1. ANSWER: B
Pediculosis, or head lice, is commonly spread by the sharing of headwear, combs, and brushes. The adult lice can also travel from one person to another if contact is close. The adult lice lay eggs, or nits. These nits are "glued" to the hair and cannot be removed unless treated with special shampoo formulated for just this purpose. The hair is then combed with a fine-toothed comb to remove the nits. Because head lice spread so easily, a child is usually kept out of school until he or she is treated and found to be free of nits.
Pediculosis, or head lice, is commonly spread by the sharing of headwear, combs, and brushes. The adult lice can also travel from one person to another if contact is close. The adult lice lay eggs, or nits. These nits are "glued" to the hair and cannot be removed unless treated with special shampoo formulated for just this purpose. The hair is then combed with a fine-toothed comb to remove the nits. Because head lice spread so easily, a child is usually kept out of school until he or she is treated and found to be free of nits.
A: Hairbrushing
will not prevent pediculosis.
C: Cleanliness
does not prevent the acquisition of pediculosis.
D: Dandruff
shampoos will not protect the child from head lice.
2. ANSWER: C
Women are instructed to examine themselves to discover changes that have occurred in the breast. Only a physician can diagnose lumps that are cancerous, areas of thickness or fullness that signal the presence of a malignancy, or masses that are fibrocystic as opposed to malignant.
Women are instructed to examine themselves to discover changes that have occurred in the breast. Only a physician can diagnose lumps that are cancerous, areas of thickness or fullness that signal the presence of a malignancy, or masses that are fibrocystic as opposed to malignant.
3. ANSWER: A
Broca's area, which controls expressive speech, is located on the left side of the brain. Therefore, a client with a cerebrovascular accident in this area is likely to exhibit expressive or motor aphasia.
Broca's area, which controls expressive speech, is located on the left side of the brain. Therefore, a client with a cerebrovascular accident in this area is likely to exhibit expressive or motor aphasia.
B: Dyslexia, the
inability of a person with normal vision to interpret written language, is
thought to be due to a central nervous system defect in the ability to organize
graphic symbols.
C: Apraxia is the
inability to perform purposeful movements in the absence or loss of motor
power, sensation, or coordination.
D: Agnosia is the
loss of comprehension of auditory, visual, or other sensations despite an
intact sensory sphere.
4. ANSWER: C
Petechiae are small hemorrhagic spots. Extravasation is the leakage of fluid in the interstitial space. Osteomalacia is the softening of bone tissue. Uremia is an excess of urea and other nitrogen products in the blood.
Petechiae are small hemorrhagic spots. Extravasation is the leakage of fluid in the interstitial space. Osteomalacia is the softening of bone tissue. Uremia is an excess of urea and other nitrogen products in the blood.
5. ANSWER: D
This statement by the patient may indicate that she suspects her husband of child abuse and does not trust him to be alone with the child. The statement requires further exploration.
This statement by the patient may indicate that she suspects her husband of child abuse and does not trust him to be alone with the child. The statement requires further exploration.
A, B & C:
Co-sleeping, in which the parents allow the child to sleep with them, is a
relatively common and accepted practice, especially among Black, Hispanic and
Asian families. Other groups that are adopting co-sleeping include single
parents, whose need for company may encourage the practice; working parents,
who desire the closeness at night that was lost during the day and parents who
have had an issue about sleep or separation in their past.
6. ANSWER: B
This is a radionuclear study that determines viability of myocardial tissue; necrotic or scar tissue does not extract thallium isotope.
This is a radionuclear study that determines viability of myocardial tissue; necrotic or scar tissue does not extract thallium isotope.
A: This
information is available from a cardiac catheterization with an angiography.
C: These are
determined by cardiac angiography.
D: This is
determined by a 12-lead ECG.
7. ANSWER: A
In hypertonic dehydration, the serum sodium level increases, the serum potassium level varies, and the serum chloride level increases.
In hypertonic dehydration, the serum sodium level increases, the serum potassium level varies, and the serum chloride level increases.
B: Normal serum
chloride levels are not seen with dehydration regardless of the type.
C: Normal serum
potassium levels may be seen with isotonic dehydration.
D: Decreased serum
chloride levels are seen with hypotonic dehydration along with a decreased
serum sodium level and a variable serum potassium level.
8. ANSWER: A
When examining small children, the nurse should proceed in a manner that allows the least intrusive procedures to be done first to gain the child's confidence and to decrease the amount of stress experienced by the child.
When examining small children, the nurse should proceed in a manner that allows the least intrusive procedures to be done first to gain the child's confidence and to decrease the amount of stress experienced by the child.
B: The child's
developmental status does not allow the child to understand detailed
explanations.
C: A head to toe
approach would permit the examination of the ear and mouth, intrusive
examinations that would upset the child and make the remainder of the
examination very difficult.
D: The child at
this age is in the period of separation anxiety. Any undue separation will
cause extreme and unwarranted stress.
9. ANSWER: B
Because shock signals a severe fluid volume loss (700 to 1300 ml) its treatment includes rapid I.V. fluid replacement to sustain homeostasis and prevent death. The nurse should expect to administer three times the estimated fluid loss to increase the circulating volume. An I.V. infusion rate of 83 ml/hour wouldn't begin to replace the necessary fluids and reverse the problem. The other options are appropriate for this client.
Because shock signals a severe fluid volume loss (700 to 1300 ml) its treatment includes rapid I.V. fluid replacement to sustain homeostasis and prevent death. The nurse should expect to administer three times the estimated fluid loss to increase the circulating volume. An I.V. infusion rate of 83 ml/hour wouldn't begin to replace the necessary fluids and reverse the problem. The other options are appropriate for this client.
10. ANSWER: D
During the evaluation step of the nursing process the nurse determines whether the goals established in the plan of care have been achieved and evaluates the success of the plan. If a goal is unmet or partially met the nurse reexamines the data and revises the plan. Assessment involves data collection. Planning involves setting priorities, establishing goals, and selecting appropriate interventions. Implementation involves providing actual nursing care.
During the evaluation step of the nursing process the nurse determines whether the goals established in the plan of care have been achieved and evaluates the success of the plan. If a goal is unmet or partially met the nurse reexamines the data and revises the plan. Assessment involves data collection. Planning involves setting priorities, establishing goals, and selecting appropriate interventions. Implementation involves providing actual nursing care.
11. ANSWER: B
Proper suctioning should produce a patent airway, as demonstrated by effective breathing through the airway at a normal respiratory rate of 12 to 20 breaths/minute. The other options suggest ineffective suctioning. A respiratory rate of 24 breaths/minute and accessory muscle use may indicate mild respiratory distress. Increased pulse rate, rapid respirations, and cyanosis are signs of hypoxia. Restlessness, pallor, increased pulse and respiratory rates, and bubbling breath sounds indicate respiratory secretion accumulation.
Proper suctioning should produce a patent airway, as demonstrated by effective breathing through the airway at a normal respiratory rate of 12 to 20 breaths/minute. The other options suggest ineffective suctioning. A respiratory rate of 24 breaths/minute and accessory muscle use may indicate mild respiratory distress. Increased pulse rate, rapid respirations, and cyanosis are signs of hypoxia. Restlessness, pallor, increased pulse and respiratory rates, and bubbling breath sounds indicate respiratory secretion accumulation.
12. ANSWER: A
Croup is an acute viral respiratory illness characterized by a barking cough. Fever is usually low grade. Croup has a gradual onset, and dysphagia isn't a symptom.
Croup is an acute viral respiratory illness characterized by a barking cough. Fever is usually low grade. Croup has a gradual onset, and dysphagia isn't a symptom.
13. ANSWER: B
The most objective answer is the blood glucose history. Answers A, C, and D are more subjective. This information is reported data.
The most objective answer is the blood glucose history. Answers A, C, and D are more subjective. This information is reported data.
14. ANSWER: A
Bronchopulmonary dysplasia occurs in very low birth weight infants who are exposed to high oxygen pressures, especially infants with respiratory distress syndrome (RDS). Therefore, the best way to prevent it is to use the lowest possible oxygen level and pressure.
Bronchopulmonary dysplasia occurs in very low birth weight infants who are exposed to high oxygen pressures, especially infants with respiratory distress syndrome (RDS). Therefore, the best way to prevent it is to use the lowest possible oxygen level and pressure.
B: Vigorous
suctioning of the hypopharynx before delivery of the shoulders is suggested to
prevent meconium aspiration.
C: Preventing
early delivery is not considered a common method of prevention, even though
nursing can provide the necessary teaching that may result in fewer premature
deliveries. This would lessen numerous problems, including RDS, a precursor to
bronchopulmonary dysplasia.
D: Administering
surfactant is a treatment of RDS. Its use does not ensure that the neonate will
not develop bronchopulmonary dysplasia.
15. ANSWER: B
Huntington's disease is an autosomal dominant disorder; therefore, each child has a 50% chance of inheriting it. Men and women are equally affected.
Huntington's disease is an autosomal dominant disorder; therefore, each child has a 50% chance of inheriting it. Men and women are equally affected.
16. ANSWER: A
As the uterus involutes and the placental attachment area heals, lochia changes from bright red (rubra), to pinkish (serosa), to clear white (alba). The other options are incorrect.
As the uterus involutes and the placental attachment area heals, lochia changes from bright red (rubra), to pinkish (serosa), to clear white (alba). The other options are incorrect.
17. ANSWER: A
With any child, but especially infants at 9 months of age, it can be difficult to maintain the child's position to administer the injection safely. Thus, having an extra pair of hands from an additional person can be helpful in stabilizing the infant's position.
With any child, but especially infants at 9 months of age, it can be difficult to maintain the child's position to administer the injection safely. Thus, having an extra pair of hands from an additional person can be helpful in stabilizing the infant's position.
B: Waiting until
the infant is asleep is inappropriate. Doing so would terrorize the infant and
cause additional upset.
C: In children
under 1 year, the dorsogluteal site is contraindicated for injections because
the muscle is not well developed and the sciatic nerve occupies a larger
portion of the area, placing the infant at risk for nerve damage.
D: Massaging the
site after administering the injection is appropriate. However, the IM
injection should be given quickly to minimize the anxiety, fear, and trauma to
the child.
18. ANSWER: A
Immobility results in increased catabolic activity related to muscle atrophy, resulting in negative nitrogen balance.
Immobility results in increased catabolic activity related to muscle atrophy, resulting in negative nitrogen balance.
B: Immobility
leads to hypercalcemia from bone demineralization, which may result in the
formation of renal calculi.
C: Immobility may
lead to dependent edema from decreased venous return. Edematous tissue is more
prone to infection.
D: Immobility may
lead to decreased movement of secretions from the tracheobronchial tree,
placing the child at risk for pneumonia.
19. ANSWER: D
Urine output below 30 mL/hour could indicate stomal edema which obstructs urine output.
Urine output below 30 mL/hour could indicate stomal edema which obstructs urine output.
A: An elevated
temperature should be noted, but it is not related to stomal edema.
B: Urine dribbling
from the stoma is normal.
C: Discomfort
around the stoma is common postoperatively after construction of an ileal
conduit.
20. ANSWER: B
Heart and lung auscultation shouldn't distress the infant, so it should be done early in the assessment. Undressing the infant before weighing, shining a light in the eyes, or placing a tape measure on the infant's head may cause more distress, making the rest of the examination more difficult.
Heart and lung auscultation shouldn't distress the infant, so it should be done early in the assessment. Undressing the infant before weighing, shining a light in the eyes, or placing a tape measure on the infant's head may cause more distress, making the rest of the examination more difficult.
21. ANSWER: C
An increased heart rate is related to an autonomic nervous system response; pain is related to the trauma of the perforation and possibly gastric reflux.
An increased heart rate is related to an autonomic nervous system response; pain is related to the trauma of the perforation and possibly gastric reflux.
A: These are signs
of the dumping syndrome.
B: These are signs
of the dumping syndrome.
C: An increased blood
pressure may occur, but increased output has no relationship to esophageal
perforation.
22. ANSWER: D
The nurse is inserting the nasopharyngeal airway correctly when she places the client in a supine position, pushes the tip of the client's nose upward, and inserts the airway along the floor of the nostril into the posterior pharynx. The airway should be inserted to a predetermined length (measuring from the tip of the nose to the ear lobe and marking the distance on the tube) or until the flange is flush with the nostril. An oropharyngeal (not nasopharyngeal) airway should be inserted by pointing the tip upward toward the roof of the mouth. Only water-based lubricant, not petroleum jelly, should be used. Because the airway is inserted nasally, the client's tongue is bypassed and doesn't need to be depressed.
The nurse is inserting the nasopharyngeal airway correctly when she places the client in a supine position, pushes the tip of the client's nose upward, and inserts the airway along the floor of the nostril into the posterior pharynx. The airway should be inserted to a predetermined length (measuring from the tip of the nose to the ear lobe and marking the distance on the tube) or until the flange is flush with the nostril. An oropharyngeal (not nasopharyngeal) airway should be inserted by pointing the tip upward toward the roof of the mouth. Only water-based lubricant, not petroleum jelly, should be used. Because the airway is inserted nasally, the client's tongue is bypassed and doesn't need to be depressed.
23. ANSWER: C
By playing with medical equipment and acting out the experience with dolls, the preschooler can begin to reduce anxiety. The nurse should schedule teaching shortly before surgery because preschoolers have little concept of time and because a delay between teaching and surgery may increase anxiety by giving the child time to worry. Detailed explanations are inappropriate for this developmental stage and may promote anxiety. The nurse should avoid such phrases as "put to sleep" because they might have a negative meaning to the child.
By playing with medical equipment and acting out the experience with dolls, the preschooler can begin to reduce anxiety. The nurse should schedule teaching shortly before surgery because preschoolers have little concept of time and because a delay between teaching and surgery may increase anxiety by giving the child time to worry. Detailed explanations are inappropriate for this developmental stage and may promote anxiety. The nurse should avoid such phrases as "put to sleep" because they might have a negative meaning to the child.
24. ANSWER: B
In infants and young children, the eustachian tubes are short and lie in a relatively horizontal position. This anatomic position favors the development of otitis media because it is easy for materials from the nasopharynx to enter the tubes.
In infants and young children, the eustachian tubes are short and lie in a relatively horizontal position. This anatomic position favors the development of otitis media because it is easy for materials from the nasopharynx to enter the tubes.
A: Although
bacteria may be present in the nasopharynx, this does not affect middle ear
function.
C: The size of the
ear canal has no impact on the increased number of ear infections in children.
Rather, in infants and young children, the eustachian tubes are short and lie
in a relatively horizontal position. This anatomic position favors the
development of otitis media because it is easy for materials from the nasopharynx
to enter the tubes.
D: An intact
tympanic membrane prevents bacteria from entering the middle ear from the
external ear canal. The tympanic membrane changes appearance with an ear
infection, but its structure does not predispose infants and young children to
ear infection.
25. ANSWER: B
The presence of an increased number of epithelial cells, especially when they exceed the number of WBCs, indicates a contaminated specimen. Proper cleaning and retrieval of the specimen may not have taken place. The presence of bacteria, WBCs, and pus suggests pyelonephritis or a urinary tract infection.
The presence of an increased number of epithelial cells, especially when they exceed the number of WBCs, indicates a contaminated specimen. Proper cleaning and retrieval of the specimen may not have taken place. The presence of bacteria, WBCs, and pus suggests pyelonephritis or a urinary tract infection.
26. ANSWER: C
A segment of the terminal ileus is used to form the conduit that collects urine from the ureters. Hence, the client with an ileal conduit can be expected to excrete urine that contains mucus from this intestinal mucous membrane.
A segment of the terminal ileus is used to form the conduit that collects urine from the ureters. Hence, the client with an ileal conduit can be expected to excrete urine that contains mucus from this intestinal mucous membrane.
A: Mucus
production is not a result of infection.
B: Mucus
production is not a result of glycosuria. There is no reason to expect to find
glucose in the client's urine.
D: Mucus
production is not a result of stomal irritation.
27. ANSWER: C
The FEV1/FVC ratio indicates disease progression. As COPD worsens, the ratio of FEV1 to FVC becomes smaller. Answer A and B reflect loss of elastic recoil due to narrowing and obstruction of the airway. Answer D is increased in clients with obstructive bronchitis.
The FEV1/FVC ratio indicates disease progression. As COPD worsens, the ratio of FEV1 to FVC becomes smaller. Answer A and B reflect loss of elastic recoil due to narrowing and obstruction of the airway. Answer D is increased in clients with obstructive bronchitis.
28. ANSWER: D
The presence of intercostal retractions is a sign of respiratory distress from an obstruction or a disease such as pneumonia, which causes the infant to have to work to breathe. Infants and children up to age 7 are abdominal breathers; after that age, they change to an adult pattern of breathing, which uses the diaphragmatic and thoracic muscles. A normal respiratory rate for an infant up to age 1 is 20 to 40 breaths/minute. An infant's skin can become mottled if the infant is left uncovered during the examination.
The presence of intercostal retractions is a sign of respiratory distress from an obstruction or a disease such as pneumonia, which causes the infant to have to work to breathe. Infants and children up to age 7 are abdominal breathers; after that age, they change to an adult pattern of breathing, which uses the diaphragmatic and thoracic muscles. A normal respiratory rate for an infant up to age 1 is 20 to 40 breaths/minute. An infant's skin can become mottled if the infant is left uncovered during the examination.
29. ANSWER: C
Epistaxis refers to nosebleeds. The other phrases don't correctly define this term.
Epistaxis refers to nosebleeds. The other phrases don't correctly define this term.
30. ANSWER: A
Cognitive distortions are similar in both disorders. Rarely do people with eating disorders have relaxed personalities. The anorectic client is more likely than the bulimic client to overexercise for weight control.
Cognitive distortions are similar in both disorders. Rarely do people with eating disorders have relaxed personalities. The anorectic client is more likely than the bulimic client to overexercise for weight control.
31. ANSWER: D
Usually, the top of the ear aligns with an imaginary line drawn across the inner and outer canthus of the eye. Ears set below this line are associated with renal anomalies or mental retardation. Low-set ears don't accompany otogenous tetanus, tracheoesophageal fistula, or congenital heart defects.
Usually, the top of the ear aligns with an imaginary line drawn across the inner and outer canthus of the eye. Ears set below this line are associated with renal anomalies or mental retardation. Low-set ears don't accompany otogenous tetanus, tracheoesophageal fistula, or congenital heart defects.
32. ANSWER: B
A red, swollen infusion site may signal extravasation; the I.V. device should be discontinued immediately and warm, not cold, towels applied to the site. Slowing the rate would do nothing to alleviate extravasation. The nurse may need to verify I.V. fluid orders with the physician and restart fluid therapy in a different location.
A red, swollen infusion site may signal extravasation; the I.V. device should be discontinued immediately and warm, not cold, towels applied to the site. Slowing the rate would do nothing to alleviate extravasation. The nurse may need to verify I.V. fluid orders with the physician and restart fluid therapy in a different location.
33. ANSWER: D
Removes microorganisms and irritants, protects the skin, and maintains skin integrity.
Removes microorganisms and irritants, protects the skin, and maintains skin integrity.
A: Irritating
agents can disrupt skin integrity.
B: Rubbing can
cause irritation, and a secondary infection may develop.
C: Hydrogen
peroxide may be irritating.
34. ANSWER: B
Although preschoolers engage in curiosity play, they are not normally familiar with the act of intercourse unless they have witnessed or experienced it. Therefore, sexual abuse should be suspected.
Although preschoolers engage in curiosity play, they are not normally familiar with the act of intercourse unless they have witnessed or experienced it. Therefore, sexual abuse should be suspected.
A: Although
preschoolers engage in curiosity play, they are not normally familiar with the
act of intercourse unless they have witnessed or experienced it. This is not
normal curiosity of this age group. Therefore, sexual abuse should be expected.
C: Even though
some children with developmental delays may exhibit difficulty with doll play,
all children at this age should be unfamiliar with the act of intercourse.
D: Inexperience
with doll play would not promote acting out of sexual simulations in preschool
children.
35. ANSWER: C
C: Use of warm sitz baths can help relieve the rectal discomfort of hemorrhoids.
C: Use of warm sitz baths can help relieve the rectal discomfort of hemorrhoids.
A: Fiber in the
diet should be increased to promote regular bowel movements.
B: Laxatives are
irritating and should be avoided.
D: Decreasing
physical activity will not decrease discomfort.
36. ANSWER: D
Angina pectoris is chest pain caused by a decreased oxygen supply to the myocardium. Lawn mowing increases the cardiac workload, which increases the heart's need for oxygen and can precipitate angina. Anginal pain typically is self-limiting and lasts 5 to 15 minutes. Food consumption doesn't reduce this pain, but may ease pain caused by a GI ulcer. Deep breathing has no effect on anginal pain.
Angina pectoris is chest pain caused by a decreased oxygen supply to the myocardium. Lawn mowing increases the cardiac workload, which increases the heart's need for oxygen and can precipitate angina. Anginal pain typically is self-limiting and lasts 5 to 15 minutes. Food consumption doesn't reduce this pain, but may ease pain caused by a GI ulcer. Deep breathing has no effect on anginal pain.
37. ANSWER: B
Drinking large amounts of water is indicated for certain kidney or urinary bladder studies, not gall bladder studies.
Drinking large amounts of water is indicated for certain kidney or urinary bladder studies, not gall bladder studies.
B: Iodine
compounds used as radiographic contrast agents, such as iopanoic acid
(Telepaque), should not be administered to the client with iodine and seafood
allergies because anaphylaxis may occur.
C: The contrast
agent is administered orally 10 to 12 hours before the test. The client is NPO
after administration of the contrast agent.
D: Enemas are not
required for cholecystography.
38. ANSWER: C
Blood-tinged sputum in the absence of pronounced coughing may be the presenting symptom; diaphoresis at night is a later symptom.
Blood-tinged sputum in the absence of pronounced coughing may be the presenting symptom; diaphoresis at night is a later symptom.
A: Recurrent fever
is present; however, frothy sputum is present with pulmonary edema, not
tuberculosis.
B: The cough would
be productive, not dry.
D: A productive
cough may occur, but engorged neck veins are symptomatic of congestive heart
failure.
39. ANSWER: B
A low-fat, bland diet prevents stimulation of the pancreas while providing adequate nutrition.
A low-fat, bland diet prevents stimulation of the pancreas while providing adequate nutrition.
A: Dietary protein
and fiber are not directly related to pancreatitis.
C: Although
calcium is important, the low-fat content is more significant.
D: The
hyperglycemia of acute pancreatitis is usually transient and does not require
long-term dietary modification.
40. ANSWER: A
Cancer of the prostate occurs mainly in men over 60; screening via palpation and by testing for prostatic specific antigen (PSA) should be performed at regular medical checkups.
Cancer of the prostate occurs mainly in men over 60; screening via palpation and by testing for prostatic specific antigen (PSA) should be performed at regular medical checkups.
B: The largest
percentage of HIV-positive individuals are in the 20- to 39-year-old age group,
not the middle adult (45 to 65 years old) and late adult (over 65 years old)
years.
C: The largest
percentage of HIV-positive individuals are in the 20- to 39-year-old age group,
not the middle adult (45 to 65 years old) and late adult (over 65 years old)
years.
D: Triglyceride
levels should be done at all regular physical examinations; in addition to
older adults, there is evidence of plaque formation in young children,
adolescents, and young adults.
ETHICAL AND LEGAL ISSUES
41. ANSWER: D
Restraints should be secured to the bed frame. Hospital bed frames are typically sturdy and immovable and therefore can be safely used in a restraint situation.
Restraints should be secured to the bed frame. Hospital bed frames are typically sturdy and immovable and therefore can be safely used in a restraint situation.
A: Side rails can
be easily moved. Restraints anchored to side rails present a danger to both
patients and staff.
B: Restraints may
become loosened from mattress hooks and present a hazardous situation.
C: The footboard
of the bed may not be secure enough for restraints, presenting a hazard.
42. ANSWER: D
The patient will most likely refuse any blood transfusions. Jehovah's Witnesses are generally opposed to transfusions, including banking their own blood.
The patient will most likely refuse any blood transfusions. Jehovah's Witnesses are generally opposed to transfusions, including banking their own blood.
A: In Judaism
(orthodox and conservative), amputated limbs, organs or surgically removed
tissue should be made available to the family for burial.
B: In Mexico, the
curandero is a spiritual healer who travels about curing those with ailments
caused by witches and sorcerers. It is assumed that they also cure regular
illnesses as well.
C: Episcopalians,
Methodists, Nazarenes, Presbyterians, Catholics and Lutherans all receive
communion. Jehovah's Witnesses do not believe in the concept of Holy Communion.
43. ANSWER: C
The nurse should file an incident report. Incident reports highlight areas of potential liability. The risk manager is responsible for notifying the facility's attorney if the incident is believed to be serious. The risk manager, in consultation with the physician and facility administrator, will decide who should inform the family of the error. The quality assurance coordinator may choose to use such incidents when trying to improve the quality of care received by clients in a particular facility. Taking no action isn't an acceptable option.
The nurse should file an incident report. Incident reports highlight areas of potential liability. The risk manager is responsible for notifying the facility's attorney if the incident is believed to be serious. The risk manager, in consultation with the physician and facility administrator, will decide who should inform the family of the error. The quality assurance coordinator may choose to use such incidents when trying to improve the quality of care received by clients in a particular facility. Taking no action isn't an acceptable option.
44. ANSWER: D
A person who has been involuntarily committed to a psychiatric hospital loses the right to leave the hospital of his own accord.
A person who has been involuntarily committed to a psychiatric hospital loses the right to leave the hospital of his own accord.
A: The person who
is involuntarily committed to a psychiatric hospital does not lose the right to
send and receive mail.
B: The person who
is involuntarily committed to a psychiatric hospital does not lose the right to
vote.
C: The person who
is involuntarily committed to a psychiatric hospital does not lose the right to
make a will or contract.
45. ANSWER: A
Informed consent is a person's agreement to allow something to happen, for example, surgery, based on full disclosure of risks, benefits, alternatives and consequences of refusal and the nature of the benefit provided. The person or the surrogate must be capable of understanding the relevant information and must, in fact, sign the consent. The nurse must make sure that the patient has not received any preoperative sedation before the consent is signed. In order for the consent to be legal, the person giving the consent must be mentally and physically competent and legally an adult.
Informed consent is a person's agreement to allow something to happen, for example, surgery, based on full disclosure of risks, benefits, alternatives and consequences of refusal and the nature of the benefit provided. The person or the surrogate must be capable of understanding the relevant information and must, in fact, sign the consent. The nurse must make sure that the patient has not received any preoperative sedation before the consent is signed. In order for the consent to be legal, the person giving the consent must be mentally and physically competent and legally an adult.
B: The physician
must validate that the patient understands the surgery, rather than the nurse.
C: This is not the
nurse's main responsibility. The exact procedure for filling in information on
the document may vary from institution to institution. Nurses should follow the
policies of the employing institution.
D: This is not in
the nurse's scope of practice. The nurse assumes the responsibility for
witnessing the patient' signature on the consent form. The duty to disclose and
obtain informed consent lies with the physician and cannot be delegated to the
nurse.
46. ANSWER: D
Breach of confidentiality occurs when a nurse shares information that can cause harm to an individual. Assault is an act that results in fear that one will be touched without consent. Battery involves unconsented touching of another person. Neglect is the failure to do what is deemed reasonable in a situation.
Breach of confidentiality occurs when a nurse shares information that can cause harm to an individual. Assault is an act that results in fear that one will be touched without consent. Battery involves unconsented touching of another person. Neglect is the failure to do what is deemed reasonable in a situation.
47. ANSWER: D
Ethnic groups tend to vary in their food customs. The nurse should be aware of what foods can be eaten, what foods are forbidden and what foods mayor may not be eaten together.
Ethnic groups tend to vary in their food customs. The nurse should be aware of what foods can be eaten, what foods are forbidden and what foods mayor may not be eaten together.
A: While marriage
customs vary among ethnic groups, knowledge of the number of marriages is not
essential to patient care.
B: The broader
question that should be addressed in a cultural assessment is the use of folk
medicines and herbs.
C: Family customs
regarding health and healthcare rather than the number of siblings are
important to identify in a cultural assessment.
48. ANSWER: A
objective; indicates nurse has monitored pt
objective; indicates nurse has monitored pt
B: Not best;
contains judgment
C: incomplete;
subjective
D: incident report
not part of legal record.
ADDITIONAL INFO:
Hydralazine (Apresoline): antihypertensive and vasodilator. Side effects: HA,
tachycardia, angina, N + V, sodium retention, lupus erythematosus-like
symptoms. Hydroxyzine (Vistaril): antianxiety, antiemetic, bronchodilator,
antihistamine, reduce narcotic requirements before surgery. Side effects:
drowsiness, dry mouth. Nursing responsibilities: give deep IM Z track, never
give IV.
49. ANSWER: D
Seclusion or restraints are special procedures for dealing with acting-out, aggressive behavior for the protection of the client or others; clear documentation in the nurse's notes is essential when suspension of the client's rights is necessary.
Seclusion or restraints are special procedures for dealing with acting-out, aggressive behavior for the protection of the client or others; clear documentation in the nurse's notes is essential when suspension of the client's rights is necessary.
A: This is not
necessary because the use of restraints and/or seclusion would be included in
the general consent form signed on admission.
B: This monitoring
should be done for all clients.
C: There is no
such form; however, documentation to justify the need for seclusion or the use
of restraints is required.
50. ANSWER: D
The release of information to an unauthorized person, gossiping about a client's activities, and the nurse's unwanted intrusion into private family matters constitute invasion of privacy.
The release of information to an unauthorized person, gossiping about a client's activities, and the nurse's unwanted intrusion into private family matters constitute invasion of privacy.
A: Libel occurs
when a person writes false statements about another that may injure the
individual's reputation.
B: Slander occurs
when a person verbally defames, detracts from, or maligns another's reputation.
C: Negligence is a
careless act of omission or commission that results in injury to another.
51. ANSWER: C
Request that the physician stop the procedure until a local anesthetic can be administered The nurse needs to be a protector and patient advocate. The nurse helps to maintain a safe environment for the client and takes steps to prevent injury and protect the client from possible adverse effects of diagnostic or treatment measures.
Request that the physician stop the procedure until a local anesthetic can be administered The nurse needs to be a protector and patient advocate. The nurse helps to maintain a safe environment for the client and takes steps to prevent injury and protect the client from possible adverse effects of diagnostic or treatment measures.
A: The patient is
in pain now and relief should be immediate.
B: The procedure
should not be allowed to continue until a local anesthetic is given.
D: The procedure
should be stopped and the patient medicated rather than distracted.
52. ANSWER: A
All facts should be documented exactly as the patient stated. When recording subjective data, document the client's exact words within quotation marks.
All facts should be documented exactly as the patient stated. When recording subjective data, document the client's exact words within quotation marks.
B: The use of such
words as appears, seems or apparently is not acceptable when documenting
because they suggest that the nurse did not know the facts.
C: The patient's
comment is subjective data and should be placed in the patient's own words.
D: The patient's
comment is subjective data and should be placed in the patient's own words.
53. ANSWER: B
The nurse has spoken to her colleague under the appropriate circumstances and the behavior hasn't changed. Therefore, the appropriate action is to bring the problem to the manager's attention. It's unproductive to talk with other staff members about the situation because they don't have the authority to bring the colleague's practice into compliance. The nurse should never point out to a client that another staff member's practice isn't meeting standards.
The nurse has spoken to her colleague under the appropriate circumstances and the behavior hasn't changed. Therefore, the appropriate action is to bring the problem to the manager's attention. It's unproductive to talk with other staff members about the situation because they don't have the authority to bring the colleague's practice into compliance. The nurse should never point out to a client that another staff member's practice isn't meeting standards.
54. ANSWER: B
When a nurse attempts to influence a family's decision with her own opinions and values, the situation becomes one of over-involvement on the nurse's part and a nontherapeutic relationship. When a nurse keeps communication channels open, works with family members to decrease their dependence on health care providers, and instructs family members so they can accomplish tasks independently, she has developed an appropriate therapeutic relationship.
When a nurse attempts to influence a family's decision with her own opinions and values, the situation becomes one of over-involvement on the nurse's part and a nontherapeutic relationship. When a nurse keeps communication channels open, works with family members to decrease their dependence on health care providers, and instructs family members so they can accomplish tasks independently, she has developed an appropriate therapeutic relationship.
55. ANSWER: A
Documentation is defined as anything written or printed that is relied on as a record of proof for authorized persons. Effective documentation reflects the quality of care and provides evidence of each healthcare team member's accountability in giving care. Accountability means that the nurse is responsible professionally and legally for the type and quality of nursing care provided.
Documentation is defined as anything written or printed that is relied on as a record of proof for authorized persons. Effective documentation reflects the quality of care and provides evidence of each healthcare team member's accountability in giving care. Accountability means that the nurse is responsible professionally and legally for the type and quality of nursing care provided.
B: Even though
accurate documentation is one of the best defenses against legal claims
associated with nursing care, the nurse must function under the Code of Ethics.
The nurse is responsible for carrying out nursing responsibilities that provide
quality nursing care.
C: Insurance
reimbursement requires accurate documentation. However, nurses must remember
that they are professionals and must be aware of their professional nursing
role.
D: Many regulatory
bodies require proper documentation. However, the primary reason for accurate
documentation relates to evidence of accountability.
56. ANSWER: A
Chest pain could be a sign of a myocardial infarction or life-threatening pulmonary embolus. The nurse should assess the patient for changes in the blood pressure, heart rate, rhythm, and electrocardiogram (EKG). Assessment of accompanying symptoms and precipitating factors to the chest pain should be performed.
Chest pain could be a sign of a myocardial infarction or life-threatening pulmonary embolus. The nurse should assess the patient for changes in the blood pressure, heart rate, rhythm, and electrocardiogram (EKG). Assessment of accompanying symptoms and precipitating factors to the chest pain should be performed.
B: The intravenous
medication is not due for 30 minutes. The nurse has time to assess the other
patients.
C: A temperature
of 1010 Fahrenheit should be assessed. However, it is not life threatening.
Because chest pain has the potential to be life threatening, it should be
assessed first.
D: Although the
preoperative patient needs to be assessed, this situation does not require immediate
assessment.
57. ANSWER: C
C: DNR is the medically acceptable abbreviation for "do not resuscitate." A DNR order is written by the physician after discussion with the patient or family regarding withholding resuscitative measures such as CPR, defibrillation and intubation in the event of a terminal illness.
C: DNR is the medically acceptable abbreviation for "do not resuscitate." A DNR order is written by the physician after discussion with the patient or family regarding withholding resuscitative measures such as CPR, defibrillation and intubation in the event of a terminal illness.
A: Dopamine and
nitroglycerin recombination is a cardiac medication. Medications must always be
spelled out and ordered with a dose, route and frequency.
B: Diagnostic
neurological radiation is a radiographic test. It is not a common procedure and
would have to be written out in its entirety to avoid an error in transcribing
the order.
D: Dependent
nitrogen re-uptake is another example of an infrequently ordered test. It also
involves the administration of a drug and would therefore require dose, route
and frequency. It would not be acceptable to abbreviate.
58. ANSWER: C
When a nurse discovers substandard practice by another nurse, it's always appropriate to address the situation before conveying the information to a manager or supervisor. Informing the nurse-supervisor first doesn't promote goodwill between nurses and can affect nursing care. It may be necessary to correct the problem before the nurse returns, but a written report may not be necessary if the issues can be remedied informally. If the problem persists, it may be necessary to meet jointly with a manager, but initially the problem should be addressed by only those directly involved.
When a nurse discovers substandard practice by another nurse, it's always appropriate to address the situation before conveying the information to a manager or supervisor. Informing the nurse-supervisor first doesn't promote goodwill between nurses and can affect nursing care. It may be necessary to correct the problem before the nurse returns, but a written report may not be necessary if the issues can be remedied informally. If the problem persists, it may be necessary to meet jointly with a manager, but initially the problem should be addressed by only those directly involved.
59. ANSWER: C
The described behaviors indicate poor personal boundaries, which is the inability to differentiate between self and others. Poor boundaries are symptoms of antisocial and passive-aggressive behavior. Manipulation is an attempt to control another person.
The described behaviors indicate poor personal boundaries, which is the inability to differentiate between self and others. Poor boundaries are symptoms of antisocial and passive-aggressive behavior. Manipulation is an attempt to control another person.
60. ANSWER: C
Policies relative to DNR orders vary among hospitals and the nurse must adhere to the policies of the institution.
Policies relative to DNR orders vary among hospitals and the nurse must adhere to the policies of the institution.
A: This is untrue;
the wish of the client is the deciding factor.
B: The decision
resides with the client.
D: This may not be
true for all hospitals or states; the information does not indicate this is so
in this situation; these orders are reviewed periodically.
61. ANSWER: A
Physicians have an ethical and legal right to refuse to care for any client in a nonemergency situation when standard medical care isn't acceptable to the client. It isn't the responsibility of the surgeon to find an alternate. Jehovah's Witnesses don't believe in any kind of transfusion, homologous or autologous. Informing the client that her decision can shorten her life is inappropriate in that the statement may be inaccurate and it ignores the client's right of autonomy.
Physicians have an ethical and legal right to refuse to care for any client in a nonemergency situation when standard medical care isn't acceptable to the client. It isn't the responsibility of the surgeon to find an alternate. Jehovah's Witnesses don't believe in any kind of transfusion, homologous or autologous. Informing the client that her decision can shorten her life is inappropriate in that the statement may be inaccurate and it ignores the client's right of autonomy.
62. ANSWER: C
This is a serious charge, and confrontation should occur in the presence of the supervisor.
This is a serious charge, and confrontation should occur in the presence of the supervisor.
A: This is
unnecessary; as a professional the nurse has enough information to confront the
other nurse.
B: This is an
assumption that may result in an altercation; a witness should be present.
D: This is not a
professional approach; the nurse has a legal responsibility to intervene.
63. ANSWER: B
When dealing with child abuse, the priority is accurate and complete documentation of physical findings and observed behaviors on the client's record. Court proceedings usually occur sometime after the nurse's involvement with the child and family, and memories fade. Thus, careful documentation of the facts, not hearsay or subjective opinion, is essential.
When dealing with child abuse, the priority is accurate and complete documentation of physical findings and observed behaviors on the client's record. Court proceedings usually occur sometime after the nurse's involvement with the child and family, and memories fade. Thus, careful documentation of the facts, not hearsay or subjective opinion, is essential.
A: Because court
proceedings usually occur sometime after the nurse’s involvement with the child
and family, remembering may be difficult because memories fade.
C: Objective data,
not subjective opinions, are key.
D: Preparing
answers to questions that may be asked by the attorneys is not a priority for
the nurse when the child is admitted. This may become appropriate later.
64. ANSWER: C
Upcoding is the practice of using a CPT code that is reimbursed at a higher rate than the code for the service actually provided. Unbundling, overbilling, and misrepresentation aren't the terms used for this illegal practice.
Upcoding is the practice of using a CPT code that is reimbursed at a higher rate than the code for the service actually provided. Unbundling, overbilling, and misrepresentation aren't the terms used for this illegal practice.
65. ANSWER: D
The nurse's release of information to the client's employer without the client's consent is a breach of confidentiality. The stigma associated with psychiatric illness may affect the client's employment; therefore, it's better to maintain confidentiality and refrain from disclosing any information about the client, including whether she's a client in the hospital.
The nurse's release of information to the client's employer without the client's consent is a breach of confidentiality. The stigma associated with psychiatric illness may affect the client's employment; therefore, it's better to maintain confidentiality and refrain from disclosing any information about the client, including whether she's a client in the hospital.
66. ANSWER: C
In order to provide culturally sensitive care, the nurse must be aware of her own ethnocultural heritage, both as a person and as a nurse. Becoming aware of one's own biases and gaining knowledge of other cultures enables the nurse to begin to develop an attitude in which the patient's culture and healthcare beliefs, values and practices are respected and incorporated into the plan of care.
In order to provide culturally sensitive care, the nurse must be aware of her own ethnocultural heritage, both as a person and as a nurse. Becoming aware of one's own biases and gaining knowledge of other cultures enables the nurse to begin to develop an attitude in which the patient's culture and healthcare beliefs, values and practices are respected and incorporated into the plan of care.
A: Many variations
in socio-economic status and social class can be found within any cultural or
ethnic group.
B: Environmental
awareness may provide some clues about a patient's culture, health beliefs,
values and practices but it is not the most effective way to increase one's
cultural sensitivity.
D: Talking with
others may provide some insight about a patient's culture, health beliefs,
values and practices but it is not the most effective way for the nurse to
increase his/her cultural sensitivity.
67. ANSWER: B
Communication facilitates joint solution of the problem; the nurse must first determine the client's understanding and perceptions before solutions to the problem can be attempted.
Communication facilitates joint solution of the problem; the nurse must first determine the client's understanding and perceptions before solutions to the problem can be attempted.
A: This will not
collect data about why the client is leaving the room.
C: This abdicates
the responsibility of the primary nurse.
D: This may be
done, but not until further assessment is done to determine the reason why the
client is leaving the room.
68. ANSWER: A
Anencephaly, a congenital disorder where both cerebral hemispheres are absent, is incompatible with life. Therefore, the nurse is frequently challenged with ethical and moral issues regarding life support withdrawal and organ donation.
Anencephaly, a congenital disorder where both cerebral hemispheres are absent, is incompatible with life. Therefore, the nurse is frequently challenged with ethical and moral issues regarding life support withdrawal and organ donation.
B: Ethical and
moral issues regarding life support and organ donation issues are not that commonly
encountered with microcephaly (small brain).
C: Encephalocele,
herniation of the brain and meninges through a skull defect, is usually
successfully treated.
D: Meningocele,
herniation of the meninges through a spinal defect, is usually successfully treated.
69. ANSWER: B
Contains full description of situation, error committed, condition of pt, remedial steps taken.
Contains full description of situation, error committed, condition of pt, remedial steps taken.
A: not accurate
C: it is a nursing
responsibility
D: inaccurate;
always complete form
70. ANSWER: D
The nurse violated confidentiality by informing the officer that the client wasn't in treatment. Even with law enforcement agents, the nurse must be a client advocate and protect the client's confidentiality. Information can be legally withheld when a court order isn't in place.
The nurse violated confidentiality by informing the officer that the client wasn't in treatment. Even with law enforcement agents, the nurse must be a client advocate and protect the client's confidentiality. Information can be legally withheld when a court order isn't in place.
71. ANSWER: A
The main goal of an incident report following an adventitious event isn't punishment for those involved in the incident. The purpose of an incident report is threefold: to identify ways to prevent recurrences of incidents, to identify patterns of care problems, and to identify facts surrounding each incident.
The main goal of an incident report following an adventitious event isn't punishment for those involved in the incident. The purpose of an incident report is threefold: to identify ways to prevent recurrences of incidents, to identify patterns of care problems, and to identify facts surrounding each incident.
72. ANSWER: B
Procrastination, a common pitfall among inexperienced nurses, is a hallmark of inappropriate time management. Setting limits, establishing realistic expectations, and making practical plans all promote effective time management.
Procrastination, a common pitfall among inexperienced nurses, is a hallmark of inappropriate time management. Setting limits, establishing realistic expectations, and making practical plans all promote effective time management.
73. ANSWER: B
The nurse should verify that the consent form has been signed by the patient and that it is attached to her chart
The nurse should verify that the consent form has been signed by the patient and that it is attached to her chart
A: Physician
should get pt to sign consent
C: Physician
should explain procedure and get consent form signed
D: must be signed
by pt unless unable to do
ADDITIONAL INFO:
Physician's responsibility to obtain informed consent.
74. ANSWER: B
Frequent breaks, working extra shifts and inaccurate narcotic counts may be indicators of substance abuse among nurses. The nurse may be volunteering for extra shifts in an effort to obtain drugs. Other indicators include irritability, absenteeism and deteriorating appearance.
Frequent breaks, working extra shifts and inaccurate narcotic counts may be indicators of substance abuse among nurses. The nurse may be volunteering for extra shifts in an effort to obtain drugs. Other indicators include irritability, absenteeism and deteriorating appearance.
A: Victims of
domestic violence present with vague physical complaints, insomnia and
headaches. There may be evidence of violence in the form of bruises.
C: The identified
symptoms are not defining characteristics of any personality disorder.
D: Individuals
trying to get out of work usually do not sign up for extra shifts.
75. ANSWER: D
The nurse should treat this episode as a risk management incident; her immediate responsibility is to fill out an incident report and notify the risk manager. Quality improvement and ethics aren't the nurse's initial concerns. The facility may choose to look at these types of problems and make changes to deliver a higher standard of care institutionally. Informed consent isn't a relevant issue in this incident.
The nurse should treat this episode as a risk management incident; her immediate responsibility is to fill out an incident report and notify the risk manager. Quality improvement and ethics aren't the nurse's initial concerns. The facility may choose to look at these types of problems and make changes to deliver a higher standard of care institutionally. Informed consent isn't a relevant issue in this incident.
76. ANSWER: D
When advance directives state that a client doesn't want life-prolonging interventions, nursing care focuses on providing emotional and spiritual support and comfort measures. The client still needs to be checked regularly. The client and family shouldn't feel as if they've been abandoned. Providing mouth and skin care makes the client more comfortable. Turning the client provides comfort and prevents potentially painful complications such as pressure ulcers.
When advance directives state that a client doesn't want life-prolonging interventions, nursing care focuses on providing emotional and spiritual support and comfort measures. The client still needs to be checked regularly. The client and family shouldn't feel as if they've been abandoned. Providing mouth and skin care makes the client more comfortable. Turning the client provides comfort and prevents potentially painful complications such as pressure ulcers.
77. ANSWER: D
Sleeping undisturbed for a period of time would indicate that the client feels more relaxed, comfortable, and trusting and is less anxious. Decreasing eye contact, asking to see family, and joking may also indicate that the client is more relaxed. However, these also could be diversions.
Sleeping undisturbed for a period of time would indicate that the client feels more relaxed, comfortable, and trusting and is less anxious. Decreasing eye contact, asking to see family, and joking may also indicate that the client is more relaxed. However, these also could be diversions.
78. ANSWER: A
An advance directive is a written document that contains directives of the person's choices regarding end of life care. A person must have the cognitive and communicative abilities to execute decisions regarding their desires. It includes wishes for treatment options should the person become unable to do so.
An advance directive is a written document that contains directives of the person's choices regarding end of life care. A person must have the cognitive and communicative abilities to execute decisions regarding their desires. It includes wishes for treatment options should the person become unable to do so.
B: A durable power
of attorney for healthcare designates an individual to make medical decisions
in case the patient is unable to do so.
C: A statement
identifying the person as an organ donor may be included in an advance
directive, but it is not the only information in an advance directive. This
information would typically be included on an organ donor card.
D: A written
statement authorizing a particular surgical procedure is a consent form.
79. ANSWER: A
The patient is the authority on his/her pain. The patient's self report using a pain rating scale (for example zero to 10) is the most reliable indicator of the existence and intensity of pain. Self-report is ranked as the number one hierarchy of importance of basic measure of pain intensity. The patient's not wanting to bother the nurse needs to be discussed further.
The patient is the authority on his/her pain. The patient's self report using a pain rating scale (for example zero to 10) is the most reliable indicator of the existence and intensity of pain. Self-report is ranked as the number one hierarchy of importance of basic measure of pain intensity. The patient's not wanting to bother the nurse needs to be discussed further.
B: Lack of pain
expression does not necessarily mean lack of pain. Even with severe pain,
periods of physiological and behavioral adaptations occur, leading to periods
of minimal signs of pain.
C: Physiological
measures, such as changes in vital signs, are the least sensitive indicators of
pain.
D: The frequency
of pain medication requests would not be a useful indicator of the patient's
pain level because of the patient's desire to be "a good patient" and
not bother the nurse.
80. ANSWER: D
In most states, the age of majority is 18 years; however, mothers younger than 18 years are considered emancipated minors and can sign consents for themselves and their children.
A: The grandmother
has no legal right to give consent; the 16-year-old mother is present and can
legally give consent.
B: This is
unnecessary; the client is an emancipated minor, and this confers adult status.
C: Consent is
always needed; the 16-year-old mother is present and can legally give consent.
FLUID AND
ELECTROLYTES
IV THERAPY
81. ANSWER: A
The mist tent decreases respiratory tract edema, which causes croup. However, the child needs to be prepared because the confinement can cause high anxiety. The tent liquefies secretions, rather than drying them, and it doesn't increase the child's fluid intake.
The mist tent decreases respiratory tract edema, which causes croup. However, the child needs to be prepared because the confinement can cause high anxiety. The tent liquefies secretions, rather than drying them, and it doesn't increase the child's fluid intake.
82. ANSWER: C
Osteoporosis of the hip increases the risk of hip fractures. Decreased bone mass density puts one at high risk for hip fractures. Installing handrails on stairways will improve mobility and prevent falls.
Osteoporosis of the hip increases the risk of hip fractures. Decreased bone mass density puts one at high risk for hip fractures. Installing handrails on stairways will improve mobility and prevent falls.
A: Disinfecting
the bathroom does not prevent falls and hip fractures in the patient with
osteoporosis.
B: Carpeting floor
surfaces often makes ambulation more difficult.
D: Poor lighting
increases the risk for falling. Areas should be well lit.
83. ANSWER: B
Following the identification of a learning need, the first step is to assess the strengths and needs of the community while identifying barriers to learning.
Following the identification of a learning need, the first step is to assess the strengths and needs of the community while identifying barriers to learning.
84. ANSWER: B
The client with rheumatoid arthritis should be encouraged to alternate periods of activity and rest throughout the day.
The client with rheumatoid arthritis should be encouraged to alternate periods of activity and rest throughout the day.
A: Encouraging the
client to perform all activities of daily living at once will worsen fatigue
and stress her ability to recover.
C: Narcotics are
not typically administered to control arthritic pain.
D: Encouraging the
client to cease all participation in daily activities will decrease activity
tolerance and make fatigue more pronounced.
85. ANSWER: B
Rotating staff members who work with a client with a borderline personality disorder keeps the client from becoming dependent on any one nurse and reduces the use of splitting and her fear of abandonment. Firm rules and consistency among staff members will help control the client's behavior. Ignoring splitting behaviors can cause the client to increase the behavior by trying to get a response from the staff. Unit rules must be consistently enforced and followed by each nurse to help the client control behavior.
Rotating staff members who work with a client with a borderline personality disorder keeps the client from becoming dependent on any one nurse and reduces the use of splitting and her fear of abandonment. Firm rules and consistency among staff members will help control the client's behavior. Ignoring splitting behaviors can cause the client to increase the behavior by trying to get a response from the staff. Unit rules must be consistently enforced and followed by each nurse to help the client control behavior.
86. ANSWER: B
When a chest tube becomes disconnected, the nurse should take immediate steps to prevent air from entering the chest cavity which may cause the lung to collapse. Therefore, when a chest tube is accidentally disconnected from the drainage tube, the nurse should either double-clamp the chest tube as close to the client as possible or place the open end of the tube in a container of sterile water or saline solution. Then the physician should be notified.
When a chest tube becomes disconnected, the nurse should take immediate steps to prevent air from entering the chest cavity which may cause the lung to collapse. Therefore, when a chest tube is accidentally disconnected from the drainage tube, the nurse should either double-clamp the chest tube as close to the client as possible or place the open end of the tube in a container of sterile water or saline solution. Then the physician should be notified.
A: First priority
must be given to clamping the chest tube.
C: To prevent
backward flow of drainage, the drainage system should never be raised above
chest level.
D: To prevent
backward flow of drainage, the drainage system should never be raised above
chest level.
87. ANSWER: C
A fluid intake of 2 to 3 L/day, providing that the client does not have cardiovascular or renal disease, helps liquefy bronchial secretions.
A fluid intake of 2 to 3 L/day, providing that the client does not have cardiovascular or renal disease, helps liquefy bronchial secretions.
A: A low-salt diet
does not help reduce the viscosity of mucus.
B: Continuous
oxygen therapy does not help reduce the viscosity of mucus.
D: Maintaining a
semi-sitting position does not help reduce the viscosity of mucus.
88. ANSWER: B
The nurse must distinguish between normal physiologic complaints of the latter stages of pregnancy and those that need referral to the health care provider. In this case, the client indicates normal physiologic changes due to the growing uterus and pressure on the diaphragm. The client doesn't need to be seen or admitted for delivery. The client's signs aren't indicative of heart failure.
The nurse must distinguish between normal physiologic complaints of the latter stages of pregnancy and those that need referral to the health care provider. In this case, the client indicates normal physiologic changes due to the growing uterus and pressure on the diaphragm. The client doesn't need to be seen or admitted for delivery. The client's signs aren't indicative of heart failure.
89. ANSWER: C
When a nurse discovers substandard practice by another nurse, it's always appropriate to address the situation before conveying the information to a manager or supervisor. Informing the nurse-supervisor first doesn't promote goodwill between nurses and can affect nursing care. It may be necessary to correct the problem before the nurse returns, but a written report may not be necessary if the issues can be remedied informally. If the problem persists, it may be necessary to meet jointly with a manager, but initially the problem should be addressed by only those directly involved.
When a nurse discovers substandard practice by another nurse, it's always appropriate to address the situation before conveying the information to a manager or supervisor. Informing the nurse-supervisor first doesn't promote goodwill between nurses and can affect nursing care. It may be necessary to correct the problem before the nurse returns, but a written report may not be necessary if the issues can be remedied informally. If the problem persists, it may be necessary to meet jointly with a manager, but initially the problem should be addressed by only those directly involved.
90. ANSWER: B
Keeping the bed at the lowest possible position is the first priority for clients at risk for falling. Keeping the call light easily accessible is important but isn't a top priority. Instructing the client not to get out of bed may not effectively prevent falls.
Keeping the bed at the lowest possible position is the first priority for clients at risk for falling. Keeping the call light easily accessible is important but isn't a top priority. Instructing the client not to get out of bed may not effectively prevent falls.
91. ANSWER: A
Administering pain medication would have the highest priority during the first hour after the client's admission.
Administering pain medication would have the highest priority during the first hour after the client's admission.
B: Completing the
admission history can be done after the client's pain is controlled.
C: Maintaining
hydration is important but will be accomplished over time. In the first hour
after admission, the highest priority is pain relief.
D: It is not
appropriate to try to teach while a client is in pain. Teaching about planned
diagnostic tests can occur after the client is comfortable.
LEADERSHIP AND
MANAGEMENT ISSUES
92. ANSWER: B
If a nurse chooses to stop and give aid at the scene of an emergency, the Good Samaritan Act provides the following guidelines. The nurse should give care that any reasonable, prudent person would consider first aid. Do not do what you don't know. Offer assistance; do not insist. Do not leave the scene until the injured victim leaves or another qualified person takes over.
If a nurse chooses to stop and give aid at the scene of an emergency, the Good Samaritan Act provides the following guidelines. The nurse should give care that any reasonable, prudent person would consider first aid. Do not do what you don't know. Offer assistance; do not insist. Do not leave the scene until the injured victim leaves or another qualified person takes over.
A: There are only
a few US states that mandate stopping to give aid at the scene of any
emergency. The Good Samaritan Act covers those who choose to give aid.
C: The nurse, like
anyone else, is only accountable for first aid as described in the above
statement. The nurse should not initiate care if he/she is unsure of the
appropriate care.
D: When acting as
a "Good Samaritan," the nurse is not expected to perform under the
direct orders of a physician.
93. ANSWER: A
When a nurse feels incapable of performing an assignment safely, the appropriate action is to speak to the manager or nurse in charge. The nurse should also document the concerns in writing and ask that the assignment be changed. In the event that the manager chooses to leave the assignment as given, the nurse should accept the assignment. The nurse should never abandon the assigned clients by leaving the workplace or asking another nurse to care for them. The nurse may, however, refuse to perform a task outside the scope of practice.
When a nurse feels incapable of performing an assignment safely, the appropriate action is to speak to the manager or nurse in charge. The nurse should also document the concerns in writing and ask that the assignment be changed. In the event that the manager chooses to leave the assignment as given, the nurse should accept the assignment. The nurse should never abandon the assigned clients by leaving the workplace or asking another nurse to care for them. The nurse may, however, refuse to perform a task outside the scope of practice.
94. ANSWER: C
Request that the physician stop the procedure until a local anesthetic can be administered The nurse needs to be a protector and patient advocate. The nurse helps to maintain a safe environment for the client and takes steps to prevent injury and protect the client from possible adverse effects of diagnostic or treatment measures.
Request that the physician stop the procedure until a local anesthetic can be administered The nurse needs to be a protector and patient advocate. The nurse helps to maintain a safe environment for the client and takes steps to prevent injury and protect the client from possible adverse effects of diagnostic or treatment measures.
A: The patient is
in pain now and relief should be immediate.
B: The procedure
should not be allowed to continue until a local anesthetic is given.
D: The procedure
should be stopped and the patient medicated rather than distracted.
95. ANSWER: C
Client-care quality should always be the first consideration when proposing a change in care provision. Institutional resources, standards of practice, and nursing recruitment will all influence the decision but none as much as client-care quality should.
Client-care quality should always be the first consideration when proposing a change in care provision. Institutional resources, standards of practice, and nursing recruitment will all influence the decision but none as much as client-care quality should.
96. ANSWER: B
The Patient's Bill of Rights addresses the client's rights to information, informed consent, timely responses to requests for services, and treatment refusal. A legal document, it serves as a guideline for the nurse's decision making. Standards of Nursing Practice, the Nurse Practice Act, and the Code for Nurses contain nursing practice parameters and primarily describe the use of the nursing process in providing care.
The Patient's Bill of Rights addresses the client's rights to information, informed consent, timely responses to requests for services, and treatment refusal. A legal document, it serves as a guideline for the nurse's decision making. Standards of Nursing Practice, the Nurse Practice Act, and the Code for Nurses contain nursing practice parameters and primarily describe the use of the nursing process in providing care.
97. ANSWER: B
Case managers plan, coordinate and monitor services to meet the needs of the client. Case managers pull together available resources to provide the client with the best help. Case management is based on a compilation of services that contains costs and it proves the quality of care while reducing fragmentation and duplication of services.
Case managers plan, coordinate and monitor services to meet the needs of the client. Case managers pull together available resources to provide the client with the best help. Case management is based on a compilation of services that contains costs and it proves the quality of care while reducing fragmentation and duplication of services.
A: The case
manager does not become involved in daily patient assignments. This is the unit
manager's responsibility.
C: Case managers
do not negotiate insurance benefits with the hospital. They coordinate care to
control costs.
D: The decision
related to what treatments are essential is the responsibility of the medical
practitioner.
98. ANSWER: B
The nurse administering the dose should have compared the MAR with the physician's order and noted the discrepancy. The transcribing nurse and pharmacist aren't void of responsibility; however, the nurse administering the dose is most responsible. The health care facility's policy does provide for a system of checks and balances. Therefore, the health care facility isn't responsible for the error.
The nurse administering the dose should have compared the MAR with the physician's order and noted the discrepancy. The transcribing nurse and pharmacist aren't void of responsibility; however, the nurse administering the dose is most responsible. The health care facility's policy does provide for a system of checks and balances. Therefore, the health care facility isn't responsible for the error.
99. ANSWER: B
Assistive personnel may not be assigned to care for clients without the supervision of a professional nurse. It's essential that assistive personnel understand that they're responsible for their own actions. Assistive personnel must be adequately trained to perform all tasks they're assigned to perform.
Assistive personnel may not be assigned to care for clients without the supervision of a professional nurse. It's essential that assistive personnel understand that they're responsible for their own actions. Assistive personnel must be adequately trained to perform all tasks they're assigned to perform.
100.
ANSWER: A
The nurse manager needs to assist an impaired nurse in obtaining treatment for his/her substance abuse. The treatment process can be initiated when a team of colleagues confronts the nurse and offers him/her assistance in seeking treatment.
The nurse manager needs to assist an impaired nurse in obtaining treatment for his/her substance abuse. The treatment process can be initiated when a team of colleagues confronts the nurse and offers him/her assistance in seeking treatment.
B: Termination of
an impaired nurse will protect the safety of the patients, but does not assist
the nurse in obtaining necessary treatment. The nurse should be removed from
his/her role until he/she has received and responded successfully to treatment.
Termination only serves to promote the growth of the problem. The nurse often
can obtain employment in another healthcare facility.
C: The impaired
nurse needs to be removed from the professional duties and responsibilities of
his/her job but should not be professionally isolated. The professional future
of the impaired nurse should be considered and a humane system of intervention
and treatment provided.
D: By providing
covert support, the nurse manager not only is promoting the growth of the
problem in the impaired nurse but also is jeopardizing the safety of patients
and increasing the risk for health care employers.
For practice test please click the link below:
PRACTICE TEST 2 - QUESTIONS
For practice test please click the link below:
PRACTICE TEST 2 - QUESTIONS
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