Foundations NCLEX Flashcards
which of the following patient transfers should not be assigned to ancillary staff without supervision by a registered nurse?
A. 66-year old patient receiving cancer radiation treatments.
B. 47 year old patient in the terminal stage of renal failure
C. 26-year old patient who is 8 hours post-caesarean surgery
D. 76 year old patient who has IV fluid in place
Correct Answer: C
A. older patient, but transfer doesn’t directly affect radiation
B.
C. Post-op= abdominal wound (life or death emergency sometimes)-do not delegate for task of transferring
D.
The nurse realizes that precautions should be taken in order to minimize the risk of injury to those involved in the transfer. Which of the following apply?
A. Medicate the uncooperative patient before attempting the transfer
B. Patient can assist
C. Make sure to have appropriate team
A. do not want to medicate if unnecessary (doesn’t guarantee minimizing risk)
B. Do not assume patient can assist
ANSWER C: Make sure to have appropriate personal to lift (life team)
D. Not a time frame
The nurse is preparing to delegate the transfer of a patient from bed to stretcher for transport to PT department to assistive personnel. Which of the following statements by the assistive personnel ,requires follow up by the nurse?
A. I’ll use gloves for the transfer if the bed sheets have been soiled
B. She said her daughter was going to PT with her. I’ll see of she’s here.
C. I noticed some red areas on her back, so I’ll be extra careful to position her on her side
D. The PT department is chilly, I’ll be sure to send an extra blanket with the patient
Correct: A. Want to ALWAYS use gloves
B. okay
C. not answering the question (if the question asked what about following up the patient, this would be correct…looking for follow up for the assistant personnel)\
D.
**Looking for which statement is WRONG (you should wear gloves all the time!)
When preparing to move or position a patient, the nurse should first:
A. Assemble adequate help to facilitate the change
B. Assess the patient’s ability to assist with the change
C. Determine the effect of the patient’s weight on the change
D. Decide upon the most effective method to facilitate the change
ALWAYS assess first!
(ADPIE) (Assess, diagnose, plan, intervention, evaluation)
Answer= B
When initially preparing to apply elastic stockings, the nurse must first:
A. Measure the patient’s legs
B. Select the appropriate size stockings
C. Determine the patient’s sensitivity to talcum powder
D. Place the patient in a comfortable sitting position in the bed
A= Answer
Want to measure first
A nurse is discussing restorative health care with a newly licensed nurse. Which of the following examples should the nurse include in the teaching? (Select all that apply.) A. Home health care B. Rehabilitation facilities C. Diagnostic centers D. Skilled nursing facilities E. Oncology centers
Answer: A, B, D
Restorative health care involves intermediate follow-up care for restoring health and promoting self-care. Home health care is a type of restorative health care.
Rehabilitation facilities are a type of restorative health care.
Secondary health care includes the diagnosis and treatment of acute illness or injury. Diagnostic centers are a type of secondary health care
Skilled nursing facilities are a type of restorative health care
Tertiary health care is specialized and highly technical care. An oncology center is a type of tertiary health care
A nurse is explaining the various types of health care coverage clients might have to a group of nursing students. Which of the following health care financing mechanisms are federally funded? (Select all that apply.) A. Preferred provider organization (PPO) B. Medicare C. Long-term care insurance D. Exclusive provider organization (EPO) E. Medicaid
Answers: B, E
PPO’s, Long-term care, and EPO’s are privately funded
Medicare and Medicaid are federally funded
A nurse manager is developing strategies to care for the increasing number of clients who have obesity. Which of the following actions should the nurse include as a primary health care strategy?
A. Collaborating with providers to perform obesity screenings during routine office visits
B. Ensuring the availability of specialized beds in rehabilitation centers for clients who have obesity
C. Providing specialized intraoperative training regarding surgical treatments for obesity
D. Educating acute care nurses on postoperative complications related to obesity
Answer: A
A=The nurse should identify obesity screenings at office visits as an example of primary health care. Primary health care emphasizes health promotion and disease control, is often delivered during office visits, and includes screenings
B=example of restorative health care (involves intermediate follow-up care for restoring health and promoting self-care)
C=example of tertiary health care (acute care; involves provision of specialized and highly technical care)
D=example of secondary health care (includes the diagnosis and treatment of acute illness and injury)
A nurse is discussing the purpose of regulatory agencies during a staff meeting. Which of the following tasks should the nurse identify as the responsibility of state licensing boards?
A. Monitoring evidence-based practice for clients who have a specific diagnosis
B. Ensuring that health care providers comply with regulations
C. Setting quality standards for accreditation of health care facilities
D. Determining if medications are safe for administration to clients
Answer=B
A=responsibility of utilization review committees
B= the nurse should identify that state licensing boards are responsible for ensuring that health care providers and agencies comply with state regulations
C=responsibility of the Join Commission
D=responsibility of the U.S. Food and Drug Administration
A nurse is explaining the various levels of health care services to a group of newly licensed nurses. Which of the following examples of care or care settings should the nurse classify as tertiary care? (Select all that apply). A. Intensive care unit B. Oncology treatment center C. Burn Center D. Cardiac rehabilitation E. Home health care
Answers=A, B, C
Tertiary health care involves the provision of specialized and highly technical care, such as the care nurses deliver in intensive care units, oncology treatment center, and burn centers
D= an example of restorative care and also of tertiary prevention, but not tertiary care
E=an example of restorative care
A nurse is caring for a group of clients on a medical-surgical unit. Which of the following client care needs should the initiate a referral for a social worker? (Select all that apply.)
A. A client who has terminal cancer requests hospice care in her home
B. A client asks about community resources available for older adults
C. A client states that she wants her child baptized before surgery
D. A client requests an electric wheelchair for use after discharge
E. A client states that he does not understand how to use a nebulizer
Answers= A, B, D
The nurse should initiate a referral for a social worker to provide information and assistance in coordinating hospice care for a client, coordinating care for community resources available for clients, and assisting the client in obtaining medical equipment to use after discharge.
C=referral for spiritual support staff
E=first, client teaching; second, referral for respiratory therapist
A goal for a client who has difficulty with self-feeding due to a rheumatoid arthritis is to use adaptive devices. The nurse caring for the client should initiate a referral to which of the following members of the interprofessional care team? A. Social worker B. Certified nursing assistant C. Registered dietitian D. Occupational therapist
Answer=D
An OT can assist clients who have physical challenges to use adaptive devices and strategies to help with self-care activities
A=social workers coordinate community services to help clients
B=CNA can help client with feeding, but doesn’t typically procure adaptive devices for the client
C= registered dietitian can help educate client on meeting nutritional needs
A client who is postoperative following knee arthroplasty is concerned about the adverse effects of the medication he is receiving for pain management. Which of the following members of the interprofessional care team can assist the client in understanding the medication's effects. (Select all that apply) A. Provider B. Certified nursing assistant C. Pharmacist D. Registered nurse E. Respiratory therapist
Answers: A, C, D
A provider, pharmacist, and registered nurse must be knowledgeable about any medication they prescribes/administer (RN) for the client (actions, effects, and interactions)
B&E= not within the scope of a CNA or respiratory therapist to counsel a client about medication
A client who has had a cerebrovascular accident has persistent problems with dysphagia (difficulty swallowing). The nurse caring for the client should initiate a referral with which of the following members of the interprofessional team? A. Social worker B. Certified nursing assistant C. Occupational therapist D. Speech-language pathologist
Answer= D
A speech-language pathologist can initiate specific therapy for clients who have difficulty with feeding due to swallowing difficulties
A=social worker coordinates community services to help client, but not specifically with dysphagia
B= A CNA can help client with feeding, but cannot assess and treat dysphagia
C= an OT can assist clients who have motor challenges to improve abilities with self-care and work, but cannot assess and treat dysphagia
A nurse is acquainting a group of newly licensed nurses with the roles of the various members of the health care team they will encounter on a medical-surgical unit. When she gives examples of the types of tasks certified nursing assistants (CNA's) my perform, which of the following client activities should she include? (Select all that apply.) A. Bathing B. Ambulating C. Toileting D. Determining pain level E. Measuring vital signs
Answers= A, B. C, E D= Determining pain level is a task that requires the assessment skills of licensed personnel, such as nurses. It is outside the scope of a CNA's duties.
A nurse is preparing information for change-of-shift report. Which of the following information should the nurse include in the report?
A. Input and output for the shift
B. Blood pressure from the previous day
C. Bone scan scheduled for today
D. Medication routine from the medication administration record
Answer= C
The bone scan is important because the nurse might have to modify the client’s care to accommodate leaving the unit
Unless there is a significant change in intake and output, blood pressure measurements since the previous day, or the medication routine, the oncoming nurse can read that information in the chart
A nurse is caring for a client who fell at a nursing home. The client is oriented to person, place, and time and can follow directions. Which of the following actions should the nurse take to decrease the risk of another fall? (Select all that apply)
A. Place a belt restraint on the client when he is sitting on the bedside commode.
B. Keep the bed in its lowest position with all side rails up.
C. Make sure that the client’s call light is within reach
D. Provide the client with nonskid footwear
E. Complete a fall risk assessment
Answers= C, D, E A= By restraining the client, the nurse risks liability for false imprisonment B= Full side rails for this client puts the client at risk for a fall because he might attempt to climb over the rails to get out of bed C= Call light enables client to contact nursing staff for assistance and prevents client from falling out of bed while reaching for the call light D= Nonskid footwear keeps the client from slipping E= A fall-risk assessment serves as basis for a plan of care the nurse can then individualize for the client
A nurse manager is reviewing with nurses on the unit about the care of a client who has had a seizure. Which of the following statements by a nurse requires further instruction?
A. “I will place the client on his side”
B. “I will go to the nurses’ station for assistance”
C. “I will administer his medications”
D. “I will prepare to insert an airway”
Answer= B
During a seizure, the nurse should stay with the client and use the call light to summon assistance
A, C, D= During a seizure, the nurse should place client in a side-lying position to allow for drainage or secretions and prevent tongue from occluding airway, should administer medications the provider prescribes, and place nothing in the client’s mouth except an oral airway, if he needs it. A tongue blade can cause airway obstruction.
A surgical wound requires a Hydrogel dressing. The primary advantage of this type of dressing is that it provides:
A. An absorbent surface to collect wound drainage
B. Decreased incidence of skin maceration
C. Protection from the external environment
D. Moisture needed for wound healing
Answer= D
A postoperative patient arrives at an ambulatory care center and states, “I am not feeling good.” Upon assessment, you note an elevated temperature. An indication that the wound is infected would be…
A. It has no odor
B. A culture is negative
C. The edges reveal the presence of fluid
D. It shows purulent drainage coming from the incision site
Answer= D
A nurse observes smoke coming from under the door of the staff's lounge. Which of the following actions is the nurse's priority? A. Extinguish the fire B. Activate the fire alarm C. Move clients who are nearby D. Close all open doors on the unit
Answer= C
The greatest risk to this client is injury from the fire. Therefore, the priority intervention is to rescue the clients. The nurse should protect and move clients in close proximity to the fire.
Although extinguishing the fire, activating the fire alarm, and closing all open doors on the unit are all protocol during the case of a fire, they are not the priority action.
A nurse is caring for a client who has a history of falls. Which of the following actions is the nurse’s priority?
A. Complete a fall-risk assessment
B. Educate the client and family about fall risks
C. Eliminate safety hazards from the client’s environment
D. Make sure the client uses assistive aids in his possession
Answer= A
The first action the nurse should take using the nursing process is to assess or collect data from the client. Therefore the priority action is to determine the client’s risk. This will guide the nurse in implementing appropriate safety measures.
It is important to educate the client and family about fall risks, eliminate safety hazards in the patient’s environment, as well as make sure client is using assistive aids, however, these are not the priority action.
A charge nurse is assigning rooms for the client to be admitted to the unit. To prevent falls, which of the following clients should the nurse assign to the room closest to the nurses’ station?
A. A middle adult who is postoperative following a laparoscopic cholecystectomy
B. A middle adult who requires telemetry for a possible myocardial infarction
C. A young adult who is postoperative following an open reduction internal fixation of the ankle
D. An older adult who is postoperative following a below-the-knee-amputation
Answer= D
The nurse should assign this client to a room near the nurses’ station due to risk factors that include client;s age plus the immobility and balance issues that result from this type of surgery. The client will also receive analgesics, which increase the risk for drowsiness, dizziness, and confusion.
A=Although the client just had surgery, the client’s age and type of surgery puts him at a low risk for falls
B=Although this client requires telemetry, the client does not have as many risk factors as another client the nurse will admit
C=Although the client just had surgery, the client’s age and type of surgery puts him at a low risk for falls
A nurse is providing discharge instructions for a client who has a prescription for oxygen use at home. Which of the following information should the nurse include about home oxygen safety? (Select all that apply)
A. Family members who smoke must be at least 10 ft from the client when oxygen is in use.
B. Nail polish should not be used near a client who is receiving oxygen
C. A “No Smoking” sign should be placed on the front door
D. Cotton bedding and clothing should be replaced with items made from wool
E. A fire extinguisher should be readily available in the home
Answers= B, C, E B= client should not use nail polish or any other flammable product near an oxygen tank C= a no smoking sign should be posted near the front door and possibly on the client's bedroom door E= All individuals should have a fire extinguisher at home
A=The nurse should remind family members who smoke to do it outside
D= Cotton materials are best. Wool materials create static and could cause a fire
A nurse educator is presenting a module on basic first aid for newly licensed home health care nurses. The nurse educator evaluates the teaching as effective when the newly licensed nurse states the client who has heat stroke will have which of the following? A. Hypotension B. Bradycardia C. Clammy skin D. Bradypnea
Answer=A
Hypotension is a manifestation of heat stroke
Other manifestations of heat stroke include:
-Tachycardia
-Hot, dry skin
-Dyspnea
A nurse educator is conducting a parenting class for new parents of infants Which of the following statements made by a participant indicates understanding of the instructions?
A. “I will set my water heater at 130 F degrees”
B. “Once my baby can sit up, he should be safe in the bathtub”
C. “I will place my baby on his stomach to sleep”
D. “Once my infant starts to push up, I will remove the mobile from over the crib”
Answer= D
The parent should plan to remove crib toys, such as mobiles, from over the bed as soon as the infant begins to push up so the infant is unable to touch them
A. Water heater temperature should be set at 120 F or less
B. Never leave an infant or toddler alone in the bathtub. Even if the child can hold up its head, it doesn’t make the child safe
C. Infant should be placed on its back to sleep and all suffocation hazards should be removed
A home health nurse is discussing the dangers of carbon monoxide poisoning with a client. Which of the following information should the nurse include in her counseling?
A. Carbon monoxide has a distinct odor
B. Water heaters should be inspected every 5 years
C. The lungs are damaged from carbon monoxide poisoning
D. Carbon monoxide binds with hemoglobin in the body
Answer= D
Carbon monoxide is very dangerous because it binds with hemoglobin and ultimately reduces the oxygen supplied to the tissues in the body
A=Carbon monoxide can not be seen, smelled, or tasted
B= Should inspect gas-burning furnaces, water heaters, and appliances annually
C= Carbon monoxide impairs the body’s ability to use oxygen, but the lungs are not damaged
A home health nurse is discussing the dangers of food poisoning with a client. Which of the following information should the nurse include in her counseling? (select all that apply)
A. Most food poisoning is caused by a virus
B. Immunocompromised individuals are at a risk for complications from food poisoning.
C. Clients who are at risk should eat or drink only pasteurized dairy products
D. Healthy individuals usually recover from the illness in a few weeks
E. Handling raw or fresh food separately can prevent food poisoning
Answers= B, C, E
B= Very young, very old, immunocompromised, and pregnant individuals are at risk for complications from food poisoning
C= The nurse should include that clients who are at high risk should follow a low-microbial diet, which includes eating or drinking only pasteurized milk, yogurt, cheese, and other dairy products
E= Nurse should include interventions to prevent food poisoning:
-proper hand hygiene
-cooking meat and fish to correct temperature
-handling raw and fresh food separately
-refrigerating perishable items
A=Most food poisoning is caused by bacteria such as Escherichia coli, Listeria monocytogenes, and Salmonella
D= Healthy individuals usually recover from illness in a few days
A nurse is caring for a client who is receiving external tube feedings due to dysphagia. Which of following bed positions should the nurse use for safe care of this client? A. Supine B. Semi-Fowler's C. Semi-prone D. Trendelenburg
Answer= B
In the semi-fowlers position, the client lies supine with the head of the bed elevated 15-45 degrees (typically 30). This position helps prevent regurgitation and aspiration by clients who have difficulty swallowing. This is the safest position for clients receiving enteral tube feedings.
A= In supine position, the clients lies on his back with his head and shoulders elevated on a pillow. This angle will not prevent regurgitation
C=In semi-prone or SIMS position, the client is on his side halfway between lateral and prone positions. This position is not safe because it promotes regurgitation
D= In the Trendelenburg position, the entire bed is tilted with the head of the bed lower than the foot of the bed. This position is not safe because it promotes regurgitation
A nurse is caring for a client who is sitting in a chair and asks to return to bed. Which of the following actions is the nurse’s priority at this time?
A. Obtain a walker for the client to use to transfer back to bed
B. Call for additional staff to assist with the transfer
C. Use a transfer belt and assist the client back into bed
D. Determine the client’s ability to help with the transfer
Answer= D
The first action the nurse should take using the nursing process is to assess or collect data from the client. The nurse should determine the client;s ability to help with transfers and the proceed with a safe transfer
A= Although for a safe transfer it would be necessary to obtain a walker, call for additional staff, or use transfer belt, it is not the priority action the nurse should take
A nurse is completing discharge instructions for a client who has COPD. The nurse should identify that the client understands the orthopneic position when she states that she will do which of the following when she has difficulty breathing at night?
A. Lie on her back with her head and shoulders on a pillow
B. Lie flat on her stomach with her head to one side
C. Sit on the side of her bed and rest her arms over pillows on top of her bedside table
D. Lie on her side with her weight on her hip and shoulder with her arm flexed in front of her
Answer= C
The client is describing the orthopneic position. This position allows for chest expansion and is especially beneficial for clients who have COPD
A= The client is describing the supine position, not the orthopneic position
B= The client is describing the prone position, not the orthopneic position
D= The client is describing the lateral or side-lying position, not the orthopneic position
A nurse manager is reviewing guidelines for preventing injury with staff nurses. Which of the following instructions should the nurse manager include? (select all that apply).
A. Request assistance when repositioning a client
B. Avoid twisting your spine or bending at the waist
C. Keep your knees slightly lower than your hips when sitting for long periods of time
D. Use smooth movements when lifting and moving clients
E. Take a break from repetitive movements every 2 to 3 hr to flex and stretch your joints and muscles
Answers= A, B, D A= To reduce the risk of injury, at least two staff members should reposition clients B= Twisting the spine or bending at the waist (flexion) increases the risk of injury D= Using smooth movements instead of sudden or jerky muscle movements helps prevent injury C= When sitting for long periods of time, it is essential to keep the knees slightly higher, not lower, than the hips to decrease strain on the lower back E= It is important to take a break every 15-20 min, not every 2-3 hr, from repetitive movements to flex and stretch joints and muscles
A nurse educator is reviewing proper body mechanics during employee orientation. Which of the following statements should the nurse identify as an indication that an attendee understands the teaching? (select all that apply)
A. “My line of gravity should fall outside my base of support”
B. “The lower my center of gravity, the more stability I have”
C. “To broaden my base of support, I should spread my feet apart”
D. “When I lift an object, I should hold it as close to my body as possible”
E. “When pulling an object, I should move my front foot forward”
Answers= B, C, D B= Being closer to the ground lowers the center of gravity, which leads to greater stability and balance C= Spreading the feet apart increases and widens the base of support D= Holding an object as close to the body as possible helps avoid displacement of the center of gravity and thus prevents injury and instability A= To reduce the risk of falling, the line of gravity should fall within the base of support, not outside it E= To promote stability, the nurse should move the rear leg back when pulling on an object
A nurse is caring for multiple clients during a mass casualty event. Which of the following clients is the priority?
A. A client who received crush injuries to the chest and abdomen and is expected to die
B. A client who has a 4-inch laceration to the head
C. A client who has partial-thickness and full-thickness burns to his face, neck, and chest
D. A client who has fractured fibula and tibia
Answer= C
The nurse should give first priority to a client who has the greatest chance of survival with prompt intervention. If not treated immediately, a client who has burns to his face, neck, and chest is at risk for airway obstruction, but is otherwise expected to live. Therefore, this client is the highest priority (Emergent Category: Class I)
A= The nurse should give the lowest priority to a client who is not expected to live. The nurse should provide comfort measures for this client (Expectant Category: Class IV)
B= The nurse should give third priority to the client who has minor injury that is not life-threatening, such as a laceration to the head (Nonurgent Category: Class III)
D= The nurse should give second priority to the client who has major fractures (Urgent category: Class II)
A nurse educator is discussing the facility protocol in the event of a tornado with the staff. Which of the following should the nurse include in the instructions? (select all that apply)
A. Open doors to client rooms
B. Place blankets over the clients who are confined to bed
C. Move beds away from the windows
D. Draw shades and close drapes
E. Instruct ambulatory clients in the hallways to return to their rooms
Answers= B, C, D B= The nurse should place blankets over clients to protect them from shattering glass or flying debris C= Th nurse should move all beds away from windows to protect clients from shattering glass or flying debris D= The nurse should draw shades and close drapes to protect clients from shattering glass A= The nurse should close all client doors to minimize the threat of flying glass and debris E= The nurse should instruct ambulatory clients to go to the hallways, away from windows, or other secure location designated by the facility
An occupational health nurse is caring for an employee who was exposed to an unknown dry chemical, resulting in a chemical burn. Which of the following interventions should the nurse include in the plan of care?
A. Irrigate the affected area with running water
B. Wash the affected area with antibacterial soap
C. Brush the chemical off the skin and clothing
D. Leave the clothing in place until emergency personnel arrive
Answer= C
The nurse should use a brush to remove the chemical off the skin and clothing
A= The nurse should not apply water to a dry chemical exposure because it could activate the chemical and cause further harm
B= The nurse should wash the skin with antibacterial soap in the event of a biological exposure
D= The nurse should plan to remove the client’s clothing following appropriate decontamination
A security officer is reviewing actions to take in the event of a bomb threat by phone to a group of nurses. Which of the following statements by a nurse indicates understanding of proper procedure?
A. “I will get the caller off the phone as soon as possible so I can alert the staff”.
B. “I will begin evacuating clients using the elevators”.
C. “I will not ask any questions and just let the caller talk”
D. “ I will listen for background information”.
Answer= D
In order to identify the location of the caller, the nurse should listen for background noises such as church bells, train whistles, or other distinguishing noises
A= In the event of a bomb threat, the nurse should keep the caller on the line in order to trace the call and to collect as much information as possible
B= The nurse should avoid using the elevators so that they are free for the authorities to use, and should not evacuate clients unless directed to by facility protocol
C= The nurse should ask the caller about the location of the bomb and the time it is set to explode in order to gather as much information as possible
A nurse on a medical-surgical unit is informed that a mass casualty event occurred in the community and that it is necessary to discharge stable clients to make beds available for injury victims. Which of the following clients should the nurse recommend for discharge? (select all that apply)
A. A client who is dehydrated and receiving IV fluids and electrolytes
B. A client who has a nasogastric tube to treat a small bowel obstruction
C. A client who is scheduled for elective surgery
D. A client who has chronic hypertension and blood pressure 135/85 mm Hg
E. A client who has acute appendicitis and is scheduled for an appendectomy
Answers= C, D C= The nurse should identify a client who is scheduled elective surgery is stable and is, therefore appropriate to recommend for discharge D= A blood pressure 135/85 mm Hg is within the reference range for prehypertension. The nurse should identify this client as stable and appropriate to recommend for discharge A= The nurse should recognize that a client who is receiving IV fluid and electrolytes requires ongoing nursing care and is, therefore unstable for discharge B= The nurse should recognize that a client who has a nasogastric tube requires ongoing nursing care and is, therefore unstable for discharge E= The nurse should recognize that a client who has an acute illness and is scheduled for surgery requires ongoing nursing care and is, therefore unstable for discharge
A nurse is caring for a 20-year old client who is sexually active and has come to the college health clinic for a first-time check up. Which of the following interventions should the nurse perform first to determine the client's need for health promotion and disease prevention? A. Measure vital signs B. Encourage HIV screening C. Determine risk factors D. Instruct the client to use condoms
Answer= C
The first action the nurse should take using the nursing process assessment is to talk to the client first to determine what risk factors the client might have before initiating the appropriate health promotion and disease prevention measures
A, B, D= The nurse should take vital signs, may suggest for the client to have an HIV screening, or provide condoms to decrease sexual health risk when determining the client’s need for health promotion and disease prevention. However, there is another action the nurse should take first.
A nurse in a clinic is planning health promotion and disease prevention strategies for a client who has multiple risk factors for cardiovascular disease. Which of the following interventions should the nurse include? (select all that apply)
A. Help the client see the benefits of her actions
B. Identify the client’s support systems
C. Suggest and recommend community resources
D. Devise and set goals for the client
E. Teach stress management strategies
Answers= A, B, C, and E A= The nurse should assist the client to recognize the benefits of her health-promoting actions while also overcoming barriers to implementing actions B= The nurse should collect information about who can help the client change unhealthy behaviors, and then suggest steps to have friends and family to become involved and supportive C= The nurse should promote the client's use of any available community or online resources that can help the client progress toward meeting set goals E= The nurse should teach that stress is a contributing factor to cardiovascular disease, as well as many other specific and systematic disorders D= The nurse and the client should work together to devise and set mutually agreeable goals that are also realistic and achievable
A nurse in a healthy clinic is caring for a 21-year-old client who reports a sore throat. The client tells the nurse that he has not seen a doctor since high school. Which of the following health screenings should the nurse expect the provider to perform for this client? A. Testicular examination B. Blood glucose C. Fecal occult blood D. Prostate-specific antigen
Answer= A
Starting at age 20, the client should have examination for testicular cancer, along with blood pressure and body mass index measurements and cholesterol determinations
B= Blood glucose testing begins at age 45
C= Testing for fecal occult blood usually begins at age 50
D= Testing for prostate-specific antigen usually begins at age 50
A nurse is talking with a client who recently attended a cholesterol screening event and a heart-healthy nutrition presentation at a neighborhood center. The client's total cholesterol was 248 mg/dL. After seeing the provider, the client started taking medication to lower his cholesterol level. The client was later hospitalized for severe chest pain and subsequently enrolled in a cardiac rehabilitation program. Which of the following activities for the client is an example of primary prevention? A. Cholesterol screening B. Nutrition presentation C. Medication therapy D. Cardiac rehabilitation
Answer= B
Primary prevention encompasses strategies that help prevent illness or injury. This level of prevention includes health information about nutrition, exercise, stress management, and protection from injuries and illness
A= A cholesterol screening is an example of secondary prevention
C= Starting medication therapy to lower cholesterol is an example of secondary prevention
D= Starting cardiac rehabilitation is an example of tertiary prevention
A nurse at a provider’s office is talking about routine screenings with a 45-year-old female client who has no specific family history of cancer or diabetes mellitus. Which of the following client statements indicates that the client understands how to proceed?
A. “So I don’t need the colon cancer procedure for another 2 to 3 years”
B. “For now, I should continue to have a mammogram each year”
C. “Because the doctor just did a Pap smear, I’ll come back next year for another one”
D. “I had my blood glucose test last year, so I won’t need it again til next year”
Answer= B
The female client who is between the ages of 40 and 50 should have a mammogram annually
A. The female client who has no specific family or personal history of colorectal cancer should begin screening procedures at age 50
C. The female client who is between the ages of 30 and 65, with no family history of cervical cancer, should have a Pap smear and human papilloma virus test every 5 years
D. The client who is age 45 should have a blood glucose test at least every 3 years. Unless there is specific family or personal history of diabetes mellitus, annual blood glucose determinations are not necessary
Mr. Jones presents to the ED with a temperature of 39 degrees Celsius. What is his temperature in Fahrenheit?
Answer= 102.2
By the second postoperative day, a client has not achieved satisfactory pain relief. Based on this evaluation, which of the following actions should the nurse take, according to the nursing process?
A. Reassess the client to determine the reasons for inadequate pain relief
B. Wait to see whether the pain lessens during the next 24 hours
C. Change the plan of care to provide different pain relief interventions
D. Teach the client about the plan of care for managing his pain
Answer= A
The nurse should collect further data on the client to determine why he has not achieved satisfactory pain relief, because various factors might be interfering with his comfort. The nursing process repeats in an ongoing manner across the span of client care.
B=The nurse should not wait longer to see how the client would respond, but should take action to determine why the client is not reaching achieving satisfactory pain relief.
C=The nurse should not make random changes to the plan of care without gathering evidence to guide te nurse in knowing what new interventions can be necessary
D=The action by the nurse does not acknowledge the client’s condition or that the current plan is ineffective
A newly licensed nurse is reporting to the charge nurse about the care she gave to a client. She states, "The client said his leg pain was back, so I checked his medical record, and he last received his pain medication 6 hours ago. The prescription reads every 4 hours PRN for pain, so I decided he needs it. I asked the unit nurse to observe me preparing and administering it. I checked with the client 40 minutes later, and he said his pain is going away." The charge nurse should inform the newly licensed nurse that she left out which of the following steps of the nursing process? A. Assessment B. Planning C. Intervention D. Evaluation
Answer= A
The newly licensed nurse should have used the assessment step of the nursing process by asking the client to evaluate the severity of his plan on a 0 to 10 scale. She also should have asked about the characteristics of his pain and assessed for any changes that might have contributed to worsening of the pain
B. The newly licensed nurse used the planning step of the nursing process when she decided that it was appropriate to administer the medication and, recognizing her level of experience in administering pain medication, prepared the dose under supervision from the unit staff.
C. The newly licensed nurse used the implementation step of the nursing process when she administered the medication
D. The newly licensed nurse used the evaluation step of the nursing process when she checked the effectiveness of the pain medication in relieving the client’s pain
A charge nurse is reviewing the steps of the nursing process with a group of nurses. Which of the following data should the charge nurse identify as objective data? (Select all that apply)
A. Respiratory rate is 22/min with even, unlabored respirations
B. The client’s partner states, “He said he hurts after walking about 10 minutes,”
C. Pain rating is 3 on a scale of 0-10
D. Skin is pink, warm, and dry
E. The assistive personnel reports the client walked with a limp
Answers= A, D, E
Objective data includes information the nurse measures (such as vitals), information the nurse observes (such as skin appearance), and information on observations of others (such as family and staff)
B&C- Subjective data includes a client;s reported symptoms (even if told by a secondary source)
A charge nurse is talking with a newly licensed nurse and is reviewing nursing interventions that do not require a provider’s prescription. Which of the following interventions should the charge nurse include? (select all that apply)
A. Writing a prescription for morphine sulfate as needed for pain
B. Inserting a nasogastric (NG) tube to relieve gastric distention
C. Showing a client how to use progressive muscle relaxation
D. Performing a daily bath after the evening meal
E. Repositioning a client every 2 hr to reduce pressure ulcer risk
Answers= C, D, E
C. Showing a client how to use progressive muscle relaxation is an appropriate nurse-initiated intervention for stress relief. Unless it is a contraindication for a specific client, the nurse can use this technique with clients without a provider’s prescription
D. Performing a bath is routine nursing care procedure. Unless it is a contraindication for a specific client, the nurse can determine when bathing is optimal for a client without a provider’s prescription
E. Repositioning a client every 2 hr is an appropriate nurse-initiated intervention for clients. Unless it is a contraindication for a specific client, the nurse can use this strategy without a provider’s prescription
A. The nurse must have a prescription from the provider to administer a medication. After obtaining the prescription, the nurse has the flexibility to determine when to administer a PRN medication
B. The nurse must have a prescription from the provider for the insertion of an NG tube. This is a provider-initiated intervention
A nurse is discussing the nursing process with a newly hired nurse. Which of the following statements by the newly hired nurse should the nurse identify as appropriate for the planning step of the nursing process?
A. “I will determine the most important client problems that we should address”.
B. “I will review the past medical history on the client’s record to get more information”.
C. “I will go carry out the new prescriptions from the provider”
D. “I will ask the client if his nausea has resolved”.
Answer= A
The nurse should prioritize client problems during the planning step of the nursing process
B. The nurse should review the client’s history during the assessment/data collection step of the nursing process
C. The nurse should implement nurse and provider-initiated actions during the intervention step of the nursing process
D. The nurse should gather information about whether the client’s problems have been resolved during the evaluation step of the nursing process
A nurse on a medical-surgical unit has received change-of-shift report and will care for four clients. Which of the following client;s needs should the nurse assign to an assistive personnel (AP)?
A. Feeding a client who was admitted 24 hr ago with aspiration pneumonia
B. Reinforcing teaching with a client who is learning to walk using a quad cane
C. Reapplying a condom catheter for a client who has urinary incontinence
D. Applying a sterile dressing to a pressure ulcer
Answer= C
The application of a condom catheter is a noninvasive routine procedure that the nurse may delegate to an AP
A. It would be inappropriate to delegate the feeding of a client who has aspiration pneumonia to an AP because the client is at risk for further aspiration
B&D. Either an RN or a PN, not an AP, may reinforce teaching or apply a sterile dressing
A nurse manager of a medical-surgical unit is assigning care responsibilities for the oncoming shift. A client is awaiting transfer back to the unit from the PACU following thoracic surgery. To which of the following staff members should the nurse assign this client? A. Charge nurse B. RN C. Practical nurse (PN) D. Assistive personnel (AP)
Answer= B
A client returning from surgery requires an RN’s assessment and the establishment of a plan of care, especially if the client is potentially unstable.
A. Although the charge nurse can provide all the care this client requires in the immediate postoperative period, administrative responsibilities might prevent the close monitoring and assessment this client needs
C. Although PN’s can perform some of the tasks crucial in the immediate postoperative period, the cannot provide the comprehensive care this client needs at this time
D. Although APs can perform some of the tasks crucial in the immediate postoperative period, they cannot provide the comprehensive care this client needs at this time, particularly assessment
A nurse is delegating the ambulation of a patient who had knee arthroplasty 5 days ago to an AP. Which of the following should the nurse share with the AP? (select all that apply)
A. The roommate ambulates independently
B. The client ambulates with his slippers on over his antiemetic stockings
C. The client uses a front-wheeled walker when ambulating
D. The client had pain medication 30 min ago
E. The client is allergic to codeine
F. The client ate 50% of his breakfast this morning
Answers= B, C, D
To complete this assignment safely, the AP should make sure the client wears stockings and slippers, uses a front-wheeled walker, and know that the client should be feeling the effects of the pain medication
A, E, F: The AP does not need to know the status of the client’s roommate, allergy status, or food intake to complete this assignment
An RN is making assignments for a practical nurse (PN) at the beginning of the shift. Which of the following assignments should the PN question?
A. Assisting a client who is 24-hr postoperative to use an incentive spirometer
B. Collecting a clean-catch urine specimen from a client who has a wound infection
C. Providing nasopharyngeal suctioning for a client who has pneumonia
D. Teaching a client who has asthma to use a metered-dose inhaler
Answer= D
The RN is responsible for primary teaching. The PN may only reinforce teaching
A, B, C: Assisting a client in using an incentive spirometer, collecting a clean-catch urine specimen, and providing nasopharyngeal suctioning is within the scope of practice of the PN
A nurse is preparing an in-service program about delegation. Which of the following elements should she identify when presenting the five rights of delegation? (select all that apply). A. Right client B. Right supervision and evaluation C. Right direction and communication D. Right time E. Right circumstances
Answers= B, C, E
The right supervision and evaluation, right direction and communication, and right circumstances are all one of the five rights of delegation. They also include the right task and the right person.
A. The right client is one of the rights of medication administration, not of delegation
D. Although the delegatee needs to know whether there is a time frame or a specific time to perform the task, the right time is not one of the five rights of delegation. It is one of the rights of medication administration.
When entering a client’s room to change a surgical dressing, a nurse notes that the client is coughing and sneezing. Which of the following actions should the nurse take when preparing the sterile field?
A. Keep the sterile field at least 6 ft away from the client’s bedside
B. Instruct the client to refrain from coughing and sneezing during the dressing change
C. Place a mask on the client to limit the spread of micro-organisms in the surgical wound
D. Keep a box of facial tissues nearby for the client to use during the dressing change
Answer= C
Placing a mask on the client prevents contamination of the surgical wound during the dressing change
A. It would be difficult for the nurse to maintain a sterile field away from the bedside. But mire important, this might not have any effect on the transmission of some micro-organisms
B. The client might be unable to refrain from coughing and sneezing during the dressing change
D. Keeping tissues close by for the client to use still allows contamination of the surgical wound
A nurse has removed a sterile pack from its outside cover and placed it on a clean work surface in preparation for an invasive procedure. Which of the following flaps should the nurse unfold first? A. The flap closest to the body B. The right side flap C. The left side flap D. The flap furthest from the body
Answer= D
The priority goal in setting up a sterile field is to maintain sterility and thus reduce the risk to the client’s safety. Unless the nurse pulls the top flap (the one farthest from her body) away from her body first, she risks touching part of the inner surface of the wrap and thus contaminating it
A. The flap closest to the nurse’s body is the innermost flap and the last one to unfold
B. The nurse should unfold the side flap that is closest to the top of the package before the one underneath it; however, there is another flap the nurse should unfold first.
C. The nurse should unfold the side flap that is closest to the top of the package before the one underneath it; however, there is another flap the nurse should unfold first
A nurse is wearing sterile gloves in preparation for performing a sterile procedure. Which of the following objects can the nurse touch without breaching sterile technique? (select all that apply)
A. A bottle containing a sterile solution
B. The edge of the sterile drape at the base of the field
C. The inner wrapping of an item on the sterile field
D. An irrigation syringe on the sterile field
E. One gloved hand with the other gloved hand
Answers= C, D, E
C. The inner wrappings of any objects the nurse dropped onto the sterile field are sterile. The nurse may touch them with sterile gloves
D. Any objects the nurse dropped onto the sterile field during the setup are sterile. The nurse may touch the syringe with sterile gloves
E. One sterile gloved hand may touch the other sterile gloved hand because both are sterile
A. A bottle of sterile solution is sterile on the inside and nonsterile on the outside. The nurse must prepare the sterile container of solution on the field before putting on sterile gloves
B. The 1-inch border at the outer edge of the sterile field is not sterile. The nurse may not touch it with sterile gloves
