

    Correct Answer
    A. Redness and warmth
    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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  • 35. 

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

    • Conduct performance evaluations in a group setting so input from peers and subordinates influences evaluation of a staff member's effectiveness.

    • Provide feedback on strengths as well as areas for improvement and clarify what she expects the staff member to accomplish before the next performance evaluation.

    • Provide written documentation of areas for improvement. Areas of strength needn't be documented because these areas are complimentary and don't describe actions the staff member must take to improve.

    • Whenever possible, delegate responsibility for conducting performance evaluations to primary nurses to help them achieve professional growth.

    Correct Answer
    A. Provide feedback on strengths as well as areas for improvement and clarify what she expects the staff member to accomplish before the next performance evaluation.
    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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  • 36. 

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

    • Figure-eight

    • Circular

    • Recurrent

    • Spiral reverse

    Correct Answer
    A. Figure-eight
    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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  • 37. 

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

    • Including the client in the discussion

    • Using technical terms

    • Providing detailed explanations

    • Using loosely structured teaching sessions

    Correct Answer
    A. Including the client in the discussion
    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?

    • Use elevators to travel to the location of the fire.

    • Make sure all fire doors are open.

    • Implement the RACE plan.

    • N't notify the fire department if the fire is small enough for the nurse to extinguish.

    Correct Answer
    A. Implement the RACE plan.
    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. 

    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?

    • Failure to act as a client advocate

    • Failure to communicate with the client

    • Failure to assess, monitor, and communicate

    • Failure to protect from harm

    Correct Answer
    A. Failure to assess, monitor, and communicate
    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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  • 40. 

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

    • My son can't eat wheat, rye, oats, or barley.

    • My son needs a gluten-rich diet.

    • My son must avoid potatoes, rice, and cornstarch.

    • My son can safely eat frozen and packaged foods.

    Correct Answer
    A. My son can't eat wheat, rye, oats, or barley.
    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?

    • Dorothy Johnson

    • Virginia Henderson

    • Dorothea Orem

    • Martha Rogers

    Correct Answer
    A. Dorothea Orem
    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?

    • Cap

    • Mask

    • Gown

    • Gloves

    Correct Answer
    A. Gloves
    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?

    • Throw the documents in the trash can.

    • Shred the documents or place them in a Health Insurance Portability and Accountability Act (HIPAA) trash container.

    • Place the documents in the client's chart.

    • Leave the documents at the nurses' station.

    Correct Answer
    A. Shred the documents or place them in a Health Insurance Portability and Accountability Act (HIPAA) trash container.
    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. 

    The American Nurses Association Code for Nurses includes:

    • Tips for correctly performing a procedure in the hospital environment.

    • Bylaws that state clients' rights.

    • A code of ethics that states the nurse's obligation and responsibility to the client.

    • Regulations stating criteria for nursing licensure.

    Correct Answer
    A. A code of ethics that states the nurse's obligation and responsibility to the client.
    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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  • 45. 

    Which one do you like?

    • Only low doses of opioids are safe; higher doses may cause respiratory depression.

    • Pain medication should be given only when a client requests it.

    • A client who can fall asleep isn't in pain.

    • Terminal cancer clients may develop tolerance to opioids and require progressively higher doses to control pain.

    Correct Answer
    A. Terminal cancer clients may develop tolerance to opioids and require progressively higher doses to control pain.
    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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  • 46. 

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

    • ½″ (1 cm)

    • 2″ (5 cm)

    • 6″ (15 cm)

    • 8″ (20 cm)

    Correct Answer
    A. 2″ (5 cm)
    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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  • 47. 

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

    • Presence of congestion on X-ray

    • Breath sounds clear on auscultation

    • Continued use of oxygen when necessary

    • Respiratory rate of 28 breaths/minute

    Correct Answer
    A. Breath sounds clear on auscultation
    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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  • 48. 

    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?

    • Does the pain worsen when you get up in the morning?

    • Does the pain increase with activity and lessen with rest?

    • Is the pain relieved when you change position?

    • Is the pain worse when you point your toes toward your knee?

    Correct Answer
    A. Is the pain worse when you point your toes toward your knee?
    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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  • 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?

    • Rectal

    • Oral

    • Axillary

    • Tympanic

    Correct Answer
    A. Rectal
    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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