26-50

Question 1

26. An older woman is brought to the emergency department for treatment of a fractured arm. On physical assessment, the nurse notes old and new ecchymotic areas on the client’s chest and legs and asks the client how the bruises were sustained. The client, although reluctant, tells the nurse in confidence that her son frequently hits her if supper is not prepared on time when he arrives home from work. Which is the most appropriate nursing response?
27. “Oh, really? I will discuss this situation with your son.”
28. “Let’s talk about the ways you can manage your time to prevent this from happening.”
29. “Do you have any friends who can help you out until you resolve these important issues with your son?”
30. “As a nurse, I am legally bound to report abuse. I will stay with you while you give the report and help find a safe place for you to stay.”

Answer 1

26. Answer: 4
    Rationale: The nurse must report situations related to child or elder abuse, gunshot wounds and other criminal acts, and certain infectious diseases. Confidential issues are not to be discussed with nonmedical personnel or the client’s family or friends without the client’s permission. Clients should be assured that information is kept confidential, unless it places the nurse under a legal obligation. Options 1, 2, and 3 do not address the legal implications of the situation and do not ensure a safe environment for the client.

Test-Taking Strategy: Note the strategic words, most appropriate. Focus on the data in the question and note that an older woman is receiving physical abuse by her son. Recall the nursing responsibilities related to client safety and reporting obligations. Options 1, 2, and 3 should be eliminated because they are comparable or alike in that they do not protect the client from injury

Question 2

27. The nurse calls the primary health care provider (PHCP) regarding a new medication prescription, because the dosage prescribed is higher than the recommended dosage. The nurse is unable to locate the PHCP, and the medication is due to be administered. Which action should the nurse take?
28. Contact the nursing supervisor.
29. Administer the dose prescribed.
30. Hold the medication until the PHCP can be contacted.
31. Administer the recommended dose until the PHCP can be located.

Answer 2

27. Answer: 1
    Rationale: If the PHCP writes a prescription that requires clarification, the nurse’s responsibility is to contact the PHCP. If there is no resolution regarding the prescription because the PHCP cannot be located or because the prescription remains as it was written after talking with the PHCP, the nurse should contact the nurse manager or nursing supervisor for further clarification as to what the next step should be. Under no circumstances should the nurse proceed to carry out the prescription until obtaining clarification.

Test-Taking Strategy: Eliminate options 2 and 4 first because they are comparable or alike and are unsafe actions. Holding the medication can result in client injury. The nurse needs to take action. The correct option clearly identifies the required action in this situation.

Question 3

28. The nurse employed in a hospital is waiting to receive a report from the laboratory via the facsimile (fax) machine. The fax machine activates and the nurse expects the report, but instead receives a sexually oriented photograph. Which is the most appropriate initial nursing action?
29. Call the police.
30. Cut up the photograph and throw it away.
31. Call the nursing supervisor and report the occurrence.
32. Call the laboratory and ask for the name of the individual who sent the photograph.

Answer 3

28. Answer: 3
    Rationale: Ensuring a safe workplace is a responsibility of an employing institution. Sexual harassment in the workplace is prohibited by state and federal laws. Sexually suggestive jokes, touching, pressuring a coworker for a date, and open displays of or transmitting sexually oriented photographs or posters are examples of conduct that could be considered sexual harassment by another worker and is an abusive behavior. If the nurse believes that he or she is being subjected to unwelcome sexual conduct, these concerns should be reported to the nursing supervisor immediately. Option 1 is unnecessary at this time. Options 2 and 4 are inappropriate initial actions.

Test-Taking Strategy: Note the strategic words, most appropriate initial. Remember that using the organizational channels of communication is best. This will assist in directing you to the correct option.

Question 4

29. The nurse is assigned to care for four clients. In planning client rounds, which client should the nurse assess first?
30. A postoperative client preparing for discharge with a new medication
31. A client requiring daily dressing changes of a recent surgical incision
32. A client scheduled for a chest x-ray after insertion of a nasogastric tube
33. A client with asthma who requested a breathing treatment during the previous shift

Answer 4

29. Answer: 4
    Rationale: Airway is always the highest priority, and the nurse would attend to the client with asthma who requested a breathing treatment during the previous shift. This could indicate that the client was experiencing difficulty breathing. The clients described in options 1, 2, and 3 have needs that would be identified as intermediate priorities.

Test-Taking Strategy: Note the strategic word, first. Use the ABCs—airway, breathing, and circulation—to answer the question. Remember that airway is always the highest priority. This will direct you to the correct option.

Question 5

30. The nurse employed in an emergency department is assigned to triage clients coming to the emergency department for treatment on the evening shift. The nurse should assign priority to which client?
31. A client complaining of muscle aches, a headache, and history of seizures
32. A client who twisted her ankle when rollerblading and is requesting medication for pain
33. A client with a minor laceration on the index finger sustained while cutting an eggplant
34. A client with chest pain who states that he just ate pizza that was made with a very spicy sauce

Answer 5

30. Answer: 4
    Rationale: In an emergency department, triage involves brief client assessment to classify clients according to their need for care and includes establishing priorities of care. The type of illness or injury, the severity of the problem, and the resources available govern the process. Clients with trauma, chest pain, severe respiratory distress or cardiac arrest, limb amputation, and acute neurological deficits and those who have sustained chemical splashes to the eyes are classified as emergent and are the highest priority. Clients with conditions such as a simple fracture, asthma without respiratory distress, fever, hypertension, abdominal pain, or a renal stone have urgent needs and are classified as a second priority. Clients with conditions such as a minor laceration, sprain, or cold symptoms are classified as nonurgent and are a third priority.

Test-Taking Strategy: Note the strategic word, priority. Use the ABCs—airway, breathing, and circulation—to direct you to the correct option. A client experiencing chest pain is always classified as priority 1 until a myocardial infarction has been ruled out.

Question 6

31. A nursing graduate is attending an agency orientation regarding the nursing model of practice implemented in the health care facility. The nurse is told that the nursing model is a team nursing approach. The nurse determines that which scenario is characteristic of the team-based model of nursing practice?
32. Each staff member is assigned a specific task for a group of clients.
33. A staff member is assigned to determine the client’s needs at home and begin discharge planning.
34. A single registered nurse (RN) is responsible for providing care to a group of 6 clients with the aid of an assistive personnel (AP).
35. An RN leads 2 licensed practical nurses (LPNs) and 3 APs in providing care to a group of 12 clients.

Answer 6

31. Answer: 4
    Rationale: In team nursing, nursing personnel are led by a registered nurse leader in providing care to a group of clients. Option 1 identifies functional nursing. Option 2 identifies a component of case management. Option 3 identifies primary nursing (relationship-based practice).

Test-Taking Strategy: Focus on the subject, team nursing. Keep this subject in mind and select the option that best describes a team approach. The correct option is the only one that identifies the concept of a team approach.

Question 7

32. The nurse has received the assignment for the day shift. After making initial rounds and checking all of the assigned clients, which client should the nurse plan to care for first?
33. A client who is ambulatory demonstrating steady gait
34. A postoperative client who has just received an opioid pain medication
35. A client scheduled for physical therapy for the first crutch-walking session
36. A client with a white blood cell count of 14,000 mm3 (14 × 109/L) and a temperature of 38.4° C

Answer 7

32. Answer: 4
    Rationale: The nurse should plan to care for the client who has an elevated white blood cell count and a fever first, because this client’s needs are the priority. The client who is ambulatory with steady gait and the client scheduled for physical therapy for a crutch-walking session do not have priority needs. Waiting for pain medication to take effect before providing care to the postoperative client is best.

Test-Taking Strategy: Note the strategic word, first, and use principles related to prioritizing. Recalling the normal white blood cell count is 5000 to 10,000 mm3 (5 to 10 × 109/L) and the normal temperature range 97.5° F to 98.6° F (36.4° C to 37° C) will direct you to the correct option.

Question 8

33. The nurse is giving a bed bath to an assigned client when an assistive personnel (AP) enters the client’s room and tells the nurse that another assigned client is in pain and needs pain medication. Which is the most appropriate nursing action?
34. Finish the bed bath and then administer the pain medication to the other client.
35. Ask the AP to find out when the last pain medication was given to the client.
36. Ask the AP to tell the client in pain that medication will be administered as soon as the bed bath is complete.
37. Cover the client, raise the side rails, tell the client that you will return shortly, and administer the pain medication to the other client.

Answer 8

33. Answer: 4
    Rationale: The nurse is responsible for the care provided to assigned clients. The appropriate action in this situation is to provide safety to the client who is receiving the bed bath and prepare to administer the pain medication. Options 1 and 3 delay the administration of medication to the client in pain. Option 2 is not a responsibility of the AP.

Test-Taking Strategy: Note the strategic words, most appropriate, and use principles related to priorities of care. Options 1 and 3 are comparable or alike and delay the administration of pain medication, and option 2 is not a responsibility of the AP. The most appropriate action is to plan to administer the medication.

Question 9

34. The nurse manager has implemented a change in the method of the nursing delivery system from functional to team nursing. An assistive personnel (AP) is resistant to the change and is not taking an active part in facilitating the process of change. Which is the best approach in dealing with the AP?
35. Ignore the resistance.
36. Exert coercion on the AP.
37. Provide a positive reward system for the AP.
38. Confront the AP to encourage verbalization of feelings regarding the change.

Answer 9

34. Answer: 4
    Rationale: Confrontation is an important strategy to meet resistance head-on. Face-to-face meetings to confront the issue at hand will allow verbalization of feelings, identification of problems and issues, and development of strategies to solve the problem. Option 1 will not address the problem. Option 2 may produce additional resistance. Option 3 may provide a temporary solution to the resistance but will not address the concern specifically.

Test-Taking Strategy: Note the strategic word, best. Options 1 and 2 can be eliminated first because of the words ignore in option 1 and coercion in option 2. From the remaining options, select the correct option over option 3 because the correct option specifically addresses problem-solving measures.

Question 10

35. The registered nurse is planning the client assignments for the day. Which is the most appropriate assignment for an assistive personnel (AP)?
36. A client requiring a colostomy irrigation
37. A client receiving continuous tube feedings
38. A client who requires urine specimen collections
39. A client with difficulty swallowing food and fluids

Answer 10

35. Answer: 3
    Rationale: The nurse must determine the most appropriate assignment based on the skills of the staff member and the needs of the client. In this case, the most appropriate assignment for the AP would be to care for the client who requires urine specimen collections. The AP is skilled in this procedure. Colostomy irrigations and tube feedings are not performed by APs because these are invasive procedures. The client with difficulty swallowing food and fluids is at risk for aspiration.

Test-Taking Strategy: Note the strategic words, most appropriate, and note the subject, an assignment to the AP. Eliminate option 4 first because of the words difficulty swallowing. Next, eliminate options 1 and 2 because they are comparable or alike and are both invasive procedures and as such an AP cannot perform these procedures.

Question 11

36. The nurse manager is discussing the facility protocol in the event of a tornado with the staff. Which instructions should the nurse manager include in the discussion? Select all that apply.
    icon01-9780323358415 1. Open doors to client rooms.
    icon01-9780323358415 2. Move beds away from windows.
    icon01-9780323358415 3. Close window shades and curtains.
    icon01-9780323358415 4. Place blankets over clients who are confined to bed.
    icon01-9780323358415 5. Relocate ambulatory clients from the hallways back into their rooms.

Answer 11

36. Answer: 2, 3, 4
    Rationale: In this weather event, the appropriate nursing actions focus on protecting clients from flying debris or glass. The nurse should close doors to each client’s room and move beds away from windows, and close window shades and curtains to protect clients, visitors, and staff from shattering glass and flying debris. Blankets should be placed over clients confined to bed. Ambulatory clients should be moved into the hallways from their rooms, away from windows.

Test-Taking Strategy: Focus on the subject, protecting the client in the event of a tornado. Visualize each of the actions in the options to determine whether these actions would assist in protecting the client and preventing an accident or injury.

Question 12

37. The nurse employed in a long-term care facility is planning assignments for the clients on a nursing unit. The nurse needs to assign four clients and has a licensed practical nurse and 3 assistive personnel (APs) on a nursing team. Which client would the nurse most appropriately assign to the licensed practical nurse?
38. A client who requires a bed bath
39. An older client requiring frequent ambulation
40. A client who requires hourly vital sign measurements
41. A client requiring abdominal wound irrigations and dressing changes every 3 hours

Answer 12

37. Answer: 4
    Rationale: When delegating nursing assignments, the nurse needs to consider the skills and educational level of the nursing staff. Giving a bed bath, assisting with frequent ambulation, and taking vital signs can be provided most appropriately by an AP. The licensed practical nurse is skilled in wound irrigations and dressing changes and most appropriately would be assigned to the client who needs this care.

Test-Taking Strategy: Focus on the subject, assignment to a licensed practical nurse, and note the strategic words, most appropriately. Recall that education and job position as described by the nurse practice act and employee guidelines need to be considered when delegating activities and making assignments. Options 1, 2, and 3 can be eliminated because they are noninvasive tasks that the AP can perform.

Question 13

38. The charge nurse is planning the assignment for the day. Which factors should the nurse remain mindful of when planning the assignment? Select all that apply.
    icon01-9780323358415 1. The acuity level of the clients
    icon01-9780323358415 2. Specific requests from the staff
    icon01-9780323358415 3. The clustering of the rooms on the unit
    icon01-9780323358415 4. The number of anticipated client discharges
    icon01-9780323358415 5. Client needs and workers’ needs and abilities

Answer 13

38. Answer: 1, 5
    Rationale: There are guidelines that the nurse should use when delegating and planning assignments. These include the following: ensure client safety; be aware of individual variations in work abilities; determine which tasks can be delegated and to whom; match the task to the delegatee on the basis of the nurse practice act and appropriate position descriptions; provide directions that are clear, concise, accurate, and complete; validate the delegatee’s understanding of the directions; communicate a feeling of confidence to the delegatee and provide feedback promptly after the task is performed; and maintain continuity of care as much as possible when assigning client care. Staff requests, convenience as in clustering client rooms, and anticipated changes in unit census are not specific guidelines to use when delegating and planning assignments.

Test-Taking Strategy: Focus on the subject, guidelines to use when delegating and planning assignments. Read each option carefully and use Maslow’s Hierarchy of Needs theory. Note that the correct options directly relate to the client’s needs and client safety.