CH 17 PrepU

Question 1

The nurse is preparing to administer a blood pressure medication to a client. To ensure the client’s safety, what is the priority action for the nurse to take?

Tell the client to report any side effects experienced.

Ask the client to verbalize the purpose of the medication.

Assess the client’s blood pressure to determine if the medication is indicated.

Determine the client’s reaction to the medication in the past.

Answer 1

Assess the client’s blood pressure to determine if the medication is indicated.

Question 2

Which action should the nurse take to ensure that an unlicensed assistive personnel (UAP) understands the instructions to perform a delegated task?

Ask another UAP to observe and assist the UAP in performing the task.

Instruct the UAP to repeat the instructions to be sure the nurse has communicated clearly.

Inform the UAP of the importance of following each step listed in the procedure manual.

Request that the UAP place the steps of the task in the framework of the nursing process.

Answer 2

Instruct the UAP to repeat the instructions to be sure the nurse has communicated clearly.

Question 3

The nurse is coordinating care for a client with continuous pulse oximetry who requires pharyngeal suctioning. To which staff member should the nurse avoid delegating the task of suctioning?

senior student in nursing school who is present for clinical

registered nurse

licensed practical/vocational nurse

unlicensed assistive personnel who is in nursing school

Question 4

A client requires a change and reapplication of a colostomy bag. The nurse has never changed an ostomy bag before. What is the nurse’s best course of action?

Determine the necessity of the bag change.

Ask a skilled nurse to assist with the procedure.

Read the policy and procedure manual.

Ask the client how the bag is changed.

Question 5

The registered nurse is working with an unlicensed assistive personnel. Which client should the nurse not delegate to the unlicensed assistive personnel?

The client who requires assistance dressing in preparation for discharge.

The client who needs vital signs taken following infusion of packed red blood cells.

The client with continuous pulse oximetry who requires pharyngeal suctioning.

The client who is pleasantly confused and requires assistance to the bathroom.

Answer 5

The client with continuous pulse oximetry who requires pharyngeal suctioning.

Question 6

The nurse is preparing a client for surgery when the client tells the nurse that the client no longer wants to have the surgery. How should the nurse most appropriately respond?

Review with the client the risks and benefits of surgery.

Discuss with the client the reasons for declining surgery.

Ask the client to discuss the decision with family members.

Notify the health care provider of the client’s refusal.

Answer 6

Discuss with the client the reasons for declining surgery.

Question 7

While observing a new nurse inserting an indwelling urinary catheter, the preceptor observes a break in sterile technique. What is the preceptor’s first action?

Report the new nurse’s error to the nurse manager for corrective action.

Assign the new nurse to view videos on sterile catheter insertion.

Allow the new nurse to continue with the insertion and discuss the error later away from the client.

Tell the new nurse that a break in sterile technique has occurred and the procedure must be stopped.

Answer 7

Tell the new nurse that a break in sterile technique has occurred and the procedure must be stopped.

Question 8

When the nurse enters the room to assess a client’s vital signs, the client insists that the nurse perform handwashing. What is the nurse’s most appropriate action?

Reassure the client that the nurse knows when to perform hand hygiene.

Tell the client that gloves are required for this procedure.

Praise the client for taking an active role in the client’s care.

Inform the client that it is not necessary to wash hands before vital signs.

Answer 8

Praise the client for taking an active role in the client’s care.

Question 9

The surgeon is insisting that a client consent to a hysterectomy. The client refuses to make a decision without the consent of the client’s spouse. What is the nurse’s best course of action?

Ask the surgeon to wait until the client has had a chance to talk to the spouse.

Ask the client whether the client is afraid that the spouse will be angry.

Inform the surgeon that the nurse will not sign the informed consent form.

Remind the client that the client is responsible for the client’s own health care decisions.

Answer 9

Ask the surgeon to wait until the client has had a chance to talk to the spouse.

Question 10

The nurse is assigned a client who had an uneventful colon resection 2 days ago and requires a dressing change. To which nursing team member should the nurse avoid delegating the dressing change?

registered nurse

licensed practical/vocational nurse

unlicensed licensed personnel

senior student in nursing school who is present for clinical

Answer 10

unlicensed licensed personnel

Question 11

Which statement by a nurse case manager regarding this nurse’s role in client care is most accurate?

“I provide a critical service that is necessary for financial reimbursement.”

“Moving away from client care is a necessary step to advancing my career.”

“Even though I do not provide care to clients, my work is very important.”

“I provide indirect care to my clients by coordinating their treatment with other disciplines.”

Answer 11

“I provide indirect care to my clients by coordinating their treatment with other disciplines.”

Question 12

After learning about a client’s limited financial resources and limited insurance benefits, the home care nurse modifies nursing interventions related to a client’s care instructions. The nurse modifies the plan of care based upon which client variable?

Psychosocial background

Current standards of care

Research findings

Developmental stage

Answer 12

Psychosocial background

Question 13

The health care provider has ordered that the client should ambulate 3 times a day. The nurse enters the room to ambulate the client and the client reports pain. What is the nurse’s most appropriate action?

Emphasize to the client the importance of following the treatment plan.

Ambulate the client and medicate later.

Explain to the client the benefits of ambulation.

Medicate the client and wait to ambulate later.

Answer 13

Medicate the client and wait to ambulate later.

Question 14

The nurse is caring for a client who is recovering from a cerebrovascular accident. When reviewing the client’s orders, the nurse notes that one of the health care providers wrote orders to ambulate the client, whereas another health care provider ordered strict bed rest for the client. How would the nurse most appropriately remedy this conflict?

Instruct the client to ask the health care providers for clarifications of instructions.

Assess the client to determine whether the client is capable of ambulation.

Communicate with the health care providers to coordinate their orders.

Collaborate with the physical therapist to determine the client’s ability.

Answer 14

Communicate with the health care providers to coordinate their orders.

Question 15

Which task would be appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)?

Provide the client with assistance in transferring to the bedside commode.

Retrieve a unit of blood from the blood bank.

Reassess the client’s sacrum for redness when doing a bed bath.

Assess an IV site for possible infiltration

Answer 15

Provide the client with assistance in transferring to the bedside commode.

Question 16

During morning report, the night nurse tells the oncoming nurse that the client has been medicated for pain and is resting comfortably. Thirty minutes later, the client calls and requests pain medication. What is the nurse’s appropriate first action?

Medicate the client with the ordered pain medication.

Instruct the client in nonpharmacologic pain management.

Go to the client and assess the client’s pain.

Determine the frequency of pain medication.

Answer 16

Go to the client and assess the client’s pain.

Question 17

The nurse ascertains that a client is failing to follow the plan of care that was collaboratively developed. Further investigation determines that the plan of care is not appropriate for this client. What is the nurse’s next step in correcting this problem?

Make changes in the plan of care based upon assessment data.

Discuss the desired outcomes with the client and the importance of the outcomes.

Provide information to the client on the benefits of complying with the plan of care.

Ask the client’s family to assist the client in following the plan of care.

Answer 17

Make changes in the plan of care based upon assessment data.

Question 18

Which action is a nursing intervention that facilitates lifespan care?

Identify coping strategies for the family that have worked in the past.

Educate family members about normal growth and development patterns.

Teach contraceptive options for planned pregnancy.

Explore factors that could motivate adolescent members of the family to engage in risky behaviors.

Answer 18

Educate family members about normal growth and development patterns.

Question 19

The nurse is caring for a client with congestive heart failure. The nurse manager informs the nurse that the client was enrolled in a clinical trial to assess whether a 10-minute walk, 3 times per day, leads to expedited discharge. Which type of evaluation best describes what the researchers are examining?

Cost-effectiveness

Outcome

Structure

Process

Answer 19

Outcome

Question 20

Which parties are essential for the nurse to include in the implementation of a client’s plan of care?

Client, surgeon, and health care provider

Client, family, and health care provider

Client, physical therapist, and nursing staff

Client, health care provider, and hospital director

Answer 20

Client, family, and health care provider

Question 21

The nurse has prepared to educate a client about caring for a new colostomy. When the nurse begins the instruction, the client states, “I am not ready to deal with this now. I am feeling overwhelmed.” What is the nurse’s most appropriate action?

Discontinue the education and ask the client for permission to teach a family member.

Medicate the client for anxiety and continue the education later.

Continue the education and remind the client that it is essential to learn self-care.

Discontinue the education and attempt at another time.

Answer 21

Discontinue the education and attempt at another time.

Question 22

What assessment data would indicate to the nurse at the conclusion of an education session that the client education was effective? Select all that apply.

The client is able to answer the nurse’s questions.

The client asks the nurse to repeat the instructions.

The client discusses the specifics of what was taught during the session.

The client verbalizes understanding of the instructions.

The client tells the nurse that the client’s spouse will handle the care.

Answer 22

The client verbalizes understanding of the instructions.

The client is able to answer the nurse’s questions

The client discusses the specifics of what was taught during the session.

Question 23

Which is the nurse’s priority question to consider prior to delegating a task to an unlicensed assistive personnel (UAP)?

What is the client’s condition?

Does this task fall within the scope of a UAP?

How can I supervise the completion of this task?

How can I explain the task to the UAP?

Answer 23

Does this task fall within the scope of a UAP?

Question 24

A nurse who is experienced caring only for well babies is assigned to the neonatal intensive care unit (NICU) because of a shortage of nurses in the NICU. The nurse is assigned to an infant on a ventilator who will require blood transfusions during the shift. What is the nurse’s most appropriate course of action?

The nurse should request that the blood transfusions be delayed until the next shift.

The nurse should ask another nurse who was previously assigned to the client for instruction.

The nurse should inform the charge nurse that the nurse does not have the experience to properly care for this client.

The nurse should recognize the necessity of the assignment and provide care to the best of the nurse’s ability.

Answer 24

The nurse should inform the charge nurse that the nurse does not have the experience to properly care for this client.

Question 25

A client cannot afford the treatment prescribed. Who would be the most appropriate professional for the nurse to involve with the client’s care?

Health care provider

Nurse case manager

Nurse manager

Insurance company

Answer 25

Nurse case manager

Question 26

The client is in a rehabilitation unit after a traumatic brain injury. In order to facilitate the client’s recovery, what would be the nurse’s most appropriate intervention?

Encourage the client to provide as much self-care as possible.

Perform all care activities for the client to facilitate rest.

Teach the family to anticipate the client’s needs to care for the client.

Arrange with the nurse case manager for an early discharge.

Answer 26

Encourage the client to provide as much self-care as possible.

Question 27

Which are benefits of using the nursing intervention classification (NIC) system for the development of interventions? Select all that apply.

Creation of a standardized language

Assistance in determining the cost of services that nurses provide

Justification of the productivity of the nursing staff

Determination of which nursing actions the nurse may delegate

Demonstration of the impact of nurses

Answer 27

Creation of a standardized language

Assistance in determining the cost of services that nurses provide

Demonstration of the impact of nurses

Question 28

The nurse has instructed the client in self-catheterization, but the client is unable to perform a return demonstration. What is the nurse’s most appropriate plan of action?

Reassess the appropriateness of the method of instruction.

Report the client’s inability to learn to the case manager.

Revise the plan to include the inclusion of a support group.

Teach the content again utilizing the same method.

Answer 28

Reassess the appropriateness of the method of instruction.

Question 29

The nurse is planning instruction on wound care to an adult client. What variables would cause the nurse to alter the education plan? Select all that apply.

The client is married.

The client denies the need for education.

The client is male.

The client is blind.

The client is an architect.

Answer 29

The client is blind.

The client denies the need for education.

Question 30

A nurse is caring for a postoperative client who reports a pain level of 6 on a scale from 1 to 10. After administering the prescribed pain medication, which intervention should the nurse include in the nursing care plan to monitor and evaluate pain?

Assess nonpharmacologic modalities used to reduce pain.

Review client goals for comfort.

Ambulate the client after administration of pain medication.

Implement the ABC guide of pain management.

Answer 30

Implement the ABC guide of pain management.

Question 31

After instituting interventions to increase oxygenation, the client shows no signs of improvement. What is the nurse’s priority action?

Document the interventions and the result.

Reassess the client for improvement in 30 minutes.

Determine the client’s code status in case of an emergency.

Communicate with the health care provider for additional orders.

Answer 31

Communicate with the health care provider for additional orders.

Question 32

The primary purpose of nursing implementation is to:

improve the client’s postoperative status.

identify a need for collaborative consults.

help the client achieve optimal levels of health.

implement the critical pathway for the client.

Answer 32

help the client achieve optimal levels of health.

Question 33

One hour after receiving pain medication, a postoperative client reports intense pain. What is the nurse’s appropriate first action?

Assist the client to reposition and splint the incision.

Assess the client to determine the cause of the pain.

Consult with the health care provider for additional pain medication.

Discuss the frequency of pain medication administration with the client.

Answer 33

Assess the client to determine the cause of the pain.

Question 34

The nurse must give instructions before discharge to a 13-year-old in a sickle cell crisis. Three of the client’s friends from school are visiting. In order to assure effective instruction, what should the nurse plan to do?

Delay the instruction until the visitors leave.

Ask the client if the client has any questions.

Leave written information for the client to read later.

Give the visitors instructions to leave in 10 minutes.

Answer 34

Delay the instruction until the visitors leave.

Question 35

Which nursing interventions are appropriate to perform when addressing a risk nursing diagnosis? Select all that apply.

Reduce or eliminate risk factors.

Promote a higher level wellness.

Prevent the problem.

Monitor the client’s status.

Collect additional data to rule out the diagnosis.

Answer 35

Reduce or eliminate risk factors.

Prevent the problem.

Monitor the client’s status.

Question 36

The nurse is discussing diabetes mellitus with the family members of a client recently diagnosed. To promote the health of the family members, what would be the most important information for the nurse to include?

The severity of the client’s disease

Medications used to treat diabetes mellitus

Risk factors for and prevention of diabetes mellitus

The cellular metabolism of glucose

Answer 36

Risk factors for and prevention of diabetes mellitus

Question 37

A nurse suspects that the client with Crohn’s disease does not understand the medication regimen or diet modifications required to manage the illness. What is the nurse’s most appropriate action?

Ask the nutritionist to give the client strict meal plans to follow.

Ask the gastroenterologist to explain the treatment plan to the client and family again.

Ask the client to verbalize the medication regimen and diet modifications required.

Refer the client to available community resources and support groups.

Question 38

The Joint Commission (TJC) encourages clients to become active, involved, and informed participants on the health care team. What nursing action follows TJC recommendations for improving client safety by encouraging them to speak up?

The nurse encourages clients to advocate for themselves instead of choosing a trusted family member or friend.

The nurse explains each procedure twice to prevent client questions from wasting time.

The nurse assures the client who questions a medication that it is the right medication prescribed for him or her and administers the medicine.

The nurse encourages the client to participate in all treatment decisions as the center of the health care team.

Answer 38

The nurse encourages the client to participate in all treatment decisions as the center of the health care team.

Question 39

Which is an independent (nurse-initiated) action?

Helping to allay a client’s fears about surgery

Meeting with other health care professionals to discuss a client

Executing health care provider orders for a catheter

Administering medication to a client

Answer 39

Helping to allay a client’s fears about surgery