Basic Physical care (Part 1)

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A client has a tumor of the posterior pituitary gland. The nurse planning his care should include which interventions? Select all that apply.
- Take daily weight.
- Restrict fluids.
- Assess urine specific gravity.
- Encourage intake of coffee or tea.
- Monitor intake and output.

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!

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2.

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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3.

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?
- Omission
- Late entry
- Improper correction
- Unauthorized entry
Correct Answer

A. Unauthorized entry

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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4.

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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5.

A nurse is performing a sterile dressing change. Which action contaminates the sterile field?
- Holding sterile objects above the waist
- Pouring solution onto a sterile field cloth
- Leaving a 1″ (2.5-cm) edge around the sterile field
- Opening the outermost flap of a sterile package away from the body
Correct Answer

A. Pouring solution onto a sterile field cloth

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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6.

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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7.

Which action should a nurse take when making a surgical bed?
- Leave the bed in the high position when finished.
- Place the pillow at the head of the bed.
- Tuck the top sheet and blanket under the bottom of the bed.
- Roll the client to the far side of the bed.
Correct Answer

A. Leave the bed in the high position when finished.

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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8.

Nursing licensure and practice are regulated by:
- Nurse practice acts.
- Standards of care.
- Civil law.
- The American Nurses Association.
Correct Answer

A. Nurse practice acts.

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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9.

Which guidelines define and regulate what the nurse may and may not do as a professional?
- State legislature
- Facility policies and procedures
- Standards of care
- Nurse practice act
Correct Answer

A. Nurse practice act

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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10.

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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11.

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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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 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?
- A nursing assistant administers medications to a client in ICU.
- A staff nurse refuses to follow a physician's order to administer medication because administering the dosage ordered could seriously harm the client.
- A nursing assistant attempts to initiate I.V. therapy.
- A staff nurse fills a client prescription at the hospital pharmacy because the pharmacist on duty is busy.
Correct Answer

A. A staff nurse refuses to follow a physician's order to administer medication because administering the dosage ordered could seriously harm the client.

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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14.

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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15.

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.
- Reduce fluid intake to less than 2,500 ml/day.
- Teach diaphragmatic, pursed-lip breathing.
- Administer low-flow oxygen.
- Keep the client in a supine position as much as possible.
- Encourage alternating activity with rest periods.
- Teach use of postural drainage and chest physiotherapy.
Correct Answer(s)

A. Teach diaphragmatic, pursed-lip breathing.
A. Administer low-flow oxygen.
A. Encourage alternating activity with rest periods.
A. Teach use of postural drainage and chest physiotherapy.

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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16.

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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17.

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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18.

A client's attorney may file a lawsuit within which time frame?
- Discovery rule
- Statute of limitations
- Grace period
- Alternative dispute resolution
Correct Answer

A. Statute of limitations

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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19.

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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20.

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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21.

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?
- All personnel should wear protective clothing, including a gown, gloves, and respiratory protection.
- Clients exposed to anthrax should immediately remove contaminated clothing and place it in the hamper.
- Clients should be instructed to wash thoroughly with soap and water.
- Access to the area should be restricted.
Correct Answer

A. Clients exposed to anthrax should immediately remove contaminated clothing and place it in the hamper.

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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22.

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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23.

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
Correct Answer

A. Referring the client to a home health nurse for follow-up visits to provide colostomy 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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24.

When providing discharge teaching to a client with a fractured toe, the nurse should include which instruction?
- Apply heat to the fracture site.
- Apply ice to the fracture site.
- Perform ankle dorsiflexion three times per day.
- Use crutches for 1 week.
Correct Answer

A. Apply ice to the fracture site.

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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25.

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:
- Alcohol.
- Ammonia.
- Acetone.
- Bleach.
Correct Answer

A. Bleach.

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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26.

When moving a client in bed, the nurse can ensure proper body mechanics by:
- Standing with her feet apart.
- Lifting the client to the proper position.
- Straightening her knees and back.
- Standing several feet from the client.
Correct Answer

A. Standing with her feet apart.

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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27.

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.
- Avoid constrictive clothing.
- Lie down for 30 minutes after eating.
- Decrease intake of caffeine and spicy foods.
- Eat three meals per day.
- Sleep in semi-Fowler's position.
- Maintain a normal body weight.
Correct Answer(s)

A. Avoid constrictive clothing.
A. Decrease intake of caffeine and spicy foods.
A. Sleep in semi-Fowler's position.
A. Maintain a normal body weight.

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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28.

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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29.

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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30.

A nurse-manager appropriately behaves as an autocrat in which situation?
- Planning vacation time for staff
- Directing staff activities if a client experiences a cardiac arrest
- Evaluating a new medication-administration process
- Identifying the strengths and weaknesses of a client-education video
Correct Answer

A. Directing staff activities if a client experiences a cardiac arrest

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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31.

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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32.

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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33.

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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34.

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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35.

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:
- Withhold all potentially life-prolonging treatments in accordance with the client's living will.
- Increase the oxygen flow rate to 4 L, but avoid initiating other interventions.
- Call the client's family and ask what they think is best.
- Initiate potentially life-prolonging treatment unless the client refuses.
Correct Answer

A. Initiate potentially life-prolonging treatment unless the client refuses.

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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36.

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?
- Notify the nursing supervisor.
- Notify the physician.
- Try to obtain more information from the client about when and how she acquired these bruises.
- Follow the facility's policy and procedures for reporting elder abuse.
Correct Answer

A. Try to obtain more information from the client about when and how she acquired these bruises.

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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37.

A nurse is planning care for a client with hyperthyroidism. Which nursing interventions are appropriate? Select all that apply.
- Instill isotonic eye drops, as necessary.
- Provide several small, well-balanced meals.
- Provide rest periods.
- Keep the environment warm.
- Encourage frequent visitors and conversation.
- Weigh the client daily.
Correct Answer(s)

A. Instill isotonic eye drops, as necessary.
A. Provide several small, well-balanced meals.
A. Provide rest periods.
A. Weigh the client daily.

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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38.

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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39.

A client has a wound with a drain. When cleaning around the drain, the nurse should wipe in which direction?
- Laterally, from the center to the opposite side
- From top to bottom
- In a circle around the drain, outward from the center
- In a circle around the drain, from the outer border to the center
Correct Answer

A. In a circle around the drain, outward from the center

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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40.

A nurse must apply an elastic bandage to a client's ankle and calf. She should apply the bandage beginning at the client's:
- Foot.
- Ankle.
- Lower thigh.
- Knee.
Correct Answer

A. Foot.

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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41.

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?
- Functional nursing
- Case management
- Team nursing
- Primary nursing
Correct Answer

A. Team nursing

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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42.

Which laboratory test result is the most important indicator of malnutrition in a client who has a wound?
- Serum potassium level
- Lymphocyte count
- Albumin level
- Differential count
Correct Answer

A. Albumin level

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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43.

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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44.

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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45.

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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46.

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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47.

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.
- Place the client in a prone position.
- Approach the client from the left side.
- Encourage deep breathing and coughing.
- Discourage bending down.
- Orient the client to his environment.
- Administer a stool softener.
Correct Answer(s)

A. Approach the client from the left side.
A. Discourage bending down.
A. Orient the client to his environment.
A. Administer a stool softener.

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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48.

To help minimize calcium loss from a hospitalized client's bones, the nurse should:
- Reposition the client every 2 hours.
- Encourage the client to walk in the hall.
- Provide the client dairy products at frequent intervals.
- Provide supplemental feedings between meals.
Correct Answer

A. Encourage the client to walk in the hall.

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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49.

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?
- Follow the chain of command to obtain adequate pain relief for the client.
- Document that the physician was notified of the client's pain and continue to administer hydrocodone/APAP as ordered.
- Give the client 1 hydrocodone/APAP tablet every 3 hours.
- Give the client 2 hydrocodone/APAP tablets every 4 hours.
Correct Answer

A. Follow the chain of command to obtain adequate pain relief 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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Basic Physical care (Part 1)

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

Quiz Preview

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

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

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

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

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

Nursing licensure and practice are regulated by:

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

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?

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

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

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?

The American Nurses Association Code for Nurses includes:

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.

Which one do you like?

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?

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

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

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?

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?

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?

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?

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

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:

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

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.

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:

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?

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

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

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

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?

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

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:

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?

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

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?

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

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

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

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

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

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?

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

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.

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