Nursing Comprehensive Exam 3

1. A nurse is caring for an 11-year-old child who has been abused. Which of the following is most important to include in the plan of care?

Encourage the child to fear the abuser

Provide a care environment that allows for the development of trust

Teach the child to make wise choice when confronted with an abusive situation

Have the child point out the abuser if they should visit while the child is hospitalized

The abused child usually requires long-term therapeutic support. The environment provided during the child’s healing must include one in which trust and empathy are modeled and provided for the child. Option A reinforces fear, which although it is a legitimate response to abuse, should not be encouraged. Options C and D ask the child to behave with a maturity beyond that which would be expected for an 11-year-old. Option B is the option that is most supportive environment in which to begin the healing process.

Explanation

The abused child usually requires long-term therapeutic support. The environment provided during the child’s healing must include one in which trust and empathy are modeled and provided for the child. Option A reinforces fear, which although it is a legitimate response to abuse, should not be encouraged. Options C and D ask the child to behave with a maturity beyond that which would be expected for an 11-year-old. Option B is the option that is most supportive environment in which to begin the healing process.

2. A nurse lawyer provides an education session to the nursing staff regarding client rights. A staff nurse asks the lawyer to describe an example that might relate to invasion of client privacy. Which of the following indicates a violation of this right?

Taking photographs of the client without consent

Telling the client that he or she cannot leave the hospital

Threatening to place a client in restraints

Performing a surgical procedure without consent

Invasion of privacy takes place when an individual’s private affairs are unreasonably intruded into. Telling the client that he or she cannot leave the hospital constitute false imprisonment.

Explanation

Invasion of privacy takes place when an individual’s private affairs are unreasonably intruded into. Telling the client that he or she cannot leave the hospital constitute false imprisonment.

3. A nurse is caring for a client with severe cardiac disease. While caring for the client, the client states to the nurse, "If anything should happen to me, please make sure that the doctors do not try to push on my chest and revive me." The most appropriate nursing action is to:

Tell the client that it is necessary to notify the physician of the client’s request

Tell the client that the family must agree with the request

Plan a client conference with the nursing staff to share the client’s request

External cardiac massage is one type of treatment that a client can refuse. The most appropriate nursing action is to notify the physician because a written “Do Not Resuscitate” (DNR) order from the physician must be present on the client’s record. The DNR order must be reviewed or renewed on a regular basis per agency policy.

Explanation

External cardiac massage is one type of treatment that a client can refuse. The most appropriate nursing action is to notify the physician because a written “Do Not Resuscitate” (DNR) order from the physician must be present on the client’s record. The DNR order must be reviewed or renewed on a regular basis per agency policy.

4. A nurse is performing an admission assessment on a male child and notes the presence of old and new bruises on the child's back and legs. The nurse suspects physical abuse. The most appropriate nursing action would be to:

File charges against the mother and father of the child

Report the case to legal authorities

Ask the mother to identify the individual who is physically abusing the child

Tell the child that he will need to go to a foster home until the situation is straightened out

The primary legal nursing responsibility when child abuse is suspected is to report the case.; All 50 states require health care professionals to report all cases of suspected abuse. It is not appropriate for the nurse to file charges against the father or mother. It is also inappropriate to ask the mother to identify the abuser, because the abuser may be the mother. If so, the possibility exists that the mother may become defensive and leave the emergency department with the child. Option D is clearly inappropriate and will produce fear in the child.

Explanation

The primary legal nursing responsibility when child abuse is suspected is to report the case.; All 50 states require health care professionals to report all cases of suspected abuse. It is not appropriate for the nurse to file charges against the father or mother. It is also inappropriate to ask the mother to identify the abuser, because the abuser may be the mother. If so, the possibility exists that the mother may become defensive and leave the emergency department with the child. Option D is clearly inappropriate and will produce fear in the child.

5. A nurse working on an adult nursing unit is told to review the client census to determine which clients could be discharged if there are a large number of admissions from a newly declared disaster. The nurse interprets that the client with which of the following problems would not be able to be discharged, even if support was available at home?

Laparoscopic cholecystectomy ( same day )

Ongoing ventricular dysrhythmias while on procainamide ( Procan )

Diabetes mellitus with blood glucose at 180 mg / dL

Fractured hip pinned 5 days ago

The client with ongoing ventricular dysrhythmias requires ongoing medical evaluation and treatment because of potentially lethal complications of the problem. Each of the other problems listed may be managed at home with appropriate agency referrals for home care services, and support from the family at home.

Explanation

The client with ongoing ventricular dysrhythmias requires ongoing medical evaluation and treatment because of potentially lethal complications of the problem. Each of the other problems listed may be managed at home with appropriate agency referrals for home care services, and support from the family at home.

6. A nurse is caring for an infant who is admitted to the hospital with a diagnosis of hemolytic disease. The nurse reviews the laboratory result, expecting to note which of the following in this infant?

Decreased red blood cell count

Decreased bilirubin count

Elevated blood glucose level

Decreased white blood cell count

The two primary path physiological alteration associated with hemolytic disease are anemia and hyperbilirubinemia. The red blood cell count is decreased because the red blood cell production cannot keep pace with red blood cell destruction. Hyperbilirubinemia results from the red blood cell destruction accompanying this disorder as well as from the normally decreased ability of the neonate’s liver to conjugate and excrete bilirubin efficiently from the body. Hypoglycemia is associated with hypertrophy of the pancreatic islet cells and increased levels of insulin. White blood cell count is not related to this disorder.

Explanation

The two primary path physiological alteration associated with hemolytic disease are anemia and hyperbilirubinemia. The red blood cell count is decreased because the red blood cell production cannot keep pace with red blood cell destruction. Hyperbilirubinemia results from the red blood cell destruction accompanying this disorder as well as from the normally decreased ability of the neonate’s liver to conjugate and excrete bilirubin efficiently from the body. Hypoglycemia is associated with hypertrophy of the pancreatic islet cells and increased levels of insulin. White blood cell count is not related to this disorder.

7. A nurse enters a client's room and finds the client lying on the floor. Following assessment of the client, the nurse calls the nursing supervisor and the physician to inform them of the occurrence. The nursing supervisor instructs the nurse to complete an incident report. The nurse understands that incident reports allow the analysis of adverse client events by:

Evaluating quality care and the potential risks for injury to the client

Determining the effectiveness of nursing interventions in relation to outcomes

Providing a method of reporting injuries to local, state, and federal agencies

Providing clients with necessary stabilizing treatments

Proper documentation of unusual occurrences, incidents and accidents, and the nursing actions taken a result of the occurrence, are internal to the institution or agency and allow the nurse and administration to review the quality of care and determine any potential risks present. Incident reports are not routinely filled out for interventions nor are they used to report occurrences to other agencies.

Explanation

Proper documentation of unusual occurrences, incidents and accidents, and the nursing actions taken a result of the occurrence, are internal to the institution or agency and allow the nurse and administration to review the quality of care and determine any potential risks present. Incident reports are not routinely filled out for interventions nor are they used to report occurrences to other agencies.

8. A nurse is preparing to assist the client from the bed to a chair using a hydraulic lift. The nurse would do which of the following to move the client safely with this device?

Have three people available to assist

Position the client in the center of the sling

Have the client grasp the chains attaching the sling to the lift.

Lower the client rapidly once positioned over the chair

When using a hydraulic lift, the client is positioned in the center of the sling, which is then attached to chains or straps that attach the sling to the lift. The client's hands and arms are crossed over the chest, and the client is raised from the bed into a sitting position. The client is also raised off the mattress with the lift, and is lowered slowly once the sling is positioned over the chair.

Explanation

When using a hydraulic lift, the client is positioned in the center of the sling, which is then attached to chains or straps that attach the sling to the lift. The client's hands and arms are crossed over the chest, and the client is raised from the bed into a sitting position. The client is also raised off the mattress with the lift, and is lowered slowly once the sling is positioned over the chair.

9. A nurse is called to a client's room by another nurse. When the nurse arrives at the room, the nurse discovers that a fire has occurred in the client's waste basket. The first nurse has removed the client from the room. What is the second nurse's next action?

Evacuate the unit

Extinguish the fire

Confine the fire

Activate the fire alarm

Remember the acronym RACE to set priorities if a fire occurs. “R” stands for rescue. “A” stands for alarm. “C” stands for confine. “E” stands for extinguish. In this situation, the client has been rescued from the immediate vicinity of the fire. The next action is to activate the fire alarm.

Explanation

Remember the acronym RACE to set priorities if a fire occurs. “R” stands for rescue. “A” stands for alarm. “C” stands for confine. “E” stands for extinguish. In this situation, the client has been rescued from the immediate vicinity of the fire. The next action is to activate the fire alarm.

10. A nurse is caring for a hospitalized child with a diagnosis of rheumatic fever (RF), and the child has developed carditis. The mother asks the nurse to explain the meaning of carditis. The nurse plans to respond, knowing that which of the following most appropriately describes this complication of RF?

Tender, painful joints, especially in the elbows, knees, ankles, and wrists

Inflammation of all part of the heart, primarily the mitral vale

Involuntary movements affecting the legs, arms, and face

Red skin lesions start as flat or slightly raised macules, usually over the trunk and spread peripherally

Carditis is the inflammation of all parts of the heart primarily the mitral valve, and is a complication of RF. Option A describes polyarthritis. Options C Describes chorea. Option D describes erythema marginatum.

Explanation

Carditis is the inflammation of all parts of the heart primarily the mitral valve, and is a complication of RF. Option A describes polyarthritis. Options C Describes chorea. Option D describes erythema marginatum.

11. A client brought to the emergency room after a serious accident is unconscious and bleeding profusely. Surgery is required immediately in order to save the client's life. In regard to informed consent for the surgical procedure, which of the following is the best nursing action?

Try to obtain the spouse’s telephone number and call the spouse to obtain telephone consent before the surgical procedure

Transport the client to the operating room immediately as required by the physician without obtaining an informed consent

Ask the friend that accompanied the client to the emergency room to sign the consent form

Call the nursing supervisor to initiate a court order for the surgical procedure

Generally, the informed consent of an adult client is not needed in two instances. One instance is when the emergency is present and delaying treatment for the purpose of obtaining informed consent would result in injury or death to the client. The second instance is when the client waives the right to give informed consent.

Explanation

Generally, the informed consent of an adult client is not needed in two instances. One instance is when the emergency is present and delaying treatment for the purpose of obtaining informed consent would result in injury or death to the client. The second instance is when the client waives the right to give informed consent.

12. A nurse educator at the local community hospital is conducting an orientation session for nurses who are newly employed at the hospital. The nurse educator informs the new nurses that the policy of the hospital requires that nurses float to other nursing departments when client census is high on other units. The nurse educator advises the new nurses that if this situation arises, and if the nurse is unfamiliar with the unit in which the nurse must float to:

Refuse to float

Call the nurse educator

Report to the unit and identify tasks that can be safely performed

Call the nursing supervisor

Floating is an acceptable, legal practice used by hospitals to solve their understaffing problems. Legally, a nurse cannot refuse to float unless union contract guarantees that nurses can only work in a specified area or the nurse can prove the lack of knowledge for the performance of assigned tasks. When encountered with this situation, nurses should set priorities and identify potential areas of harm to the client. The nursing supervisor or the nurse educator may need to become involved in the situation at some point if the nurse requires assistance or education regarding a new skill, but the action that the nurse must take is identified in option C.

Explanation

Floating is an acceptable, legal practice used by hospitals to solve their understaffing problems. Legally, a nurse cannot refuse to float unless union contract guarantees that nurses can only work in a specified area or the nurse can prove the lack of knowledge for the performance of assigned tasks. When encountered with this situation, nurses should set priorities and identify potential areas of harm to the client. The nursing supervisor or the nurse educator may need to become involved in the situation at some point if the nurse requires assistance or education regarding a new skill, but the action that the nurse must take is identified in option C.

13. A client has emergency surgery for a ruptured appendix. After assessing that the client is manifesting symptoms of shock the nurse should:

Prepare for a blood transfusion

Notify the physician immediately

Elevate the head of the bed 30 degrees

Administer the oxygen prescribed postoperatively

Peritonitis and shock are potentially life-threatening complications following abdominal surgery; prompt, rigorous treatment is necessary

Explanation

Peritonitis and shock are potentially life-threatening complications following abdominal surgery; prompt, rigorous treatment is necessary

14. An elderly woman is brought to the emergency room. On physical assessment, the nurse noted old and new ecchymotic areas on both arms and buttocks. The nurse asks the client on how the bruises were sustained. The client, although reluctant, tells the nurse in confidence that her daughter frequently hits her if she gets in the way. Which of the following is the most appropriate nursing response?

"I promise I will not tell anyone but let’s see what we can do about this."

"I have a legal obligation to report this type of abuse."

"Lets talk about ways that will prevent your daughter from hitting you."

"This should not be happening, and if it happens again you must call the emergency department."

Confidential issues are not to be discussed with non-medical personnel or the person’s family or friend without the person’s permission. Clients should be assured that information is kept confidential, unless it places the nurse under a legal obligation. The nurse must report situations related to child or elderly abuse, gunshot wounds, and certain infectious diseases.

Explanation

Confidential issues are not to be discussed with non-medical personnel or the person’s family or friend without the person’s permission. Clients should be assured that information is kept confidential, unless it places the nurse under a legal obligation. The nurse must report situations related to child or elderly abuse, gunshot wounds, and certain infectious diseases.

15. A client tells the home health care nurse of the decision to refuse external cardiac massage. Which of the following is the most appropriate initial nursing action?

Notify the physician of the client’s request

Document the client’s request in the home health nursing care plan

Conduct a client conference with the home health care staff to share the client’s request

Discuss the client’s request with the family

External cardiac massage is one type of treatment that a client can refuse. The most appropriate nursing action is to notify the physician because a written “Do Not Resuscitate” (DNR) order from the physician must be present. The DNR order must be reviewed or renewed on a regular basis per agency policy. Although options B, C, and D may be appropriate, remember that first a written physician’s order is necessary

Explanation

External cardiac massage is one type of treatment that a client can refuse. The most appropriate nursing action is to notify the physician because a written “Do Not Resuscitate” (DNR) order from the physician must be present. The DNR order must be reviewed or renewed on a regular basis per agency policy. Although options B, C, and D may be appropriate, remember that first a written physician’s order is necessary

16. A physician visits a client on the nursing unit. During the visit, the physician is called to another nursing unit to assess a client in extreme pain. The physician states to the nurse, "I'm in a hurry. Can you write the order to decrease the atenolol (Tenormin) to 25 mg daily?" Which of the following is the most appropriate nursing action?

Write the order as stated

Call the nursing supervisor to write the order

Ask the physician to return to the nursing unit to write the order

Inform the client of the change of medication

Nurses are encouraged not to accept verbal orders from the physician because of the risks of error. The only exception to this may be in an emergency situation and then the agency policy and procedure must be adhered to. Although the client will be informed of the change of the treatment plan, this is not the most appropriate action at this time. The physician needs to write the new order. It is inappropriate to ask another individual other than the physician to write the order.

Explanation

Nurses are encouraged not to accept verbal orders from the physician because of the risks of error. The only exception to this may be in an emergency situation and then the agency policy and procedure must be adhered to. Although the client will be informed of the change of the treatment plan, this is not the most appropriate action at this time. The physician needs to write the new order. It is inappropriate to ask another individual other than the physician to write the order.

17. A nurse observes that the client received pain medication 1 hour ago from another nurse, but that the client still has severe pain. The nurse has previously observed this same occurrence. The nurse practice act requires the observing nurse to do which of the following?

Talk with the nurse who gave the medication

Report the information to a nursing supervisor

Call the impaired nurse organization

Report the information to the police

Nurse practice acts require reporting the suspicion of impaired nurses. The board of nursing has jurisdiction over the practice of nursing and may develop plans for treatment and supervision. This suspicion needs to be reported to the nursing supervisor, who will then report to the board of nursing.

Explanation

Nurse practice acts require reporting the suspicion of impaired nurses. The board of nursing has jurisdiction over the practice of nursing and may develop plans for treatment and supervision. This suspicion needs to be reported to the nursing supervisor, who will then report to the board of nursing.

18. A nurse is planning care for a child with an infections and communicable disease. The nurse determines that the primary goals is that the:

Child will experience only minor complications

Child will not spread the infection to others

Public health department will be notified

Child will experience mild discomfort

The primary goal is to prevent the spread of the disease to others. The child should experience no complications. Although the health department may need to be notified at some point, it is not the most important primary goal. It is also important to prevent discomfort as much as possible.

Explanation

The primary goal is to prevent the spread of the disease to others. The child should experience no complications. Although the health department may need to be notified at some point, it is not the most important primary goal. It is also important to prevent discomfort as much as possible.

19. A client has just been diagnosed with multiple sclerosis. The client is obviously upset with the diagnosis and asks, "Am I going to die?" The nurse's best response would be:

"Most individuals with your disease live a normal life span"

"Is your family here? I would like to explain your disease to all of you"

"The prognosis is variable; most individuals experience remissions and exacerbations"

"Why don't you speak with your physician who can give you more details about your disease"

This is a truthful answer that provides some realistic hope.

Explanation

This is a truthful answer that provides some realistic hope.

20. A nurse is planning care for an infant who has pyloric stenosis. In order to most effectively meet the infant's preoperative needs, the nurse includes which of the following in the plan of care?

Monitor the IV infusion, intake and output, and weight

Provide small, frequent feedings of glucose, water, and electrolytes

Administer enemas until returns are clear

Provide the mother privacy to breastfeed every 2 hours

Preoperatively, important nursing responsibilities include monitoring the intravenous infusion, intake and output, and weight, and obtaining urine specific gravity measurements. In addition, weighing the infant’s diapers provides information regarding output. Preoperatively, the infant is kept NPO unless the physician prescribes a thickened formula. Enema until clear would further compromise the fluid volume status.

Explanation

Preoperatively, important nursing responsibilities include monitoring the intravenous infusion, intake and output, and weight, and obtaining urine specific gravity measurements. In addition, weighing the infant’s diapers provides information regarding output. Preoperatively, the infant is kept NPO unless the physician prescribes a thickened formula. Enema until clear would further compromise the fluid volume status.

21. A nurse is planning care for an infant with a diagnosis of encephalocele located in the occipital area. Which of the following items would the nurse use to assist in positioning the child to avoid pressure on the encephalocele?

Sheepskin

Foam hal-donut

Feather pillow

Sandbag

The infant is positioned to avoid pressure on the lesion. If the encephalocele is in the occipital area, a foam half-donut may be useful in positioning to prevent this pressure. A sheepskin, feather pillow, or sandbag will not protect the encephalocele from pressure.

Explanation

The infant is positioned to avoid pressure on the lesion. If the encephalocele is in the occipital area, a foam half-donut may be useful in positioning to prevent this pressure. A sheepskin, feather pillow, or sandbag will not protect the encephalocele from pressure.

22. A client is brought to the emergency room by the ambulance team following collapse at home. Cardiopulmonary resuscitation is attempted but unsuccessful. The wife of the client tells the nurse that the client is an organ donor and that the eyes are to be donated. Which of the following is the most appropriate nursing action?

Elevate the head of the bed of the deceased and place dry sterile dressing over the eyes

Call the National Donor Association to confirm that the client is a donor

Close the deceased client’s eyes and place wet saline gauze pads and an ice pack on the eyes

Ask the wife to obtain the legal documents regarding organ donation from the lawyer.

When a corneal donor dies, the eyes are closed and gauze pads wet with saline solution are placed over them with a small ice pack. Within 2 to 4 hours the eyes are enucleated. The cornea is usually transplanted within 24 to 48 hours. The head of the bed should also be elevated.

Explanation

When a corneal donor dies, the eyes are closed and gauze pads wet with saline solution are placed over them with a small ice pack. Within 2 to 4 hours the eyes are enucleated. The cornea is usually transplanted within 24 to 48 hours. The head of the bed should also be elevated.

23. A registered nurse (RN) on the night shift assists a staff member in completing an incident report for a client who was found sitting on the floor. Following completion on the report, the RN avoids which action?

Documents in the nurses notes that an incident report was filed.

Forwards the incident report to the Continuous Quality Improvement Department

Asks the unit secretary to call the physician

Notifies the nursing supervisor

Nurses are advised not to document the filing of an incident report in the nurses notes for legal reasons. Incident reports inform the facility's administration of the incident so that risk management personnel can consider changes that might prevent similar occurrences in the future. Incident reports also alert the facility's insurance company to a potential claim and the need for further investigation. Option B,C and D are accurate interventions.

Explanation

Nurses are advised not to document the filing of an incident report in the nurses notes for legal reasons. Incident reports inform the facility's administration of the incident so that risk management personnel can consider changes that might prevent similar occurrences in the future. Incident reports also alert the facility's insurance company to a potential claim and the need for further investigation. Option B,C and D are accurate interventions.

24. A nurse is taking a temperature on a client using a glass thermometer. The nurse shakes down the thermometer and drops the thermometer on the floor. Which of the following actions will the nurse take?

Carefully wipe up the spill, avoiding getting cut from the glass

Use a mop and dustpan to clean up the spill, avoiding contact with the glass and mercury

Notify the Environmental Services Department of the spill

Call house keeping department to clean up the spill and broken glass

Mercury is a hazardous material. Accidental breakage of a mercury-in-glass thermometer is a health hazard to the client, nurse, and other health care workers. Mercury droplets are not to be touched. If a breakage or spill occurs, the Environmental Services Department is called and a mercury spill kit is used to clean up the spill.

Explanation

Mercury is a hazardous material. Accidental breakage of a mercury-in-glass thermometer is a health hazard to the client, nurse, and other health care workers. Mercury droplets are not to be touched. If a breakage or spill occurs, the Environmental Services Department is called and a mercury spill kit is used to clean up the spill.

25. A client arrives at the emergency room after being bitten by a stray dog. The bite involved tearing of skin and deep soft tissue injury. The client says the dog was foaming at the mouth and afterward ran away. The first nursing action is to:

Ask the client about horse serum allergy

Notify the police department to capture the dog

Assess the client's injury, vital signs, and past history

Inoculate the client with human rabies immune globulin

To make effective decisions, baseline information on the client's condition, extent of injury, and significant past health history are needed.

Explanation

To make effective decisions, baseline information on the client's condition, extent of injury, and significant past health history are needed.

26. A registered nurse ( RN ) is orienting a nursing assistant to the clinical nursing unit. The RN would intervene if the nursing assistant did which of the following during a routine handwashing procedure?

Kept hands lower than elbows

Used 3 to 5 mL of soap from the dispenser

Washed continuously for 10 to 15 seconds

Dried from forearm down to fingers

Proper handwashing procedure involves wetting hands and wrists, keeping hands lower than forearms so water flows toward the fingertips. The nurse uses 3 to 5 mL of soap and scrubs for 10 to 15 seconds using rubbing and circular motions. The hands are rinsed and then dried, moving from the fingers to the forearms. The paper towel is then discarded, and a second one is used to turn off the faucet to avoid hand contamination.

Explanation

Proper handwashing procedure involves wetting hands and wrists, keeping hands lower than forearms so water flows toward the fingertips. The nurse uses 3 to 5 mL of soap and scrubs for 10 to 15 seconds using rubbing and circular motions. The hands are rinsed and then dried, moving from the fingers to the forearms. The paper towel is then discarded, and a second one is used to turn off the faucet to avoid hand contamination.

27. An elderly client in a long-term care facility has a nursing diagnosis of risk for Injury related to confusion. The client's gait is stable. The nurse uses which of the following methods of restraint to prevent injury to the client?

Vest restraint

Waist restraint

Chair with locking lap tray

Alarm - activitating bracelet

If the client is confused and has a stable gait, the least intrusive method of restraint is the use of an alarm activating bracelet, or "wandering bracelet." This allows the client to move about the residence freely while preventing the client from leaving the premises. Options A,B,and C are restrictive devices and should not be used.

Explanation

If the client is confused and has a stable gait, the least intrusive method of restraint is the use of an alarm activating bracelet, or "wandering bracelet." This allows the client to move about the residence freely while preventing the client from leaving the premises. Options A,B,and C are restrictive devices and should not be used.

28. A client has cholelithiasis with possible obstruction of the common bile duct. Before the scheduled cholecystectomy, nutritional deficiencies and excesses should be corrected. A nutritional assessment should be conducted to determine whether the client:

Is deficient in vitamins A, D, and K

Eats adequate amounts of dietary fiber

Consumes excessive amounts of protein

Has excessive levels of potassium and folic acid

Bile promotes the absorption of the fat-soluble vitamins; an obstruction of the common bile duct limits the flow of bile to the duodenum.

Explanation

Bile promotes the absorption of the fat-soluble vitamins; an obstruction of the common bile duct limits the flow of bile to the duodenum.

29. A home health care nurse arrives at a client's home for the scheduled home visit. The client's lawyer is present and the client is preparing a living will. The living will requires that the client's signature be witnessed, and the client asks the nurse to witness the signature. Which of the following is the most appropriate nursing action?

Sign the will as a witness to signature only

Sign the will, clearly identifying credentials and employment agency

Decline to sign the will

Call the home health care office and notify the supervisor that the will is being witnessed

Living wills are required to be in writings and signed by the client. The client’s signature either must be witnessed by specified individuals or notarized. Many states prohibit any employee, including a nurse of a facility where the declaring is receiving care, from being a witness. The nurse should decline to sign the will.

Explanation

Living wills are required to be in writings and signed by the client. The client’s signature either must be witnessed by specified individuals or notarized. Many states prohibit any employee, including a nurse of a facility where the declaring is receiving care, from being a witness. The nurse should decline to sign the will.

30. A nurse is developing a plan of care for a newborn infant diagnosed with bilateral club feet. The nurse includes instructions in the plan to tell the parents that:

Genetic testing is wise for future pregnancies, since other children born to this couple may also be affected.

If casting is needed, it will begin at birth and continue for 12 weeks; then the condition will be reevaluated.

Surgery performed immediately after birth has been found to be most effective in achieving a complete recovery.

The regimen of manipulation and casing is effective in all cases of bilateral club feet.

Casting should begin at birth and continue for at least 12 weeks or until maximum correction is achieved. At this time, corrective shoes may provide support to maintain alignment or surgery can be performed. Surgery is usually delayed until 4 to 12 months of age. Options C and D are inaccurate. Option A does not address the issue of the question.

Explanation

Casting should begin at birth and continue for at least 12 weeks or until maximum correction is achieved. At this time, corrective shoes may provide support to maintain alignment or surgery can be performed. Surgery is usually delayed until 4 to 12 months of age. Options C and D are inaccurate. Option A does not address the issue of the question.

31. A client appears very anxious, with respirations that are shallow and very rapid (40 per minute). The client complains of feeling dizzy and light-headed and having tingling sensations of the fingertips and around the lips. The nurse should recognize that the client's complaints are probably related to:

Eupnea

Hyperventilation

Kussmaul's respirations

Carbon dioxide intoxication

The client is hyperventilating and blowing off excessive carbon dioxide, which leads to these symptoms; if uninterrupted this could lead to respiratory alkalosis.

Explanation

The client is hyperventilating and blowing off excessive carbon dioxide, which leads to these symptoms; if uninterrupted this could lead to respiratory alkalosis.

32. A client has a permanent sigmoid colostomy because of cancer. The physician orders daily colostomy irrigations. The nurse should explain to the client that the primary purpose of these irrigations is to:

Prevent straining at passage of stool

Establish a regular elimination schedule

Decrease the amount of flatus in the bowel

Limit the amount of fluid lost from the intestine

Irrigations regulate the bowel to function at a specific time for the convenience of the client.

Explanation

Irrigations regulate the bowel to function at a specific time for the convenience of the client.

33. A client has decided to become a total vegetarian (vegan) and wishes to plan a diet to ensure adequate protein quality. To provide guidance, the nurse should instruct this client to:

Add milk to grains to provide complete proteins

Use eggs with plant foods to provide essential amino acids

Plan a careful mixture of plant proteins to provide a balance of amino acids

Add cheese to grains and beans to increase the quality of protein consumed

Complementary mixtures of essential amino acids in plant proteins provide complete dietary protein equivalents.

Explanation

Complementary mixtures of essential amino acids in plant proteins provide complete dietary protein equivalents.

34. A nurse is for a child with a head injury. On review of he record the nurse notes that the physician has documented decorticate posturing. On assessment of the child, the nurse notes extension of the upper extremities and internal rotation of the upper arm and wrist. The nurse also notes that the lower extremities are extended, with some internal rotation noted at the knees and feet. On the basis of these findings, which of the following is the appropriate nursing action?

Document the findings

Continue to monitor for posturing of the child

Attempt to flex the child’s lower extremities

Notify the physician

Decorticate posturing refers to flexion of the upper extremities and extension of the lower extremities. Plantar flexion of the feet may also be observed. Decerebrate posturing involves extension of the upper extremities with internal rotation of the upper arm and wrist. The lower extremities will extend, with some internal rotation noted at the knees and feet. The progression from decorticate to decerebrate posturing usually indicates deteriorating neurological function and warrants physician notification.

Explanation

Decorticate posturing refers to flexion of the upper extremities and extension of the lower extremities. Plantar flexion of the feet may also be observed. Decerebrate posturing involves extension of the upper extremities with internal rotation of the upper arm and wrist. The lower extremities will extend, with some internal rotation noted at the knees and feet. The progression from decorticate to decerebrate posturing usually indicates deteriorating neurological function and warrants physician notification.

35. Furosemide ( Lasix ) 40 mg PO has been prescribed for a client. A nurse administers Lasix 80 mg PO to the client at 10:00 A.M. Following discovery of the error, the nurse completes an incident report. Which of the following would the nurse document on this report?

Lasix 80 mg was given to the client instead of 40 mg.

The wrong dose of medication was given to the client at 10:00 A.M

Lasix 80 mg administered at 10:00 A.M.

When completing an incident report, the nurse should state the fact clearly. The nurse should not record assumptions, opinions, judgments, or conclusions about what occurred. The nurse should not point blame or suggest how to prevent an occurrence of a similar incident.

Explanation

When completing an incident report, the nurse should state the fact clearly. The nurse should not record assumptions, opinions, judgments, or conclusions about what occurred. The nurse should not point blame or suggest how to prevent an occurrence of a similar incident.

36. A nursing instructor is discussing professional liability insurance to the senior class of nursing students. The instructor most appropriately advises the students who will be graduating in two months:

To obtain their own malpractice insurance

That malpractice insurance is not required and is expensive

To discuss liability insurance with the employment agency

That most lawsuits are filed against physicians

Nurses need their own liability insurance for protection against malpractice law suits. Nurses erroneously assume that they are protected by an agency’s professional liability policies. Usually when a nurse is sued, the employer is also sued for the nurse’s actions or inaction’s. Even though this is the norm, nurses are encouraged to have their own malpractice insurance.

Explanation

Nurses need their own liability insurance for protection against malpractice law suits. Nurses erroneously assume that they are protected by an agency’s professional liability policies. Usually when a nurse is sued, the employer is also sued for the nurse’s actions or inaction’s. Even though this is the norm, nurses are encouraged to have their own malpractice insurance.

37. A nurse is obtaining a health history for an adolescent. Which statement by the adolescent indicates a need for follow-up assessment and intervention?

I find myself very moody-happy one minute and crying the next.

I can’t seem to wake up in the morning. I would sleep until noon if I could.

I don’t eat anything with fat in it, and I’ve lost 8 pounds in 2 weeks.

When I get stressed out about school, I just like to be alone.

During the adolescent period there is a heightened awareness of body image and peer pressure to go on excessively restrictive diets. The extreme limitation of omitting all fat in the diet and weight loss during a time of growth suggests inadequate nutrition and a possible eating disorder.

Explanation

During the adolescent period there is a heightened awareness of body image and peer pressure to go on excessively restrictive diets. The extreme limitation of omitting all fat in the diet and weight loss during a time of growth suggests inadequate nutrition and a possible eating disorder.

38. A client comes to the clinic after being bitten by a raccoon in the woods in an area where rabies is endemic. The nurse recalls that rabies is:

An acute bacterial infection characterized by encephalopathy and opisthotonos

An acute bacterial septicemia that results in convulsions and a morbid fear of water

A nonspecific immunoresponse to organisms deposited under the skin by an animal bite

An acute viral infection, characterized by convulsions and difficult swallowing, that affects the nervous system

This is a viral infection that enters the body through a break in the skin and is characterized by convulsions and choking

Explanation

This is a viral infection that enters the body through a break in the skin and is characterized by convulsions and choking

39. A nurse witnesses an automobile accident and provides care to the open wound of a young child at the scene of the accident. The family is extremely grateful and insists that the nurse accept monetary compensation for the care provided to the child. Because of the family insistence, the nurse accepts the compensation to avoid offending the family. The child develops an infection and sepsis and is hospitalized. The family files suit against the nurse who provided care to the child at the scene of the accident. Which of the following is accurate regarding the nurse's immunity from the suit?

The Good Samaritan Law will protect the nurse.

The Good Samaritan Law will protect the nurse if the care given at the scene was not negligent

The Good Samaritan Law will not provide immunity from suit if the nurse accepted compensation for the care provided.

The Good Samaritan Law protects lay persons and not professional health care providers

A Good Samaritan Law is passed by state legislator to encourage nurses and other health care providers to provide care to a person when an accident, emergency, or injury occurs, without fear of being sued for the care provided. Called immunity from suit, this protection usually applies only if all of the conditions of the law are met, such as the health care provider receives no compensation for the care provided, and the care given is not willfully and wantonly negligent.

Explanation

A Good Samaritan Law is passed by state legislator to encourage nurses and other health care providers to provide care to a person when an accident, emergency, or injury occurs, without fear of being sued for the care provided. Called immunity from suit, this protection usually applies only if all of the conditions of the law are met, such as the health care provider receives no compensation for the care provided, and the care given is not willfully and wantonly negligent.

40. A nurse is developing a plan of care for a child returning from the operating room after a tonsillectomy. The nurse avoids placing which intervention in the plan of care?

Offer clear, cool liquids when the child is awake

Eliminate milk or milk products from the diet

Monitor for bleeding from the surgical site

Suction whenever necessary

After tonsillectomy, suction equipment should be available, but suctioning is not performed unless there is an airway obstruction. Clear, cool liquids are encouraged. Milk and milk products are avoided initially because they coat the throat, causing the child to clear the throat, thus increasing the risk of bleeding. Option C is an important intervention after any type of surgery.

Explanation

After tonsillectomy, suction equipment should be available, but suctioning is not performed unless there is an airway obstruction. Clear, cool liquids are encouraged. Milk and milk products are avoided initially because they coat the throat, causing the child to clear the throat, thus increasing the risk of bleeding. Option C is an important intervention after any type of surgery.

41. A nurse is caring for a child with renal disease and is analyzing the laboratory results. The nurse notes a sodium level of 148 mEq/L. On the basis of this finding which clinical manifestation would the nurse expect to note in the child?

Increased heart rate

Cold clammy skin

Dry sticky mucous membranes

Lethargy

Hypernatremia occurs when the sodium level is greater that 145 mEq/L Clinical manifestations include intense thirst, oliguria, agitation and restlessness, flushed skin, peripheral and pulmonary edema, dry sticky mucous membranes, and nausea and vomiting. Options A B and D are not associated with the clinical manifestations of hypernatremia.

Explanation

Hypernatremia occurs when the sodium level is greater that 145 mEq/L Clinical manifestations include intense thirst, oliguria, agitation and restlessness, flushed skin, peripheral and pulmonary edema, dry sticky mucous membranes, and nausea and vomiting. Options A B and D are not associated with the clinical manifestations of hypernatremia.

42. A client complains of urinary problems. Cholinergic medications are prescribed. The nurse is aware that this type of medication is prescribed to prevent:

Kidney stones

A flaccid bladder

A spastic bladder

Urinary tract infections

Cholinergics intensify and prolong the action of acetylcholine, which increases the tone in the genitourinary tract, preventing urinary retention.

Explanation

Cholinergics intensify and prolong the action of acetylcholine, which increases the tone in the genitourinary tract, preventing urinary retention.

43. A nurse is caring for an infant after pyloromyotomy performed to treat hypertrophic pyloric stenosis. The nurse places the infant in which position following surgery?

Flat on the nonoperative side

Flat on the operative side

Prone with the head of the bed elevated

Supine with the head of the bed elevated

Following pyloromyotomy, the head of the bed is elevated and the infant is placed prone to reduce the risk of aspiration. Options, A B and D are incorrect position after this type of surgery.

Explanation

Following pyloromyotomy, the head of the bed is elevated and the infant is placed prone to reduce the risk of aspiration. Options, A B and D are incorrect position after this type of surgery.

44. A client has a Swan-Ganz catheter inserted for monitoring cardiovascular status. With the Swan-Ganz catheter the most accurate measurement of the client's left ventricular pressure would be the:

Right atrial pressure

Cardiac output by thermodilution

Pulmonary artery diastolic pressure

Pulmonary capillary wedge pressure

Pulmonary capillary wedge pressure is an indirect measure of left ventricular end diastolic pressure, an indication of ventricular contractility.

Explanation

Pulmonary capillary wedge pressure is an indirect measure of left ventricular end diastolic pressure, an indication of ventricular contractility.

45. A nurse is performing an assessment of a child who is to receive a measles, mumps, and rubella (MMR) vaccine. The nurse notes that the child is allergic to eggs. Which of the following would be the nurse anticipate to be prescribed for this child?

Administration of diphenhydramine (Benadryl) and acetaminophen (Tylenol) prior to the administration of the MMR vaccine

Administration of a killed measles vaccine

Eliminating this vaccine from the immunization schedule

Administration of epinephrine (Adrenalin) prior to the administration of the MMR

Live measles vaccine is produced by chick embryo cell culture, so the possibility of an anaphylactic hypersensitivity in children with egg allergies should be considered. If there is a question of sensitivity, children should be tested before the administration of MMR vaccine. If a child tests positive for sensitivity, the killed measles vaccine may be given as an alternative.

Explanation

Live measles vaccine is produced by chick embryo cell culture, so the possibility of an anaphylactic hypersensitivity in children with egg allergies should be considered. If there is a question of sensitivity, children should be tested before the administration of MMR vaccine. If a child tests positive for sensitivity, the killed measles vaccine may be given as an alternative.

46. A client has a chest tube for pneumothorax. The nurse finds the client in respiratory difficulty with the chest tube separated from the drainage system. The nurse should:

Obtain a new sterile drainage system

Clamp the drainage tubing with two clamps

Reconnect the client's tube to the drainage system

Place the client in the high-Fowler's position immediately

To prevent further possibility of pneumothorax, the nurse should immediately reconnect the tube.

Explanation

To prevent further possibility of pneumothorax, the nurse should immediately reconnect the tube.

47. A client has a history of progressive carotid and cerebral atherosclerosis and transient ischemic attacks (TIAs). The nurse understands that TIAs are:

Temporary episodes of neurologic dysfunction

Transient attacks caused by multiple small emboli

Periods of alternating exacerbations and remissions

Ischemic attacks that result in progressive neurologic deterioration

Narrowing of arteries supplying the brain causes temporary neurologic deficits that last for a short period; between attacks the neurologic examination is normal.

Explanation

Narrowing of arteries supplying the brain causes temporary neurologic deficits that last for a short period; between attacks the neurologic examination is normal.

48. A client has a tumor of the cerebellum. In view of the functions of this structure, the nurse should expect to observe an:

Unconscious state

Inability to execute voluntary movements

Absence of the knee-jerk and other reflexes

Inability to execute smooth, precise movements

The cerebellum is involved in the synergistic control of muscle action. Below the level of consciousness it functions to produce smooth, steady, coordinated, and efficient movements.

Explanation

The cerebellum is involved in the synergistic control of muscle action. Below the level of consciousness it functions to produce smooth, steady, coordinated, and efficient movements.

49. A client has a tentative diagnosis of primary biliary cirrhosis. Symptoms include jaundice, ascites, and peripheral edema. When performing the physical assessment, the nurse would expect to observe the skin change known as:

Vitiligo

Hirsutism

Melenosis

Telangiectasis

This is a vascular lesion associated with cirrhosis; it is thought to be related to elevated estrogen levels.

Explanation

This is a vascular lesion associated with cirrhosis; it is thought to be related to elevated estrogen levels.

50. A nurse is caring for an infant with laryngomalacia (Congenital) laryngeal stridor. In which of the following positions would the nurse place the infant to decrease the incidence of stridor?

Supine

Supine with the neck flexed

Prone

Prone with the neck hyperextended

The prone position with the neck hyperextended improves the child’s breathing. Options A, B and C are not appropriate positions.

Explanation

The prone position with the neck hyperextended improves the child’s breathing. Options A, B and C are not appropriate positions.