CHAPTER 7: Safe and Effective Care Environment

Safe and Effective Care Environment Practice Questions

The nurse is developing an educational session on client

advocacy for the nursing staff. The nurse would include

which interventions as examples of the nurse acting as a

client advocate? Select all that apply.

1. Obtaining an informed consent for a surgical procedure

2. Providing information necessary for a client to make

informed decisions

3. Providing assistance in asserting the client’s human

and legal rights if the need arises

4. Including the client’s religious or cultural beliefs when

assisting the client in making an informed decision

5. Defending the client’s rights by speaking out against

policies or actions that might endanger the client’s wellbeing

Answer: 2, 3, 4, 5

Rationale:

In the role of client advocate, the nurse protects the client’s human and legal rights and provides assistance in asserting those rights if the need arises. The nurse advocates for the client by providing information needed so that the client can make an informed decision. The nurse needs to consider the client’s religion and culture when functioning as an advocate and when providing care. The nurse would include the client’s religious or cultural beliefs in discussions about treatment plans so that an informed decision can be made. The nurse also defends clients’ rights in a general way by speaking out against policies or actions that mi ght endanger the client’s well-being or conflict with the client’s rights. Informed consent is part of the primary health care provider–client relationship; in most situations, obtaining the client’s informed consent does not fall within the nursing duty. Even though the nurse assumes the responsibility for witnessing the client’s signature on the consent form, the nurse does not legally assume the duty of obtaining informed consent.

The registered nurse (RN) planning the assignments for the day is leading a team comprised of a licensed practical nurse (LPN) and an unlicensed assistive personnel (UAP). Based on licensure, which client is most appropriate to assign to the LPN?

1. A client diagnosed with dementia

2. A 1-day postoperative mastectomy client

3. A client who requires some assistance with bathing

4. A client who requires some assistance with ambulation

Answer: 2

Rationale:

Assignment of tasks must be implemented based on the job description of the LPN and UAP, the level of education and clinical competence, and state law. The 1-day postoperative mastectomy client will need care that requires the skill of a licensed nurse. The UAP has the skills to care for a client requiring noninvasive care, such as a client with dementia, a client who requires some assistance with bathing, and a client who requires some assistance with ambulation.

The nurse is delegating unit nursing tasks for the day. Which tasks would the nurse delegate to the unlicensed assistive personnel (UAP)? Select all that apply.

1. Deliver fresh water to clients.

2. Empty urine out of urinary catheter bags.

3. Take temperatures, pulses, respirations, and blood pressures.

4. Count the substance control medications in the opioid medication supply.

5. Check the crash cart (cardiopulmonary resuscitation cart) for necessary supplies using a checklist.

6. Check all intravenous (IV) solution bags on clients receiving IV therapy for the remaining amounts of solution in the bags.

Answer: 1, 2, 3

Rationale:

Delegation is the transfer of responsibility for the performance of an activity or task while retaining accountability for the outcome. When delegating an activity, the nurse must consider the educational preparation and experience of the individual. The UAP is trained to perform noninvasive tasks and those that meet basic client needs. The UAP is also trained to take vital signs. Therefore, the appropriate activities to assign to the UAP would be to deliver fresh water to clients; empty urine out of urinary catheter bags; and take temperatures, pulses, respirations, and blood pressures. Although the UAP is trained in performing cardiopulmonary resuscitation, the UAP is not trained to check a crash cart, and this activity must be assigned to a licensed nurse. Any activities related to medications and IV therapy must be delegated to a licensed nurse.

In the middle of bathing a client, the unit secretary notifies the nurse that there is an emergency telephone call. Which action would the nurse implement to best ensure client safety?

1. Quickly finish the bath before answering the call.

2. Immediately leave the client’s room and answer the call.

3. Cover the client, place the call light within reach, and then leave to answer the call.

4. Leave the door open and ask staff to monitor the client, and then leave to answer the call.

Answer: 3

Rationale:

Because the telephone call is an emergency, the nurse may need to answer it. To maintain privacy and safety, the nurse covers the client and places the call light within the client’s reach. Additionally, the client’s door needs to be closed or the room curtains pulled around the bathing area. The other appropriate action is to ask another nurse to accept the call. This, however, is not one of the options. None of the other options effectively meet the

client’s safety needs.

The nurse manager reviewing the purposes for applying restraints to a client determines that further education is necessary when a nursing staff member makes which statement supporting the use of a restraint?

1. “It limits movement of a limb during a painful procedure.”

2. “It prevents the violent client from injuring self and others.”

3. “At night it keeps the client in bed instead of wandering about.”

4. “It is useful in preventing the client from pulling out intravenous lines.”

Answer: 3

Rationale:

Wrist and ankle restraints are devices used to limit the client’s movement in situations when it is necessary to immobilize a limb. Restraints are not applied to keep a client in bed at night and are never used as a form of punishment. Restraints are applied to prevent the client from injuring self or others; pulling out intravenous lines, catheters, or tubes; or removing dressings. Restraints also may be used to keep children still and from injuring themselves during treatments and diagnostic procedures. A physician’s prescription is required for the use of restraints, and state and agency procedures are always followed when restraints are used.

A client diagnosed with epilepsy has a prescription for valproic acid 250 mg once daily. To maximize the client’s safety, which time is best for the nurse to schedule administration of the medication?

1. With lunch

2. With breakfast

3. Before breakfast

4. At bedtime with a snack

Answer: 4

Rationale:

Valproic acid is an anticonvulsant that causes central nervous system (CNS) depression. For this reason, the side and adverse effects include sedation, dizziness, ataxia, and confusion. When the client is taking this medication as a single daily dose, administering it at bedtime negates the risk of injury from sedation and enhances client safety. Otherwise, it may be given after meals to avoid gastrointestinal upset. Carbonated beverages need to be avoided with its administration, and the client needs to follow the physician’s prescription regarding its administration.

Which findings documented in the history of an older adult client would require the nurse to implement an accident prevention protocol? Select all that apply.

1. Range of motion is limited.

2. Peripheral vision is decreased.

3. Transmission of hot impulses is delayed.

4. The client reports incidences of nocturia.

5. High-frequency hearing tones are perceptible.

6. Voluntary and autonomic reflexes are slowed.

Answer: 1, 2, 3, 4, 6

Rationale:

The physiologic changes that occur during the aging process increase the client’s risk for accidents. Musculoskeletal changes include a decrease in muscle strength and function, lessened joint mobility, and limited range of motion. Sensory changes include a decrease in peripheral vision and lens accommodation, delayed transmission of hot and cold impulses, and impaired hearing as high-frequency tones become less perceptible. Nervous system changes include slowed voluntary and autonomic reflexes.

Genitourinary changes may include nocturia.

Which actions would the nurse take when obtaining a sputum culture from a client with a diagnosis of pneumonia?

Select all that apply.

1. Explain the procedure to the client.

2. Obtain the specimen early in the morning.

3. Have the client brush their teeth before expectoration.

4. Instruct the client to take deep breaths before coughing.

5. Place the lid of the culture container face down on the bedside table.

Answer: 1, 2, 3, 4

Rationale: The nurse always explains a procedure to the client. The specimen is obtained early in the morning whenever possible because increased amounts of sputum collect in the airways during sleep. The client needs to rinse the mouth or brush the teeth before specimen collection to avoid contaminating the specimen. The client would take deep breaths before expectoration for best sputum production. Placing the lid face down on the bedside table contaminates the lid and could result in inaccurate findings.

The nurse would wear this protective device when caring for hospitalized clients with which diagnosed disorders? (Refer

to the figure.) Select all that apply.

1. Scabies

2. Tuberculosis

3. Hepatitis A virus

4. Pharyngeal diphtheria

5. Streptococcal pharyngitis

6. Meningococcal pneumonia

Answer: 4, 5, 6

Rationale: A standard surgical mask is used as part of droplet precautions to protect the nurse from acquiring the client’s infection. Droplet precautions refer to precautions used for organisms that can spread through the air but are unable to remain in the air farther than 3 feet. Many respiratory viral infections such as respiratory viral influenza require the use of a standard surgical mask when caring for the client. Some other disorders requiring the use of a standard surgical mask include pharyngeal diphtheria; rubella; streptococcal pharyngitis; pertussis; mumps; pneumonia, including meningococcal pneumonia; and the pneumonic plague. Scabies and hepatitis A are transmitted by direct contact with an infected person and require the use of contact precautions for protection. Tuberculosis requires the use of airborne precautions and the use of an individually fitted particulate filter mask. A standard surgical mask would not protect the nurse from Mycobacterium tuberculosis.

The nurse is developing a hospital policy on guidelines for telephone and verbal prescriptions. Which guidelines would the nurse include in the policy? Select all that apply.

1. Avoid using all abbreviations.

2. Verbal prescriptions are rarely acceptable.

3. Clarify any questions with the physician.

4. Repeat the prescribed prescriptions back to the physician.

5. If the prescriber is the client’s physician, documentation is unnecessary

Answer: 3, 4

Rationale: To avoid misunderstandings, the nurse would always clarify a telephone or verbal prescription with the physician if the nurse had any questions about the prescription, and the nurse would repeat any prescriptions back to the physician. A telephone order (TO) or prescription involves a physician stating a prescribed therapy over the phone to the nurse. TOs are frequently given at night or during an emergency and need to be given only when absolutely necessary. Likewise, a verbal order (VO) or prescription is acceptable when there is no opportunity for the physician to write the prescription such as in an emergency situation. Additional guidelines for telephone and verbal prescriptions include the following: clearly determine the client’s name, room number, and diagnosis; indicate TO or VO, including the date and time, name of the client, complete prescription, name of the physician giving the prescription, and nurse taking the prescription; and have the physician cosign the prescription within the time frame designated by the health care agency (usually 24 hours). There are some abbreviations that are acceptable, and documentation is necessary regardless of the prescriber.

The nurse employed in a preschool agency is planning a staff education program to prevent the spread of an intestinal parasitical disease. Which prevention measure would the nurse include in the educational session?

1. All food will be cooked before eating.

2. Only bottled water will be used for drinking.

3. All toileting areas will be cleansed daily with soap and water.

4. Standard precautions will be used when assisting children with toileting.

Answer: 4

Rationale:

The fecal-oral route is the mode of transmission of an intestinal parasitical disease. Standard precautions prevent the transmission of infection. Some fresh foods do not need to be cooked as long as they are washed well and were not grown in soil contaminated with human feces. Water and fresh foods can be vehicles for transmission, but municipal water sources are usually safe. Cleaning with soap and water is not as effective as the use of bleach.

A client has arrived at the labor and delivery unit in active labor. The nursing assessment reveals a recurrent history of diagnosed genital herpes and the presence of lesions in the genital tract. Which intervention would the nurse initiate?

1. Limiting visitors

2. Maintaining reverse isolation

3. Preparing for a cesarean delivery

4. Preparing for the artificial membrane rupturing

Answer: 3

Rationale:

A cesarean delivery can reduce the risk of neonatal infection with a client in labor who has herpetic genital tract lesions. There is no need to limit visitors or maintain isolation, although standard precautions need to be maintained. A vaginal delivery presents a risk of transmitting the disease to the neonate. Intact membranes provide another barrier to transmitting the disease to the neonate.

13. Which interventions would the nurse perform when inserting an indwelling urinary catheter in order to maintain both the integrity of the catheter and the client’s safety?

Select all that apply.

1. Use strict aseptic technique.

2. Place the drainage bag lower than the bladder level.

3. Inflate the balloon 4 to 5 mL beyond its capacity.

4. Swab the urinary catheter with sterile water before inserting.

5. Advance the catheter 1 to 2 inches after urine appears in the tubing.

Answer:

1, 2, 5

Rationale:

The nurse would use strict aseptic technique to insert the catheter. The drainage bag is placed lower than bladder level to ensure drainage, prevent retrograde flow of urine, and reduce the risk of infection. Advancing the catheter 1 to 2 inches beyond the point where the flow of urine is first noted is also good practice because this ensures that the catheter balloon is completely in the bladder before it is inflated. The nurse risks rupturing the catheter’s balloon by overinflating it; therefore, the nurse inflates the balloon with the specified volume for the catheter because inflating the balloon 4 to 5 mL beyond its capacity is unsafe. The urinary catheter is sterile, so it is inappropriate and unnecessary to swab it with sterile water before inserting.

14. A client admitted 2 days ago with a diagnosis of moderate depression begins smiling and reporting that the crisis is over. Which priority modification to the treatment plan would occur based on the behavioral cues of the client?

1. Allowing off-unit privileges PRN

2. Suggesting a reduction of medication

3. Allowing increased “in-room” activities

4. Increasing the level of suicide precautions

Answer: 4

Rationale:

A client who is diagnosed as moderately depressed and has only been hospitalized 2 days is unlikely to have such a dramatic cure. When a mood suddenly lifts, it is likely that the client may have made the decision to cause self-harm. Suicide precautions are necessary to keep the client safe. Options 1 and 2 are incorrect because they support a “quick” cure. In-room activities do not encourage social interaction; social interaction would be a desired outcome for a moderately depressed client.

15. The nurse is planning care for a client admitted with suicidal ideations. To best ensure client safety the nurse would implement additional precautions during which time period?

1. During the day shift

2. On weekday evenings

3. Between 0800 and 1000

4. During the unit shift change

 Answer: 4

Rationale:

At shift change, there is often less availability of staff. The psychiatric nurse and staff need to increase precautions for suicidal clients at that time. The night shift also presents a high-risk time, as do weekends, not weekdays.

16. The nurse is assisting with the transfer of a client from the operating room table to a stretcher. Which interventions would the nurse implement to ensure client safety? Select all that apply.

1. Check the client’s level of consciousness.

2. Check wheel locks of the operating room table.

3. Complete the client transfer as quickly as possible.

4. Tell the client to move self from the table to the stretcher.

5. Raise side rails after the client is positioned on the stretcher per agency policy.

Answer: 1, 2, 5

Rationale:

As part of the safe transfer of a client after a surgical procedure, the nurse would assess the client’s level of consciousness and, if appropriate, let the client know that they will be transferred from the operating room table to the stretcher. The nurse checks the wheel locks of the table and the stretcher to prevent any movement during the transfer. In addition, the nurse raises the side rails per agency policy to prevent the client from falling off the stretcher. This is important because the client is likely to be sedated or disoriented and unable to protect themselves from falling. Personnel avoid hurried movements and rapid changes in position because hurried movements predispose the client to hypotension; moreover, secure, deliberate movement increases the security of the client. Because the client remains affected by anesthesia, the client should not move themself.

17. The nurse is planning care for a suicidal client who is hallucinating and delusional. Which intervention would the nurse incorporate into the nursing care plan to best ensure client safety?

1. Check the client’s location every 15 minutes.

2. Begin suicide precautions with 30-minute checks.

3. Initiate one-to-one suicide precautions immediately.

4. Ask the client to report suicidal thoughts immediately.

Answer: 3

Rationale:

One-to-one suicide precautions are required for the client rescued from a suicide attempt. In this situation, additional significant information is that the client is delusional and hallucinating. Both of these factors increase the risk of unpredictable behavior, compromised judgment, and the risk of suicide. Options 1, 2, and 4 do not provide the constant supervision necessary for this client.

18. The nurse is planning care for a client with a prescription for an anticoagulant agent as part of treatment for a deep vein thrombosis. Which would the nurse identify as a potential concern for this client?

1. Fatigue

2. Bruising

3. Infection

4. Dehydration

Answer: 2

Rationale:

Anticoagulant therapy predisposes the client to injury because of the agent’s inhibitory effects on the body’s normal blood clotting mechanism. Bruising, bleeding, and hemorrhage may occur in the course of activities of daily living and with other activities. Options 1, 3, and 4 are unrelated to this form of therapy.

A client reporting abdominal pain has a diagnosis of acute abdominal syndrome, but the cause has not been determined. Which prescription would the nurse question at this time?

1. Clear liquid diet only

2. Insertion of a nasogastric tube

3. Administration of an analgesic

4. Insertion of an intravenous (IV) line

Answer: 1

Rationale:

Until the cause of the acute abdominal syndrome is determined and a decision about the need for surgery is made, the nurse would question a prescription to give a clear liquid diet. The nurse can expect the client to be placed on nothing by mouth (NPO) status and to have an IV line inserted. Insertion of a nasogastric tube may be helpful to provide decompression of the stomach. Pain management with medications that do not alter level of consciousness can decrease diffuse abdominal pain and rigidity, help with localizing the pain, and lead to more prompt diagnosis and treatment.

20. A friend of the parents of a newborn with a diagnosis of congenital tracheoesophageal fistula contacts the home health nurse with an offer to help. Which is the best nursing action at this time to address the needs and rights of the

family?

1. Advise the friend to contact the family directly and offer assistance to them.

2. Request that the friend come to the client’s home during the next home health visit.

3. Report the friend’s call to the nurse manager for referral to the client’s social worker.

4. Assure the friend that there is no need for assistance since the nurse is visiting daily.

Answer: 1

Rationale:

The nurse must uphold the client’s rights and does not give any information regarding a client’s care needs to anyone who is not directly involved in the client’s care. To request that the friend come for teaching is a direct violation of the client’s right to privacy. There is no information in the question to indicate that the family desires assistance from the friend. To refer the call to the nurse manager and social worker again assumes that the friend’s assistance and involvement are desired by the family. Informing the friend that the nurse is visiting daily is providing information that is considered confidential. Option 1 directly refers the friend to the family.

21. The home health nurse is not willing to care for a client who identifies as a homosexual and is diagnosed with human immunodeficiency virus (HIV) because of religious beliefs and objections. The nurse then leaves the client’s home. Which statement accurately identifies the nurse’s rights and actions? Select all that apply.

1. The nurse has the moral right to leave the client’s home at any time.

2. The nurse has a legal right to inform the client of any barriers to providing care.

3. The nurse has a duty to protect self from client care situations that are morally repellent.

4. The nurse has a duty to provide competent care to assigned clients in a nondiscriminatory manner.

5. The nurse has the right to refuse to care for any client on religious grounds if competent care coverage is arranged.

Answer: 4, 5

Rationale:

The nurse has a duty to provide care to all clients in a nondiscriminatory manner. Personal autonomy does not apply if it interferes with the rights of the client. Refusal to provide care may be acceptable if that refusal does not put the client’s safety at risk and the refusal is primarily associated with religious objections, not personal objection, to lifestyle or medical diagnosis. There is no legal obligation to inform the client of the nurse’s personal objections to the client. The nurse also has an obligation to observe the principle of nonmaleficence (neither causing nor allowing harm to befall the client).

22. The nurse is preparing to administer prescribed heparin

sodium 5000 units subcutaneously for deep vein thrombosis

prophylaxis. Which action would the nurse take to safely

administer the medication?

1. Inject via an infusion device.

2. Inject within 1 inch of the umbilicus.

3. Massage the injection site after administration for a full

minute.

4. Change the needle on the syringe after withdrawing the

medication from the vial.

Answer: 4

Rationale:

After withdrawal of heparin from the vial, the needle is changed before injection to prevent leakage of medication along the needle tract. Heparin administered subcutaneously does not require an infusion device. The injection site is located in the abdominal fat layer. It is not injected within 2 inches of the umbilicus or into any scar tissue. The needle is withdrawn rapidly, pressure is applied, and the area is not massaged. Injection sites are rotated.

23. A client asks the nurse to act as a witness for an advance

directive. Which is the best intervention for the nurse to

implement?

1. Suggest the nurse manager as a witness.

2. Agree to sign the document as a witness.

3. Notify the physician of the client’s request.

4. Help the client find an unrelated third party.

Answer: 4

Rationale:

An advance directive addresses the withdrawal or withholding of life-sustaining interventions that can prolong life and identifies the person who will make care decisions if the client becomes incompetent. Two people unrelated to the client witness the client’s signature and then sign the document signifying that the client signed the advance directive authentically. Nurses or employees of a facility in which the client is receiving care and beneficiaries of the client should not serve as a witness because of conflict of interest concerns. There is no reason to call the physician unless the absence of the advance directive interferes with client care.

24. The nurse provides home care instructions to the parent of a child with a diagnosis of chickenpox about preventing the transmission of the virus. Which is the best statement for the nurse to include in the instructions?

1. Isolate the child until the skin vesicles have dried and crusted.

2. Ensure that the child uses a separate bathroom for elimination.

3. Bring all household members to the clinic for a varicella vaccine.

4. Request a prescription for antibiotics for all household members.

Answer: 1

Rationale:

Chickenpox is caused by the varicella-zoster virus. The communicable period is from 1 to 2 days before the onset of the rash to 6 days after the first crop of vesicles, when crusts have formed. Transmission occurs by direct contact with secretions from the vesicles or contaminated objects and via respiratory tract secretions. It is not transmitted via urine or feces. The recommended preventative schedule for receiving the varicella vaccine is at 12 to 15 months of age (first dose) and 4 to 6 years of age (second dose). It is not administered at the time of exposure to the virus. Antibiotics are not used to treat a viral infection. Rather, they are used for treating bacterial infections.

25. An older adult client has been identified as a victim of psychological abuse. Which action by the nurse is the priority nursing intervention?

1.    Obtaining mental health treatment for the client

2.   Adhering to federal mandatory abuse reporting laws

3.   Notifying the case worker to intervene in the familysituation

4.   Removing the client from any situation that presents immediate danger

Answer: 4

Rationale: The priority nursing intervention is to remove the abused victim from the abusive environment. Options 1, 2, and 3 may be appropriate interventions but are not the priority.

26. A client with a diagnosis of leukemia asks the nurse questions about preparing a living will. Which recommendation from the nurse would be the best method of preparing this document?

1.    Talk to the hospital chaplain.

2.   Obtain advice from an attorney.

3.   Consult the American Cancer Society.

4.   Discuss the request with the physician.

Answer: 4

Rationale: Living wills are legal documents known as advance directives wherein the client delineates the withdrawal or withholding of treatment when the client is incompetent. Living wills should not be confused with a will that bequeaths personal property and specifies other actions at the time of the client’s death. The client starts the process of writing a living will by discussing treatment options and other related issues with the physician. In addition, the client should discuss this issue with the family. Although options 1 and 2 may be helpful, contacting them is not the initial step because both professionals lack the medical information the client needs to make an informed decision; however, the lawyer may be involved after discussion with the physician and family. The American Cancer Society may have pertinent information on living wills; however, the information is not individualized to the client’s needs.

27. Which clinical situation would the nurse identify as an example of slander?

1.  The physician tells a client that the nurse “does not know anything.”

2. The nurse tells a client that a nasogastric tube will be inserted if client continues to refuse to eat.

3. The nurse restrains a client at bedtime because the client gets up during the night and wanders around.

4. The laboratory technician restrains the arm of a client refusing to have blood drawn so that the specimen can be obtained.

Answer: 1

Rationale: Defamation takes place when a falsehood is said (slander) or written (libel) about a person that results in injury to that person’s good name and reputation. Battery involves offensive touching or the use of force by a perpetrator without the permission of the victim. An assault occurs when a person puts another person in fear of a harmful or offensive act.

28. A client with a diagnosis of subarachnoid hemorrhage secondary to ruptured cerebral aneurysm has been placed on aneurysm precautions. To promote safety, the nurse would ensure that which intervention is provided to the client?

1.    Liquid diet

2.   Enemas as needed

3.   Help with ambulation

4.   Daily stool softeners

Answer: 4

Rationale: Aneurysm precautions include a variety of measures designed to decrease stimuli that could increase the client’s intracranial pressure. Stool softeners should be provided, but enemas need to be avoided. Straining at stool is contraindicated because it increases intracranial pressure. Other measures to decrease stimuli include instituting dim lighting and reducing environmental noise and stimuli. The remaining options are not related to minimizing stimulation.

29. The nurse is about to administer a prescribed intravenous dose of tobramycin when the client reports vertigo and ringing in the ears. Which action would the nurse take next?

1.    Check the client’s pupillary responses.

2.   Hang the dose of medication immediately.

3.   Give a dose of droperidol with the tobramycin.

4.   Hold the dose and call the physician.

Answer: 4

Rationale: Tobramycin is an antibiotic (aminoglycoside). Ringing in the ears and vertigo are two symptoms that may indicate dysfunction of the eighth cranial nerve. The nurse would hold the dose and notify the physician. Ototoxicity is an adverse effect of therapy with aminoglycosides and could result in permanent hearing loss. There is no need to check the pupillary response. Administering the dose would be an unsafe response.

30. The nurse is preparing to administer prescribed amiodarone intravenously. To provide a safe environment, the nurse would ensure that which specific safety consideration is in place for the client before administering the medication?

1.    Oxygen therapy

2.   Oxygen saturation monitor

3.   Continuous cardiac monitoring

4.   Noninvasive blood pressure cuff

Answer: 3

Rationale: Amiodarone is an antidysrhythmic used to treat lifethreatening ventricular dysrhythmias. The client needs to have continuous cardiac monitoring in place for safety, and the medication needs to be infused by intravenous pump. Although options 1, 2, and 4 may be in place for the client, they are not specific items needed for the administration of this medication.

31. During the admission process of a client being admitted for surgery, the client asks the nurse if a living will, prepared 3 years ago, remains in effect. Which response is most appropriate for the nurse to provide the client?

1.    “Yes, a living will never expires.”

2.   “You need to speak with an attorney.”

3.   “I will call someone to answer your question.”

4.   “Yes, if it accurately reflects your situation and wishes.”

Answer: 4

Rationale: The client needs to discuss the living will with the physician on a regular basis to ensure that it contains the client’s current wishes and desires based on the client’s current health status. Option 1 is incorrect. Although the client can consult an attorney if the living will must be changed, the accurate nursing response is to tell the client that a living will needs to be reviewed. Option 3 is not at all helpful to the client and is, in fact, a communication block and places the client’s question on hold.

32. The nurse reviews wound culture results and learns that an assigned client has methicillin-resistant Staphylococcus aureus (MRSA) in a wound bed. Which type of transmission based precautions would the nurse implement for this client?

1.    Enteric precautions

2.   Droplet precautions

3.   Contact precautions

4.   Airborne precautions

Answer: 3

Rationale: Contact precautions include standard precautions and require the use of barrier precautions such as gloves and goggles. Contact precautions are used for clients who have diarrhea, draining wounds, or methicillin-resistant infections. The goal of these precautions is to eliminate disease transmission resulting either from direct contact with the client or from indirect contact through inanimate objects or surfaces that the pathogen has contaminated, such as instruments, linens, dressing materials, or hands. Enteric precautions are initiated if the organism is transmitted via the gastrointestinal tract. Droplet and airborne precautions are used if the organism is transmitted via the respiratory tract.

33. The nurse is caring for a client immediately after a bronchoscopy. The client received intravenous sedation and a topical anesthetic for the procedure. Which priority nursing intervention would the nurse perform to provide a safe environment for the client at this time?

1.    Place pads on the side rails.

2.   Connect the client to a bedside ECG.

3.   Remove all food or fluids within the client’s reach.

4.   Place a water-seal chest drainage set at the bedside.

Answer: 3

Rationale: After this procedure, the client remains on nothing by mouth (NPO) status until the cough, gag, and swallow reflexes have returned, which is usually in 1 to 2 hours. Once the client can swallow and the gag reflex has returned, oral intake may begin with ice chips and small sips of water. No information in the question suggests that the client is at risk for a seizure. Even though the client is monitored for signs of any distress, seizures would not be anticipated. No data are given to support that the client is at increased risk for cardiac dysrhythmias. A pneumothorax is a possible complication of this procedure, and the nurse needs to monitor the client for signs of distress. However, a water-seal chest drainage set would not be placed routinely at the bedside.

A client with a history of silicosis is admitted, diagnosed

with respiratory distress and impending respiratory failure.

The nurse would plan to have which supplies/equipment

readily available at the client’s bedside to ensure a safe

environment?

1. Code cart

2. Intubation tray

3. Thoracentesis tray

4. Chest tube and drainage system

Answer: 2

Rationale: Respiratory failure occurs when insufficient oxygen is transported to the blood or inadequate carbon dioxide is removed from the lungs and the client’s compensatory mechanisms fail. The client with impending respiratory failure may need intubation and mechanical ventilation. The nurse ensures that an intubation tray is readily available. The other items are not needed at the client’s bedside. A code cart is used for resuscitation. A thoracentesis tray contains the necessary items for performing a thoracentesis. A chest tube drainage system is used to treat a pneumothorax.

35. The nurse is preparing to administer a first dose of prescribed pentamidine isethionate intravenously to a client diagnosed with pneumonia. Before administering the dose, which safety measure would the nurse plan for this client?

1.    Assign to a private room.

2.   Establish a supine position.

3.   Place on respiratory precautions.

4.   Assist to a semi-Fowler’s position.

Answer: 2

Rationale: Pentamidine isethionate is an anti-infective medication and can cause severe and sudden hypotension, even with administration of a single dose. The client needs to be lying down during administration of this medication. The blood pressure is monitored frequently during administration. Assigning to a private room, instituting respiratory precautions, or assisting to a semiFowler’s position are all unnecessary interventions.

 36. The nurse is administering a dose of prescribed intravenous hydralazine to a client. To provide a safe environment, the nurse would ensure that which safety measure is in place before injecting the medication?

1.    Central line

2.   Thermometer

3.   Indwelling urinary catheter

4.   Blood pressure cuff

Answer: 4

Rationale: Hydralazine is an antihypertensive medication used in the management of moderate to severe hypertension. The blood pressure and pulse need to be monitored frequently after administration, so a blood pressure cuff is the item to have in place. Although intravenous access is needed, a central line is unnecessary. The other options are also unnecessary and are unrelated to the administration of this medication.

37. A hospitalized client is found lying on the floor next to the bed. Once the client is cared for, the nurse completes an incident report. Which written statements exemplify correct documentation on the report? (Refer to exhibit.) Select all that apply.

Answer: 2, 4, 5, 6

Rationale: An incident report is a tool used by health care facilities to document situations that have caused harm or have the potential to cause harm to clients, employees, or visitors. The nurse who identifies the situation initiates the report. The report identifies the people involved in the incident, including witnesses; describes the event; and records the date, time, location, factual findings, actions taken, and any other relevant information. The primary health care provider is notified of the incident and completes the report after examining the client. Documentation on the report needs to always be as factual as possible and needs to avoid accusations. Because the client was found lying on the floor, it is unknown whether the client actually fell out of bed. Additionally, the nurse does not know that the client climbed over the side rails when the nurse was out of the room.

38. A home care nurse is visiting an older client recovering from stroke affecting the left side. The client lives alone but receives regular assistance from their two adult children, who both live within 10 miles. To assess for risk factors related to safety, which actions would the nurse take? Select all that apply.

 1. Assess the client’s visual acuity.

 2. Observe the client’s gait and posture.

 3. Evaluate the client’s muscle strength.

 4. Look for any hazards in the home care environment.

 5. Ask a family member to move in with the client until recovery is complete.

 6. Request that the client transfer to an assisted living environment for at least 1 month.

Answer: 1, 2, 3, 4

Rationale: To conduct a thorough client assessment, the nurse assesses for possible risk factors related to safety. The assessment needs to include visual acuity, gait and posture, and muscle strength because alterations in these areas place the client at risk for falls and injury. The nurse needs to also assess the home environment, looking for any hazards or obstacles that would affect safety. Asking a family member to move in with the client until recovery is complete and requesting that the client transfer to an assisted living environment for at least 1 month are not assessment activities. Additionally, nothing in the question indicates that these actions are necessary; therefore, these options are unrealistic and unreasonable.

39. Which medical asepsis actions would the nurse implement to reduce and prevent the spread of microorganisms? Select all that apply.

 1. Practicing hand hygiene

 2. Reapplying a sterile dressing

 3. Sterilizing contaminated items

 4. Applying a sterile gown and gloves

 5. Routinely cleaning the hospital environment

 6. Wearing clean gloves to prevent direct contact with blood or body fluids

Answer: 1, 5, 6

Rationale: Medical asepsis, or clean technique, includes procedures to reduce and prevent the spread of microorganisms. Practicing hand hygiene, routinely cleaning the hospital environment, and wearing clean gloves to prevent direct contact with blood or body fluids are examples of medical asepsis. Surgical asepsis involves the use of sterile technique. Examples of surgical asepsis include reapplying a sterile dressing, sterilization of contaminated items, and applying a sterile gown and gloves.

40. The nurse is caring for a hospitalized client who is having a prescribed dosage of clonazepam adjusted. Because of the adjustment in the medication administration, which priority safety activity would the nurse plan to implement?

1.    Weigh the client daily.

2.   Assess for ecchymoses.

3.   Institute seizure precautions.

4. Monitor blood glucose levels.

Answer: 3

Rationale: Clonazepam is a benzodiazepine that is used as an anticonvulsant. During initial therapy and periods of dosage adjustment, the nurse needs to initiate seizure precautions for the client. This medication does not cause weight gain or loss, bleeding or bruising, or fluctuations in blood glucose levels.

41. The nurse is planning to obtain an arterial blood gas (ABG) from the radial artery of a client with a diagnosis of chronic obstructive pulmonary disease (COPD). To prevent bleeding after the procedure, which priority activity would the nurse plan time for after the arterial blood is drawn?

1.  Holding a warm compress over the puncture site for 5 minutes

2. Encouraging the client to open and close the hand rapidly for 2 minutes

3. Applying pressure to the puncture site by applying a 2 ×2 gauze for 5 minutes

4. Having the client keep the radial pulse puncture site in a dependent position for 5 minutes

Answer: 3

Rationale: Applying pressure over the puncture site for 5 to 10 minutes reduces the risk of hematoma formation and damage to the artery. A cold compress would aid in limiting blood flow; a warm compress would increase blood flow. Keeping the extremity still and out of a dependent position will aid in the formation of a clot at the puncture site.

42. The nurse is admitting a client with an arteriovenous (AV) fistula in the right arm for hemodialysis. Which strategy would the nurse plan to implement to best prevent injury to the AV fistula site?

1.   Applying an allergy bracelet to the right arm

2. Placing an alert bracelet per agency procedure on the client’s right arm

3. Putting a large note about the access site on the front of the medical record

4. Telling the client to inform all caregivers who enter the room about the presence of the access site

Answer: 2

Rationale: No venipunctures or blood pressure measurements are done in the extremity with a hemodialysis access device. This is commonly communicated to all caregivers by placing an alert bracelet on the arm that needs to be protected. This alert bracelet prompts health care providers to investigate the need for the bracelet. The use of an alert wrist bracelet (rather than a visibly posted note or sign) also maintains client confidentiality. Agency procedure is always followed. An allergy bracelet is placed on the client with an allergy. Placing a note on the front of the medical record does not ensure that everyone caring for the client is aware of the access device. The client should not be responsible for informing the caregivers.

43. Regular insulin by continuous intravenous (IV) infusion is prescribed for a client diagnosed with diabetes mellitus, and the nurse checks the client’s most recent blood glucose result.

How would the nurse administer this medication safely?

Test and Results Reference Range Blood glucose 700 mg/dL (40 mmol/L) 70–99 mg/dL (3.9–5.5 mmol/L)

1.    Mix the solution in 5% dextrose.

2.   Change the solution every 6 hours.

3.   Infuse the medication via an electronic infusion pump.

4.   Titrate the infusion according to the client’s urine glucoselevels.

Answer: 3

Rationale: Insulin is administered via an infusion pump to prevent inadvertent overdose and subsequent hypoglycemia. Dextrose is added to the IV infusion once the serum glucose level reaches 250 mg/dL (14.2 mmol/L) to prevent the occurrence of hypoglycemia. Administering dextrose to a client with a serum glucose level of 700 mg/dL (40 mmol/L) would counteract the beneficial effects of insulin in reducing the glucose level. There is no reason to change the solution every 6 hours. Glycosuria is not a reliable indicator of the actual serum glucose levels because many factors affect the renal threshold for glucose loss in the urine.

44. Which action demonstrates a situational leadership style by the nurse manager?

1.  The nurse manager delegates tasks to each team member.

2. The nurse manager allows team members to work without supervision.

3. The nurse manager invites team members to provide input about a unit problem.

4. The nurse manager quickly delegates activities to team members during an emergency situation.

Answer: 4

Rationale: The situational leadership style uses a style depending on the situation and events. This type of leadership style is used in emergency situations when the nurse manager needs to quickly delegate activities to achieve a successful outcome for the situation. A laissez-faire leader abdicates leadership and responsibilities, allowing staff to work without assistance, direction, or supervision. Participative leadership demonstrates an “inbetween” style, neither authoritarian nor democratic. In participative leadership, the manager presents an analysis of problems and proposals for actions to team members, inviting critique and comments. The participative leader then analyzes the comments and makes the final decision. The autocratic style of leadership is task oriented and directive.

45. The clinic nurse wants to develop a teaching program for clients with a diagnosis of diabetes mellitus. Which strategy would the nurse initiate first in order to best meet the clients’ needs?

1.   Assess the clients’ functional abilities.

2. Ensure that insurance will pay for participation in theprogram.

3. Discuss the focus of the program with the multidisciplinary team.

4. Include everyone who comes into the clinic in the teaching sessions.

Answer: 1

Rationale: Nurse-managed clinics focus on individualized disease prevention and health promotion and maintenance. Therefore, the nurse must first assess the clients and their needs to effectively plan the program. Options 2, 3, and 4 do not address the clients’ needs related to the diagnosis.

46. The nurse notes that a postoperative client has not been obtaining relief from pain with the prescribed opioid analgesics when a particular licensed coworker is assigned to the client. Which action is most appropriate for the nurse to implement initially?

1.  Reassign the coworker to the care of clients not receiving opioids.

2. Notify the physician that the client needs an increase inopioid dosage.

3. Review the client’s medication administration record immediately, and discuss the observations with the nursing supervisor.

4. Confront the coworker with the information about theclient having pain control problems, and ask if the coworker is using the opioids personally.

Answer: 3

Rationale: In this situation, the nurse has noted an unusual occurrence, but before deciding what action to take next, the nurse needs more data than just suspicion. This can be obtained by reviewing the client’s record. State and federal labor and opioid regulations, as well as institutional policies and procedures, must be followed. It is, therefore, most appropriate that the nurse discuss the situation with the nursing supervisor before taking further action. To reassign the coworker to clients not receiving opioids ignores the issue. The client does not need an increase in opioids. A confrontation is not the most advisable action because it could result in an argumentative situation.

47. The medication nurse is supervising a newly hired licensed practical nurse (LPN) during the administration of prescribed oral pyridostigmine bromide to a client with a diagnosis of myasthenia gravis. Which observation by the medication nurse indicates safe practice by the LPN?

1.    Asking the client to take sips of water

2.   Asking the client to lie down on the right side

3.   Asking the client to look up at the ceiling for 30 seconds

4.   Instructing the client to void before taking the medication

Answer: 1

Rationale: Myasthenia gravis can affect the client’s ability to swallow. The primary assessment is to determine the client’s ability to handle oral medications or any oral substance. Options 2 and 3 are not appropriate. Option 2 could result in aspiration, and option 3 has no useful purpose. There is no specific reason for the client to void before taking this medication.

48. The nurse does not intervene when a client becomes hypotensive after surgery. As a result, the client requires emergency surgery to stop postoperative bleeding later that night. The nurse could potentially face which types of prosecution for failing to act? Select all that apply.

 1. Felony

 2. Tort law

 3. Malpractice

 4. Statutory law

 5. Misdemeanor

Answer: 2, 3

Rationale: Tort law deals with wrongful acts intentionally or unintentionally committed against a person or the person’s property. The nurse commits a tort offense by failing to act when the client became hypotensive. Malpractice occurs when a duty to the client is established and the nurse neglects to act responsibly. Options 1 and 5 are offenses under criminal law. Option 4 describes laws enacted by state, federal, or local governments.

49. The nurse gives medical information regarding the client’s condition to a person who is assumed to be a family member. Later the nurse discovers that this person is not a family member and realizes that this violated which legal concepts of the nurse–client relationship? Select all that apply.

 1. Duty to provide care

 2. Client’s right to privacy

 3. Client’s right of autonomy

 4. Client’s right to confidentiality

 5. Duty to comply with nursing standards

Answer: 2, 4

Rationale: Discussing a client’s condition without client permission violates a client’s rights to privacy and confidentiality and places the nurse in legal jeopardy. This action by the nurse is both an invasion of privacy and affects the confidentiality issue with client rights. Options 1, 3, and 5 do not represent violation of the situation presented.

50. In which situation is the nurse manager using an autocratic leadership style?

1.  The nurse manager provides the solution for a unit problem.

2. The nurse manager allows the staff to solve their own unit problem.

3. The nurse manager proposes several alternatives and has the unit staff vote on the best proposal.

4. The nurse manager arranges for a staff meeting where all unit employees can share proposals to solve a problem.

Answer: 1

Rationale: The autocratic style of leadership is task oriented and directive. The leader uses their power and position in an authoritarian manner to set and implement organizational goals or solutions. Decisions are made without input from the staff. The situational leadership style uses a style depending on the situation and events. Democratic styles best empower staff toward excellence because this style of leadership allows nurses to provide input regarding the decision-making process and an opportunity to grow professionally. Participatory leadership encourages input from the staff.

51. The nurse performing an admission assessment notes that a client diagnosed with gastroesophageal reflux disease (GERD) has been prescribed metoclopramide for a prolonged period. The nurse would immediately call the primary health care provider if which signs/symptoms were then noted by the nurse?

1.    Dry mouth

2.   Anxiety or irritability

3.   Excessive drowsiness

4.   Uncontrolled rhythmic movements of the face or limbs

Answer: 4

Rationale: If the client experiences tardive dyskinesia (rhythmic movements of the face or limbs), the nurse needs to call the primary health care provider because these adverse effects may be irreversible. The medication would be discontinued, and no further doses would be given by the nurse. Anxiety, irritability, and dry mouth are mild side effects that do not harm the client.

52. Which clinical situation would justifiably be viewed as an assault?

1.  The nurse threatens to apply restraints to a client who is exhibiting aggressive behavior.

2. The client requests a medical discharge, but the nurse physically forces the client to stay.

3. The charge nurse sends an email to a staff member that includes a poor performance evaluation about another person.

4. The nurse overhears the physician making derogatory remarks to the client about the nurse’s level of competency.

Answer: 1

Rationale: An assault occurs when a person puts another person in fear of a harmful or offensive act.

Battery involves offensive touching or the use of force by a perpetrator without the permission of the victim.

Defamation takes place when a falsehood is said (slander) or written (libel) about a person that results in injury to that person’s good name and reputation.

Priority Nursing Tip: False imprisonment occurs when a client is not allowed to leave a health care facility when there is no legal justification to detain the client.

53. After finding a client sitting on the floor, the nurse ensures the client’s safety, completes an incident report, and notifies the physician of the incident. Which action would the nurse implement next?

1.   Staple the incident report in the client’s medical record.

2. Document the client events and follow-up nursing actions.

3. Provide a copy of the incident report to the physician and family.

4. Document that a copy of the report was sent to risk management.

Answer: 2

Rationale: The nurse documents the incident completely and objectively in the client’s record to communicate client data to the health care team. The incident report is a confidential, privileged, and internal document used to improve client safety and quality of care and, therefore, would not be copied, stapled, or placed in the chart.

Furthermore, the nurse avoids referring to the incident report in the client’s record, such as recording that the incident report has been sent to another department. These actions are necessary because any mention of an incident report in the medical record allows the plaintiff’s attorney access to the document through discovery.

 54. A client had a colon resection made necessary by a cancer diagnosis. A nasogastric tube was in place when a regular diet was brought to the client’s room. The client did not want to eat solid food and asked that the physician be called. The nurse insisted that the solid food was the correct diet. The client ate and subsequently required additional surgery as a result of complications. The determination of negligence is based on which premise in this situation?

1.    The nurse’s persistence

2.   A duty existed that was breached

3.   Not notifying the physician

4.   The dietary department sending the wrong food

Answer: 2

Rationale: For negligence to be proved, there must be a duty and then a breach of duty; the breach of duty must cause the injury, and damages or injury must be experienced. Options 1, 3, and 4 do not fall under the criteria for negligence. Option 2 is the only option that fits the criteria of negligence.

55. The nurse is caring for a child with a diagnosis of intussusception. During care, the child passes a formed brown stool. Which action is most appropriate for the nurse to take at this time?

1.    Note the child’s physical symptoms.

2.   Prepare the child for hydrostatic reduction.

3. Prepare the child and parents for the possibility ofsurgery.

4. Report the passage of a normal brown stool to the pediatrician.

Answer: 4

Rationale: Intussusception is the telescoping of one portion of the bowel into another portion. Passage of a normally formed brown stool usually indicates that the intussusception has reduced itself. This is immediately reported to the pediatrician, who may choose to alter the diagnostic or therapeutic plan of care. Although the nurse would note the child’s physical symptoms, based on the data in the question, option 4 is the appropriate action. Hydrostatic reduction and surgery may not be necessary.

56. The nurse caring for a client with a diagnosis of end-stage kidney failure is asked by a family member about advance directives. Which statements would the nurse plan to include when discussing advance directives with the client’s family member? Select all that apply.

 1. A health care proxy can write a living will for a client if the client becomes incompetent and unable to do so.

 2. Two witnesses, either a relative or physician, are needed when the client signs a living will.

 3. The determination of decisional capacity of a client is usually made by the physician and family.

 4. Living wills are written documents that direct treatment in accordance with a client’s wishes in the event of a terminal illness or condition.

 5. Under the Patient Self-Determination Act (PSDA), it must be documented in the client’s record whether the client has signed an advance directive.

 6. For advance directives to be enforceable, the client must be legally incompetent or lack decisional capacity to make decisions regarding health care treatment.

Answer: 3, 4, 5, 6

Rationale: The two basic advance directives are living wills and durable powers of attorney for health care. Under the PSDA, it must be documented in the client’s record whether the client has signed an advance directive. For living wills or durable powers of attorney for health care to be enforceable, the client must be legally incompetent or lack decisional capacity to make decisions regarding health care treatment. The determination of decisional capacity is usually made by the physician and family, whereas the determination of legal competency is made by a judge. Living wills are written documents that direct treatment in accordance with a client’s wishes in the event of a terminal illness or condition. Generally, two witnesses, neither of whom can be a relative or physician, are needed when the client signs the document. A durable power of attorney for health care designates an agent, surrogate, or proxy to make health care decisions if and when the client is no longer able to make decisions on their own behalf; however, a health care proxy cannot legally write a living will for a client.

57. A client asks the nurse how to become an organ donor. Which information would the nurse include in the discussion?

1.    The client can donate by written consent.

2.   A family member must witness the consent.

3.   The donor must be older than 21 years of age.

4.   A family member must be present when a client consentsto organ donation.

Answer: 1

Rationale: The client has the right to donate their own organs for transplantation, and any person who is 18 years of age or older may become an organ donor by written consent without the permission or presence of the family. In the absence of suitable documentation, a family member or legal guardian can authorize donation of the decedent’s organs.

58. A registered nurse (RN) is providing postmortem care for a deceased client whose eyes will be donated. Which measure would the nurse anticipate will most likely be prescribed that will provide appropriate care of the client’s body?

1.    Closing the eyes with paper tape

2.   Maintaining the client in a supine position

3.   Placing gauze pads wet with saline covered by a small icepack on the eyes

4.   Placing the client in a lateral recumbent position,rotating right and left sides

Answer: 3

Rationale: When a corneal donor dies, the eyes are closed and usually the primary health care provider prescribes placing gauze pads wet with saline over them with a small ice pack. Within 2 to 4 hours the eyes are enucleated, and the corneas are usually transplanted within 24 to 48 hours. The head of the bed needs to be elevated. With the head of the bed elevated, the eyes will likely remain closed.

59. A clinical nurse manager conducts an educational session for the staff nurses about case management. Which premise regarding case management, if stated by one of the staff nurses, would necessitate a need for further teaching?

1.  Manages client care by managing the client care environment

2. Maximizes hospital revenues while providing for optimal client care

3. Represents a primary health prevention focus managed by a single case manager

4. Is designed to promote appropriate use of hospital personnel and material resources

Answer: 3

Rationale: Case management represents an interdisciplinary health care delivery system to promote appropriate use of hospital personnel and material resources to maximize hospital revenues while providing for optimal client care. It manages client care by managing the client care environment and includes assessment and development of a plan of care, coordination of all services, referral, and follow-up.

60. A registered nurse is delegating activities to the nursing staff. Which activities can be safely assigned to the unlicensed assistive personnel (UAP)? Select all that apply.

 1. Collecting a urine specimen from a client

 2. Obtaining frequent oral temperatures on a client

 3. Assessing a client who returned from the recovery room 6 hours ago

 4. Assisting a post–cardiac catheterization client who needs to lie flat to eat lunch

 5. Accompanying a client being discharged to meet spouse at the hospital exit door

Answer: 1, 2, 5

Rationale: Work that is delegated to others must be consistent with the individual’s level of expertise and licensure, if any. Options 1, 2, and 5 do not include situations that indicate that these activities carry foreseeable risk. The least appropriate activities for the UAP would be assessing a client and assisting the post–cardiac catheterization client. The UAP is not trained or educated to safely and accurately perform an assessment on a client. Because the post– cardiac catheterization client needs to eat while lying flat, the client is at risk for aspiration.

Priority Nursing Tip: Generally, noninvasive interventions, such as skin care, range-of-motion exercises, ambulation, grooming, and hygiene measures, can be assigned to UAP.

61. The nurse manager is reviewing the critical paths of the clients on the nursing unit. The nurse manager collaborates with each nurse assigned to the clients and performs a variance analysis. Which finding would indicate the need for further assessment and analysis?

1.   A client is performing their own colostomy care.

2. A 1-day postoperative client has a temperature of 98.8° F(37.1° C).

3. A 2-day post abdominal hysterectomy client has drainage noted from the incision.

4. A client newly diagnosed with diabetes mellitus is preparing their own insulin for injection.

Answer: 3

Rationale: Variances are actual deviations or detours from the critical paths. Option 3 is the only option that identifies the need for further action. Variances can be either positive or negative or avoidable or unavoidable and can be caused by a variety of things. Positive variance occurs when the client achieves maximum benefit and is discharged earlier than anticipated. Negative variance occurs when untoward events prevent a timely discharge. Variance analysis occurs continually to anticipate and recognize negative variance early so that appropriate action can be taken.

Priority Nursing Tip: Variation analysis is a continuous process that the case manager and other caregivers conduct by comparing the specific client outcomes with expected outcomes.

62. Which client would the nurse safely assign to the unlicensed assistive personnel (UAP)?

1.    A client requiring dressing changes

2.   A client requiring frequent ambulation

3.  A client on a bowel management program requiring rectal suppositories

4.A client newly admitted with nausea, vomiting, and moderate neck pain

Answer: 2

Rationale: Assignment of tasks to the UAP needs to be made based on job description, level of clinical competence, and state law. The client described in option 2 has needs, frequent ambulation, that can be met by the UAP. Options 1, 3, and 4 involve care that requires the skill of a licensed nurse.

63. A client with a diagnosis of schizophrenia and psychosis is pacing, agitated, and presenting with aggressive gestures. The client’s speech pattern is rapid, and the client’s affect is belligerent. Which priority nursing intervention based on these objective data would the nurse implement?

1.   Provide safety for the client and other clients on the unit.

2. Bring the client to a less stimulated area to regain control.

3. Provide the clients on the unit with a sense of comfort and safety.

4. Assist the staff in caring for the client in a controlled environment.

Answer: 1

Rationale: If a client is exhibiting signs that indicate loss of control, the nurse’s immediate priority is to ensure safety for all clients. Option 1 is the only option that addresses the client’s and other clients’ safety needs. Option 2 addresses the client’s needs. Option 3 addresses other clients’ needs. Option 4 is not client centered.

64. The nurse manager is developing an educational session for nursing staff on the components of informed consent and the information to be shared with a client to obtain informed consent. Which information would the nurse manager include in the session? Select all that apply.

 1. The client needs to be informed of the prognosis if the test, procedure, or treatment is refused.

 2. The client cannot refuse a test, procedure, or treatment once the test, procedure, or treatment is started.

 3. The name(s) of the persons performing the test or procedure or providing treatment needs to be documented on the informed consent form.

 4. A description of the complications and risks of the test, procedure, or treatment, as well as anticipated pain or discomfort, needs to be explained to the client.

 5. The nurse is responsible for obtaining the client’s signature on an informed consent form even if the client has questions about the test, procedure, or treatment to be performed.

Answer: 1, 3, 4

Rationale: Informed consent is a person’s agreement to allow something to happen based on full disclosure of risks, benefits, alternatives, and consequences of refusal. The physician is responsible for conveying information and obtaining the informed consent. The nurse may be the person who actually ensures that the client signs the informed consent form; however, the nurse does this only after the physician has instructed the client and it has been determined that the client has understood the information. The following factors are required for informed consent: a brief, complete explanation of the test, procedure, or treatment; names and qualifications of persons performing and assisting in the test, procedure, or treatment; a description of the complications and risks, as well as anticipated pain or discomfort; an explanation of alternative therapies to the proposed test, procedure, or treatment, as well as the risks of doing nothing; and the client’s right to refuse the test, procedure, or treatment even after it has been started.

65. Wrist restraints have been prescribed for a client who is continuously pulling at the gastrostomy tube placed as part of the treatment for esophageal cancer. The nurse develops a care plan and would determine that which findings would be negative outcomes related to the use of restraints? Select all that apply.

 1. The client is increasingly agitated.

 2. The client’s left hand is pale and cold.

 3. The client’s skin under the restraint is red.

 4. The client verbalizes the reason for the restraints.

 5. The client is unable to reach the gastrostomy tube with their hands.

 6. The client demonstrates behavior that includes biting the attending staff.

Answer: 1, 2, 3, 6

Rationale: A physical restraint is a mechanical or physical device used to immobilize a client or extremity. The restraint restricts freedom of movement. Negative outcomes in the use of restraints include signs of impaired skin integrity such as redness or skin breakdown; altered neurovascular status such as cyanosis, pallor, or coldness of the skin or complaints of tingling, numbness, or pain; increased confusion, disorientation, or agitation; or injuring staff. Client verbalization of the reason for the restraints and the client’s inability to reach the gastrostomy tube with their hands are expected outcomes.

Priority Nursing Tip:

If the restraints are placed on a client during a period in which the behavior cannot be controlled or in an emergency situation, a physician’s prescription for the restraints must be obtained in a timely manner. Additionally, the continued need for restraints needs to be assessed regularly according to agency policy.

66. The nurse is discussing accident prevention with the family of a client who is being discharged from the hospital after having hip surgery. Which physical factors place the client at risk for injury in the home? Select all that apply.

 1. A night-light in the bathroom

 2. Elevated toilet seat with armrests

 3. Cooking equipment such as a stove

 4. Smoke and carbon monoxide detectors

 5. Objects such as a doormat and scatter rugs

 6. A low thermostat setting on the water heater

Answer: 3, 5

Rationale: Physical hazards in the environment place the client at risk for accidental injury and death. Injuries in the home frequently result from tripping over or coming into contact with common household objects such as a doormat, small rugs on the floor or stairs, or clutter around the house. Adequate lighting such as night-lights in dark hallways and bathrooms reduces the physical hazard by illuminating areas in which a person moves about. An elevated toilet seat with armrests and nonslip strips on the floor in front of the toilet are useful in reducing falls in the bathroom. Cooking equipment and appliances, particularly stoves, can be a main source for in-home fires and fire injuries. Smoke and carbon monoxide detectors need to be placed throughout the home to alert members of the household of a potential danger. A low thermostat setting on the water heater reduces the risk of burns during water use such as bathing or showering.

Priority Nursing Tip: A client with peripheral neuropathy (decreased sensation in the extremities), such as the client with diabetes mellitus, is at a high risk for injury such as falls, cuts, or burns because of the inability to sense objects or high temperatures.

67. The nurse is caring for a client receiving total parenteral nutrition (TPN). Which action is most appropriate for the nurse to implement in order to decrease the risk of infection?

1.    Assess vital signs at 4-hour intervals.

2.   Administer prophylactic antimicrobial agents.

3.   Check the solution’s label against the prescription.

4.   Use aseptic technique in handling the TPN solution.

Answer: 4

Rationale: Clients receiving TPN are at high risk for developing infection because the concentrated glucose solutions are an excellent medium for bacterial growth. The nurse reduces the client’s risk of infection by using aseptic technique when handling all equipment and solutions related to the TPN infusion (option 4). Option 1 is a reasonable intervention for early detection of infection but does not prevent infection. Prophylactic antibiotics are not indicated for TPN infusions and can contribute to the development of secondary infections. The nurse implements option 3 to ensure that the client receives the correct infusion, but it is not relevant to decreasing the risk of infection.

68. To ensure that the client diagnosed with cancer has adequate and safe pain control, which plan would the nurse implement?

1.Rely primarily on prescription and over-the-counter medications to relieve pain.

2. Keep a baseline level of pain so that the client does not become sedated or addicted.

3. Try multiple medication modalities for pain relief to getthe maximum pain relief effect.

4. Start with low doses of medication and gradually increase to a safe dose that relieves pain.

Answer: 4

Rationale: Safe pain control includes starting with low doses and working up to a dose of medication that relieves the pain. Option 1 does not take into account other nursing interventions that may relieve pain, such as massage, therapeutic touch, or music.

Maintaining a baseline level of pain to avoid sedation or addiction is not appropriate practice unless the client requests this, and this information has not been provided in the case situation.

Interventions using multiple medication modalities can be unsafe and ineffective.

.

69. To ensure that the client self-administers medications safely in the home, which action would the nurse implement?

1.  Perform a pill count of each prescription bottle at everyhome visit.

2. Provide information on the purpose of all the prescribed medications.

3. Instruct the client to double up on a medication when adose is missed.

4. Ask the client to explain and demonstrate self administration procedures.

Answer: 4

Rationale: To ensure safe administration of medication, the nurse asks the client to explain and demonstrate correct self administration of medication procedures because demonstrating the proper procedure for the client does not ensure that the client can safely perform any procedure. Usually it is not acceptable to double up on missed medication, and conducting a pill count on each visit is unrealistic and disrespectful.

70. A client remains in diagnosed atrial fibrillation with rapid ventricular response despite prescribed pharmacologic intervention. Synchronous cardioversion is scheduled to convert the rapid rhythm. Which action would the nurse plan to take to ensure safety and prevent complications of this procedure?

1.    Cardiovert the client at 360 joules.

2.   Sedate the client before cardioversion.

3.   Ensure that emergency equipment is available.

4.   Check that the defibrillator is set on the synchronous mode.

Answer: 4

Rationale: Cardioversion is similar to defibrillation with two major exceptions: the countershock is synchronized to occur during ventricular depolarization (QRS complex), and less energy is used for the countershock. The rationale for delivering the shock during the QRS complex is to prevent the shock from being delivered during repolarization (T wave), often termed the vulnerable period. If the shock is delivered during this period, the resulting complication is ventricular fibrillation. It is crucial that the defibrillator is set on the “synchronous” mode for a successful cardioversion. Cardioversion usually begins with 50 to 100 joules. Options 2 and 3 will not prevent complications.

Priority Nursing Tip: Indicators of a successful response to cardioversion include conversion of the dysrhythmia to sinus rhythm, strong peripheral pulses, an adequate blood pressure, and an adequate urine output.

71. A client with a diagnosis of thrombophlebitis is being treated with prescribed heparin sodium therapy. In planning a safe environment, the nurse would ensure that which medication is available if the client develops a significant bleeding problem?

1.    Reteplase

2.   Phytonadione

3.   Protamine sulfate

4.   Fresh frozen plasma

Answer: 3

Rationale: Protamine sulfate is the antidote for heparin sodium.

Fresh frozen plasma may be used for bleeding related to warfarin therapy. Reteplase is a thrombolytic agent used to dissolve blood clots. Phytonadione is the antidote for warfarin.

Priority Nursing Tip: To maintain a therapeutic level of anticoagulation when a client is receiving a continuous infusion of heparin sodium, the activated partial thromboplastin time (aPTT) needs to be 1.5 to 2.5 times the normal value.

72. The nurse is teaching a client with a diagnosis of cardiomyopathy about home care safety measures. Which instruction is most important for the nurse to include?

1.    Reporting pain

2.   Appropriate vasodilator administration

3.   Avoiding over-the-counter medications

4.   Moving slowly from a sitting to a standing position

Answer: 4

Rationale: Orthostatic changes can occur in the client with cardiomyopathy as a result of venous return obstruction. Sudden changes in blood pressure may lead to falls. Reporting pain, while important, is not directly related to the issue of safety. Vasodilators are not normally prescribed for the client with cardiomyopathy. Option 3, although important, is not directly related to the issue of safety.

73. The nurse instructs a client with a diagnosis of atrial fibrillation who has been prescribed warfarin to use an electric razor for shaving. Which premise best supports the rationale for this instruction?

1.    Cuts need to be avoided.

2.   Any cut may cause infection.

3.   Electric razors can be disinfected.

4.   All straight razors contain bacteria.

Answer: 1

Rationale: Clients with atrial fibrillation are placed on anticoagulants to prevent thrombus formation and possible stroke. Therefore, measures to prevent bleeding need to be taught to the client. The importance of use of an electric razor is to prevent cuts and possible bleeding. Not all cuts cause infection. Electric razors can be cleaned but usually cannot be disinfected. Not all straight razors contain bacteria. Additionally, options 2, 3, and 4 are all unrelated to the subject of bleeding; rather, they relate to infection.

74. A cardiac catheterization, using the femoral artery approach, is performed to assess the degree of coronary artery thrombosis in a client. Which priority safety actions would the nurse implement in the postprocedure period? Select all that apply.

 1. Restricting visitors

 2. Checking the client’s groin for bleeding

 3. Encouraging the client to increase fluid intake

 4. Placing the client’s bed in the high-Fowler’s position

 5. Instructing the client to move the toes when checking circulation, motion, and sensation

Answer: 2, 3, 5

Rationale: Immediately after a cardiac catheterization with the femoral artery approach, the client should not flex or hyperextend the affected leg to avoid blood vessel occlusion or hemorrhage. The groin is checked for bleeding, and, if any occurs, the nurse immediately places pressure on the site and asks another staff member to contact the cardiologist. Fluids are encouraged to assist in removing the contrast medium from the body. Asking the client to move the toes is done to assess motion, which could be impaired if a hematoma or thrombus was developing. There is no need to restrict visitors. Placing the client in the high-Fowler’s position (flexion) increases the risk of occlusion or hemorrhage.

75.The nurse is reviewing general injury prevention guidelines with the pediatric department staff in the hospital. Which interventions aimed at promoting safety specifically for infants and toddlers would the nurse include in this review?

Select all that apply.

 1. Ensure that crib sides are up.

 2. Place large, soft pillows in the crib.

 3. Use large, soft toys without small parts.

 4. Attach a pacifier to a stretchable piece of ribbon and pin to the infant’s clothing.

 5. Allow a toddler who is toilet training privacy in the bathroom to promote autonomy.

 6. Ensure that an infant or toddler is never left unattended while lying on a changing table.

Answer: 1, 3, 6

Rationale: To promote safety for infants and toddlers, crib sides are never left down because the child could roll and fall. Large, soft toys without small parts need to be used because small parts can become dislodged and choking and aspiration may occur. For this same reason, an infant or toddler is never left unattended while lying on a changing table. Pillows, stuffed toys, comforters, or other objects are not placed in the crib because the child can become entwined in these items and suffocate. Pacifiers would not be attached to string or ribbon because of the risk associated with choking. The child is never left alone in the bathroom, in the tub, or near any other water source because of the risk of drowning.

76. Which scenarios demonstrate a participative style of leadership? Select all that apply.

 1. The nurse manager presents a problem to the staff and tells the staff to solve the problem.

 2. The nurse manager arranges unit meetings for all shifts to deal with an identified problem.

 3. The nurse manager assesses a problem and informs the staff of the solution to be implemented.

 4. The nurse manager proposes several methods of dealing with a problem and invites team input.

 5. The nurse manager proposes several solutions to a problem and has the unit staff vote on the best option.

 6. The nurse manager considers staff input related to a problem but makes the final decision on implementation of the solution.

Answer: 2, 4, 6

Rationale: Participative leadership demonstrates an “inbetween” style, neither authoritarian nor democratic. In participative leadership, the manager presents an analysis of problems and proposals for actions to team members, inviting critique and comments. The participative leader then analyzes the comments and makes the final decision. The autocratic style of leadership is task oriented and directive. A laissez-faire leader abdicates leadership and responsibilities, allowing staff to work without assistance, direction, or supervision. The democratic style of leadership involves a majority rule.

77. A physician prescribes 1000 mL of 0.45% normal saline solution to run over 8 hours. The drop factor is 15 drops/mL. The nurse adjusts the flow rate to how many drops per minute to safely administer this intravenous (IV) solution? Fill in the blank and round answer to the nearest whole number.

Answer: _____ gtt/min

Answer: 31

Rationale:

The prescribed 1000 mL is to be infused over 8

hours. Follow the formula for calculating IV flow rates and multiply

1000 mL by 15 (drop factor). Then divide the result by 480 minutes

(8 hours × 60 minutes). The infusion is to run at 31.2 or 31

drops/min.

Formula:

78. A client diagnosed with terminal liver cancer asks the

home care nurse to witness the client’s signature on a living

will with the client’s attorney in attendance. Which action is

most appropriate for the nurse to implement?

1. Decline to witness the signature on the living will.

2. Sign the living will as a witness to the signature only.

3. Notify the supervisor that a living will is being witnessed.

4. Sign the living will with identifying credentials and

employment agency.

Answer: 1

Rationale: Living wills are written documents and need to be signed by the client. The client’s signature must be either witnessed by nonagency individuals or notarized; thus, the nurse would decline to sign the will to avoid a conflict of interest. There is no need to contact the supervisor or sign the living will with or without credentials because the nurse cannot sign this document as a witness. Therefore, options 2, 3, and 4 are incorrect.

79. The nurse notices old and new ecchymotic areas on an older adult client’s arms and buttocks upon admission. The client states to the nurse in confidence that “the family members frequently hit me.” Which therapeutic statement would the nurse communicate in response?

1.    “I have a legal obligation to report this type of abuse.”

2.   “Let’s get these treated, and I will maintain confidence.”

3.   “Let’s talk about ways to prevent someone from hitting you.”

4. “If this happens again, you must call the emergency department.”

Answer: 1

Rationale: The nurse would inform the client that nurses cannot maintain confidence about alleged abusive behavior and that the nurse must report situations related to abuse. The nurse avoids bargaining with the client about treatment to maintain a confidence that the nurse is legally bound to report. Options 3 and 4 delay protective action and place the client at risk for future abuse.

 80. At the scene of a train crash, the nurse triages the victims. Which clients would be coded for triage as most urgent or the first priority? Refer to chart. Select all that apply.

Answer: 2, 4, 6

Rationale: In a disaster situation, saving the greatest number of lives is the most important goal. During a disaster the nurse would triage the victims to maximize the number of survivors and sort the treatable from the untreatable victims. Prioritizing victims can be done in many ways, and many communities use a color-coding system. First priority victims (most urgent and coded red) have lifethreatening injuries and are experiencing hypoxia or near hypoxia. Examples of injuries in this category are shock, chest wounds, internal hemorrhage, head injuries producing loss of consciousness, partial- or full-thickness burns over 20% of the body surface, and chest pain. Second priority victims (urgent and coded yellow) have injuries with systemic effects but are not yet hypoxic or in shock and can withstand a 2-hour wait without immediate risk (e.g., a victim with multiple fractures). Third priority victims (coded green) have minimal injuries unaccompanied by systemic complications and can wait for more than 2 hours for treatment without risk (leg sprain). Dying or dead victims have catastrophic injuries, and the dying victims would not survive under the best of circumstances (coded black).

81. A client tells the home care nurse of a personal decision to refuse external cardiac resuscitation measures. Which is the most appropriate initial nursing action?

1.    Discuss the client’s request with the client’s family.

2.   Document the client’s request in the home care nursingcare plan.

3.   Notify the client’s physician of the client’s request.

4.   Conduct a client conference with the home care staff toshare the client’s request.

Answer: 3

Rationale: External cardiac resuscitation is a lifesaving treatment that a client may refuse. The most appropriate initial nursing action is to notify the physician because a written “do not resuscitate” (DNR) prescription from the physician is needed to ensure that the client’s wishes are followed. The DNR prescription must be reviewed or renewed on a regular basis per agency policy. Although options 1, 2, and 4 may be appropriate, remember that obtaining a written physician’s DNR prescription must be completed first.

82. The nurse prepares a client for discharge who is prescribed intermittent antibiotic infusions through a peripherally inserted central catheter (PICC) line for a foot infection. Which instruction would the nurse include in client teaching about necessary daily infusion care in the home?

1.    Keep the affected arm immobilized.

2.   Aspirate 3 mL of blood from the line daily.

3.   Maintain a continuous intravenous infusion.

4.   Check the insertion site for redness and swelling.

Answer: 4

Rationale: A PICC line is designed for long-term intravenous infusions and usually is inserted into the median cubital vein with the terminal end of the catheter in the superior vena cava. Although the risk of infection is less with a PICC line than with a central venous catheter, it is possible for phlebitis or infection to develop.

Clients must inspect the insertion site and affected arm daily and report any discharge, redness, swelling, or pain to the nurse or physician immediately. A PICC line does not require the affected arm to be immobilized. Although a PICC line can be used to obtain a blood specimen, the risk of occlusion from aspirating blood as part of the related daily care is greater than any potential benefit. The PICC line can be used for intermittent or continuous fluid infusion.

 

83. The nurse is preparing the client assignments for the day to a licensed practical nurse (LPN) and an unlicensed assistive personnel (UAP). Which clients would the nurse assign to the LPN because of client needs that cannot be met by a UAP?

Select all that apply.

 1. Client requiring frequent suctioning

 2. Client requiring a dressing change to the foot

 3. Client requiring range-of-motion exercises twice daily

 4. Client requiring reinforcement of teaching about a diabetic diet

 5. Client on bed rest requiring vital sign measurement every 4 hours

 6. Client requiring collection of a urine specimen for urinalysis testing

Answer: 1, 2, 4

Rationale: Delegation is the transferring to a competent individual the authority to perform a nursing task. When the nurse plans client assignments, the nurse needs to consider the educational level and experience of the individual and the needs of the client. The LPN is trained to perform all the tasks indicated in the options; the clients who have needs that cannot be met by the UAP are those requiring suctioning, a dressing change, and reinforcement of teaching about a diabetic diet. UAPs are trained to perform range-ofmotion exercises, measure vital signs, and collect a urine specimen.

 84. A charge nurse observes that a staff nurse is not able to meet client needs in a reasonable time frame, does not problem-solve situations, and does not prioritize nursing care. Which strategy is most appropriate for the charge nurse to employ?

1.  Ask other staff members to help the staff nurse get the work done.

2. Supervise the staff nurse more closely so that tasks are completed.

3. Provide support and identify the underlying cause of the staff nurse’s problem.

4. Report the staff nurse to the supervisor so that remediation to resolve the problem occurs.

Answer: 3

Rationale: Option 3 empowers the charge nurse to assist the staff nurse while trying to identify and reduce the behaviors that make it difficult for the staff nurse to function. Options 1, 2, and 4 are punitive actions, shift the burden to other workers, and do not solve the problem.

85. A registered nurse is a preceptor for a new nurse and is observing the new nurse organize the client assignments and prioritize daily tasks. The registered nurse would intervene if the new nurse implements which action?

1.    Provides times for staff meals

2.   Gathers the supplies needed for a task

3.   Combines all tasks for clients in one list

4.   Documents task completions at the end of the day

Answer: 4

Rationale: The nurse needs to document task completion continuously throughout the day. Options 1, 2, and 3 identify accurate components of time management.

86. The registered nurse instructs the new nurse that a variance analysis is performed on all clients with respect to which time frame?

1.    Continuously

2.   Daily during hospitalization

3.   Every third day of hospitalization

4.   Every other day of hospitalization

Answer: 1

Rationale: Variance analysis occurs continuously as the case manager and other caregivers monitor client outcomes against critical paths. The goal of critical paths is to anticipate and recognize negative variance early so that appropriate action can be taken. A negative variance occurs when untoward events preclude a timely discharge and the length of stay is longer than planned for a client on a specific critical path. Options 2, 3, and 4 are incorrect.

87. When the nurse manager encourages staff to provide input in the decision-making process, which leadership style is being demonstrated?

1.    Autocratic

2.   Situational

3.   Democratic

4.   Laissez-faire

Answer: 3

Rationale: The democratic style of leadership best empowers staff toward excellence because this style of leadership allows nurses to provide input regarding the decision-making process and an opportunity to grow professionally. The autocratic style of leadership is task oriented and directive. The leader uses their power and position in an authoritarian manner to set and implement organizational goals. Decisions are made without input from the staff. The situational leadership style uses a style depending on the situation and events. The laissez-faire style allows staff to work without assistance, direction, or supervision.

88. A hospital administrator has implemented a change in the method of assigning nurses to client care units. A group of registered nurses is resistant to the change, and the nursing administrator anticipates that the nurses will not facilitate the process of change. Which approach is best for the administrator to take initially in dealing with the resistance?

1.    Cancel the implementation of the change.

2.   Implement the change first on a trial basis.

3.   Delay implementing the change for a few weeks.

4. Encourage the nurses to verbalize feelings regarding thechange.

Answer: 4

Rationale: Face-to-face meetings to address the issue at hand will allow verbalization of feelings, identification of problems and issues, and the development of strategies to solve the problem. Option 1 will not address the problem. Option 2 is not the initial intervention. Option 3 may provide a temporary solution to the resistance but will not specifically address the concern.

89. Which situation represents the primary nursing care delivery model?

1.  The registered nurse (RN) performs all tasks needed by the individual client to optimize health.

2. The RN provides care to four clients, while the unlicensed assistive personnel (UAP) is assigned to care for two clients.

3. The RN develops a plan of care for each client andc ollaborates with other staff members assigned to the same group of clients.

4. The UAP is assigned to make beds and fill water pitchers. The RN is assigned to administer medications.

Answer: 1

Rationale: In primary nursing, option 1, concern is with keeping the nurse at the bedside actively involved in care, providing goaldirected and individualized client care. Option 2 does not follow the guidelines for any specific type of nursing care delivery approach. Team nursing, option 3, is characterized by a high degree of communication and collaboration among members. The team is generally led by an RN who is responsible for assessing, developing nursing diagnoses, planning, and evaluating each client’s plan of care. The functional model of care involves an assembly line approach to client care, with major tasks being delegated by the charge nurse to individual staff members.

90. The nurse assesses a client 24 hours following an above the-knee amputation. Which action would the nurse take to ensure that the client’s residual limb is placed in the most appropriate position?

1.    Elevate the foot of the bed.

2.   Put the bed in reverse Trendelenburg’s.

3.   Position the residual limb flat on the bed.

4. Keep the residual limb slightly elevated with the client lying on the operative side.

Answer: 3

Rationale: Some (not all) surgeons may prescribe elevation of the residual limb for the first 24 hours following amputation to control edema. If elevation is allowed, after the first 24 hours the residual limb is usually placed flat on the bed (as prescribed) to reduce hip contracture. Edema is also controlled by residual limb wrapping techniques. Reverse Trendelenburg’s is an inappropriate position and may cause pressure on the diaphragm, affecting breathing.

91. An emergency department nurse is a member of an allhazards disaster preparedness planning group. The group is developing a specific emergency response plan in the event that a client with smallpox arrives in the emergency department. Which interventions would initially be included in the plan? Select all that apply.

 1. Isolate the client.

 2. Don protective equipment immediately.

 3. Notify infectious disease specialists, public health officials, and the police.

 4. Lock down the emergency department and the entire hospital immediately.

 5. Identify all client contacts, including transport services to the emergency department and clients in the waiting room.

 6. Administer smallpox vaccines to all hospital staff, client contacts, and clients sitting in the emergency department waiting room immediately.

Answer: 1, 2, 3, 5

Rationale: An all-hazards disaster preparedness group is a multifaceted internal and external disaster preparedness group that establishes action plans for every type of disaster or combination of disaster events. In the event of emergency department exposure to a communicable disease such as smallpox, the client would be isolated immediately and the staff would immediately don protective equipment. The emergency department would be locked down immediately. Locking down the entire hospital may not be necessary, and infectious disease specialists and public health officials will determine whether it is necessary to take this action. Infectious disease specialists, public health officials, and the police are notified. All client contacts (name, addresses, telephone numbers), including transport services to the emergency department and clients in the waiting room, would be identified so that the public health department can follow through on notifying and treating these individuals appropriately. Although getting the vaccine within 3 days after exposure will help prevent the disease or make it less severe, it is unreasonable and unnecessary to administer smallpox vaccines to all hospital staff, client contacts, and clients sitting in the emergency department waiting room.

92. A pregnant client tests positive for the hepatitis B virus. The client asks the nurse about being able to breastfeed/chest-feed the baby as planned after delivery. Which therapeutic response would the nurse communicate to the client?

1.  “You will not be able to breast-feed/chest-feed the baby until 6 months after delivery.”

2. “Breast-feeding/chest-feeding is not advised, and you need to seriously consider bottle-feeding the baby.”

3. “Breast-feeding/chest-feeding is not a problem, and you will be able to breast-feed/chest-feed immediately after delivery.”

4. “Breast-feeding/chest-feeding is allowed if the baby receives prophylaxis treatment at birth and scheduled immunizations.”

Answer: 4

Rationale: The pregnant client who tests positive for hepatitis B virus needs to be reassured that breast-feeding/chest-feeding is not contraindicated if the infant receives prophylaxis at birth and remains on the schedule for immunizations. Therefore, options 1, 2, and 3 are incorrect.

93. The nurse manager is planning to implement needed changes in the method of the documentation system for the nursing unit. Which would be the initial step in the process of change for the nurse manager?

1.    Plan strategies to implement the change.

2.   Set goals and priorities regarding the change process.

3. Identify the inefficiency that needs improvement or correction.

4.   Identify potential solutions and strategies for the change process.

Answer: 3

Rationale: When beginning the change process, the nurse needs to identify and define the problem that needs improvement or correction. This important first step can prevent many future problems because, if the problem is not correctly identified, a plan for change may be aimed at the wrong problem. This is followed by goal setting, prioritizing, and identifying potential solutions and strategies to implement the change.

94. A delivery room nurse is preparing a client for a cesarean delivery to facilitate the birth of triplets. Which position will promote maximum uteroplacental perfusion during this surgery?

1.    Prone position

2.   Semi-Fowler’s position

3.   Trendelenburg’s position

4.   Supine position with a wedged right hip

Answer: 4

Rationale: Vena cava and descending aorta compression by the pregnant uterus impede blood return from the lower trunk and extremities, thereby decreasing cardiac return, cardiac output, and blood flow to the uterus and subsequently the fetus. The best position to prevent this would be side-lying with the uterus displaced off the abdominal vessels. Positioning for abdominal surgery necessitates a supine position, so a wedge placed under the right hip provides displacement of the uterus off of the vena cava. A semi Fowler’s or prone position is not practical for this type of abdominal surgery. Trendelenburg’s positioning places pressure from the pregnant uterus on the diaphragm and lungs, decreasing respiratory capacity and oxygenation.

Priority Nursing Tip: Vena cava syndrome, also known as supine hypotension, occurs when the venous return to the heart is impaired by the weight of the pregnant uterus on the vena cava.

95. The nurse in the day care center is told that a child with a diagnosis of autism will be attending the center. The nurse collaborates with the staff of the day care center and plans activities that will meet the child’s needs. Which priority consideration would the nurse incorporate in planning activities for this child?

1.    Safety

2.   Verbal stimulation

3.   Social interactions

4.   Familiarity and orientation

Answer: 1

Rationale: The child with autism is unable to anticipate danger, has a tendency for self-mutilation, and has sensory perceptual deficits. Safety with activities is a priority in planning activities with the child. Although verbal communications, social interactions, and providing familiarity and orientation are also appropriate interventions, the priority is safety.

96. The registered nurse (RN) is reviewing a plan of care developed by a new nurse for a child who is being admitted to the pediatric unit with a diagnosis of seizures. The RN determines that the new nurse needs further teaching and needs to revise the plan of care if which incorrect intervention is documented?

1.    Maintain the bed in a low position.

2.   Immobilize the child if a seizure occurs.

3.   Place padding on the side rails of the bed.

4.   Place the child in a side-lying lateral positionpostseizure.

Answer: 2

Rationale: Restraints (immobilization) are not to be applied to a child with a seizure because they could cause injury to the child. The bed is maintained in low position to provide safety in the event that the child has a seizure. The side rails of the bed are padded to prevent injury. Positioning the child on their side will prevent aspiration as the saliva drains out of the child’s mouth during the seizure.

97. The nurse is caring for the body and personal belongings of a client who died as a result of multiple gunshot wounds. Which actions would the nurse take to properly secure and handle legal evidence? Select all that apply.

 1. Place paper bags on the hands and feet.

 2. Give the clothing and wallet to the family.

 3. Cut clothing along the seams, avoiding bullet holes.

 4. Collect all personal items, including items from clothing pockets.

 5. Place wet clothing and personal belongings in a labeled, sealed plastic bag.

 6. Do not allow family members, significant others, or friends to be alone with the client.

Answer: 1, 3, 4, 6

Rationale: Basic rules for securing and handling evidence include minimally handling the body of a deceased person; placing paper bags on the hands and feet and possibly over the head of a deceased person (protects trace evidence and residue); placing clothing and personal items in paper bags (plastic bags can destroy items because items can sweat in plastic); cutting clothes along seams, avoiding areas where there are obvious holes or tears; and collecting all personal items, including items from clothing pockets. Evidence is never released to the family to take home, and family members, significant others, or friends are not allowed to be alone with the client because of the possibility of jeopardizing any existing legal evidence.

Priority Nursing Tip: Nurses are required to report certain communicable diseases or criminal activities such as child or elder abuse or domestic violence; a dog bite or other animal bite; gunshot or stab wounds, assaults, or homicides; and suicides to the appropriate authorities.

98. The nurse prepares for the admission of the child with a diagnosis of tonic-clonic seizures and plans to place which items at the bedside?

1.    A tracheotomy set and oxygen

2.   Suction apparatus and oxygen

3.   An endotracheal tube and an airway

4.   An emergency cart and laryngoscope

Answer: 2

Rationale: Tonic-clonic seizures cause tightening of all body muscles followed by tremors. Obstructed airway and increased oral secretions are the major complications during and after a seizure. Suction is helpful to prevent choking, and oxygen is helpful to prevent cyanosis. Options 1 and 3 are incorrect because inserting an endotracheal tube or a tracheotomy is not performed. It is not necessary to have an emergency cart (which contains a laryngoscope) at the bedside, but a cart needs to be available in the treatment room or on the nursing unit.

99. The nurse is admitting a 56-year-old client with a diagnosis of exacerbation of chronic obstructive pulmonary disease (COPD) and learns that the client received immunization for pneumococcal pneumonia 6 years ago. Which consideration is essential to include in the plan of care during the client’s hospital admission?

1.   Offer revaccination to the client.

2. Document the previous immunization on the client record.

3. Instruct the client that this vaccine provides life long immunity.

4. Explain to the client that revaccinations can only be given during the fall months.

Answer: 1

Rationale: During the history-taking of a client diagnosed with a respiratory disorder, the nurse would ask if the client had been previously vaccinated for influenza (flu) and had received pneumococcal pneumonia vaccine. Revaccination with pneumococcal pneumonia vaccine is currently advised in a client with COPD if the client received the vaccine more than 5 years previously and if the client was younger than 65 years of age at the time of vaccination. Although documentation would be completed, this is not the essential action at this time. This vaccine does not provide lifelong immunity in a 56-year-old client who received the vaccine 6 years ago. The pneumococcal pneumonia vaccine is administered any time during the year.

100. The nurse in a well-baby clinic is providing safety instructions to the parent of a 1-month-old infant. Which safety instructions are most appropriate to include at this age? Select all that apply.

 1. Lock up all poisons.

 2. Cover electrical outlets.

 3. Never shake the infant’s head.

 4. Place the infant on the back to sleep.

 5. Remove hazardous objects from low places.

Answer: 3, 4

Rationale: The age-appropriate instructions that are most important are to instruct the parent not to shake or vigorously jiggle the baby’s head and to place the infant on their back to sleep. Options 1, 2, and 5 are important instructions to provide to the parents as the child reaches the age of 6 months and begins to explore the environment.