NSG 3100 textbook ?s

Question 1

A nurse sees smoke emerging from the suction equipment being used. Which is the greatest priority in the event of a fire?

1. Report the fire.
2. Extinguish the fire.
3. Protect the clients.
4. Contain the fire.

Answer 1

Protect the clients.
Rationale: In the event of a fire, the nurse’s priority responsibility is to rescue or protect the clients under his or her care. The next priorities are to report or alert the fire department, contain or confine, and extinguish the fire.

Cognitive Level: Understanding.
Client Need: Safe, Effective Care Environment.
Nursing Process: Implementation.

Question 2

A nurse who is teaching a group of adults ages 20 to 40 years old about safety is going to ensure that which topic is a priority?

1. Automobile crashes
2. Drowning and firearms
3. Falls
4. Suicide and homicide

Answer 2

Automobile crashes
Rationale: When educating a group of young to middle-aged adults on safety, it is important to instruct them on the leading cause of injuries in this group. The leading cause of injuries in this group is related to automobile use. Option 2 is the leading cause for school-age children. Option 3 is the leading cause for older adults, and option 4 relates to adolescents.

Cognitive Level: Understanding.
Client Need: Safe, Effective Care Environment.
Nursing Process: Implementation.

Question 3

An 87-year-old man is admitted to the hospital for cellulitis of the left arm. He ambulates with a walker and takes a diuretic medication to control symptoms of fluid retention. Which intervention is most important to protect him from injury?

1. Leave the bathroom light on.
2. Withhold the client’s diuretic medication.
3. Provide a bedside commode.
4. Keep the side rails up.

Answer 3

Provide a bedside commode.
Rationale: The placement of the bedside commode next to his bed will assist in decreasing the number of steps he is required to ambulate. This will assist in protecting him from injury due to falls. Option 1: Leaving the light on would assist the client in locating the bathroom, but would not reduce the risk of fall when rushing to the bathroom. Option 2: The nurse cannot withhold a client’s medication without consulting with the primary care provider. Option 4: If the client has orders to be up with assistance and the side rails are up, he is at risk for falls as well as falling from a greater distance.

Cognitive Level: Applying.
Client Need: Safe, Effective Care Environment.

Question 4

A mother and her 3-year-old live in a home built in 1932. Which NANDA nursing diagnosis is most applicable for this child?

1. Risk for Suffocation
2. Risk for Injury
3. Risk for Poisoning
4. Risk for Disuse Syndrome

Answer 4

Risk for Poisoning
Rationale: A home that was built prior to 1978 has lead-based paint. The ingestion of lead-based paint chips places that child at risk for elevated serum lead levels and neurologic deficits. The most appropriate nursing diagnosis for this child is Risk for Poisoning. Option 1: The risk for suffocation is greater in infants and is not related to a home with lead-based paint. Options 2 and 4 are not related to lead-based paint.

Cognitive Level: Applying.
Client Need: Safe, Effective Care Environment.
Nursing Process: Nursing Diagnosis.

Question 5

A 75-year-old client, hospitalized with a cerebrovascular accident (stroke), becomes disoriented at times and tries to get out of bed, but is unable to ambulate without help. What is the most appropriate safety measure?

1. Restrain the client in bed.
2. Ask a family member to stay with the client.
3. Check the client every 15 minutes.
4. Use a bed exit safety monitoring device.

Answer 5

Use a bed exit safety monitoring device.
Rationale: Option 4 is an intervention that can allow the client to feel independent and also alert the nursing and nursing staff when the client needs assistance. It is the most realistic answer that promotes client safety. Option 1 can increase agitation and confusion and removes the client’s independence. Option 2 would help but transfers the responsibility to the family member. Option 3 is inappropriate since the client could fall during the unobserved interval and it is not a realistic answer for the nurse.

Cognitive Level: Analyzing.
Client Need: Safe, Effective Care Environment.
Nursing Process: Implementation

Question 6

A client is being admitted to the hospital because of a seizure that occurred at his home. The client has no previous history of seizures. In planning the client’s nursing care, which of the following measures is most essential at this time of admission? Select all that apply.

1. Place a padded tongue depressor at the head of the bed.
2. Pad the bed with blankets.
3. Inform the client about the importance of wearing a medical identification tag.
4. Teach the client about epilepsy.
5. Test oral suction equipment.

Answer 6

Pad the bed with blankets.

Test oral suction equipment.
Rationale: Options 2 and 5 are measures needed to keep the client safe in the event of another seizure. Option 1 is incorrect because the current nursing literature states to not put anything in the client’s mouth during a seizure. Options 3 and 4 are more relevant after the cause of the seizure is known. Seizures are not all classified as epilepsy.

Cognitive Level: Applying.
Client Need: Safe, Effective Care Environment.
Nursing Process: Planning.

Question 7

Which nursing intervention is the highest in priority for a client at risk for falls in a hospital setting?

1. Keep all of the side rails up.
2. Review prescribed medications.
3. Complete the “get up and go” test.
4. Place the bed in the lowest position.

Answer 7

Place the bed in the lowest position.
Rationale: Placing the bed in the lowest position results in a client falling the shortest distance. The client is least likely to fall when getting out of bed is at an appropriate height. Option 1 can cause a fall with injury because the client may fall from a higher distance when trying to get over the rail. Option 2 is important to do as certain medications can increase the risk of falling. However this is not the best answer because it is N/A to all clients. Option 3 would help the nurse to assess a client’s risk for falling but would not prevent injury.

Cognitive Level: Analyzing.
Client Need: Safe, Effective Care Environment.

Question 8

Medication errors can place the client at significant risk. Which practice(s) will help decrease the possibility of errors? Select all that apply.

1. Hire only competent nurses.
2. Improve the nurse’s ability to multitask.
3. Establish a reporting system for “near misses.”
4. Communicate effectively.
5. Create a culture of trust.

Answer 8

Establish a reporting system for “near misses.”

Communicate effectively.

Create a culture of trust.
Rationale: Reviewing near misses could identify flaws in the system or practices that placed the client at risk. Communication among staff and with clients will increase the efficiency and create an atmosphere where nurses are willing to discuss errors openly so that the flaws in the system can be corrected. Options 1 and 2 are inappropriate answers. A competent nurse may make medication errors. Also, evidence is needed to support these conclusions.

Question 9

When planning to teach health care topics to a group of male adolescents, which topic should the nurse consider a priority?

1. Sports contribute to an adolescent’s self-esteem.
2. Sunbathing and tanning beds can be dangerous.
3. Guns are the most frequently used weapon for adolescent suicide.
4. A driver’s education course is mandatory for safety.

Answer 9

Guns are the most frequently used weapon for adolescent suicide.
Rationale: Suicide and homicide are two leading causes of death among teenagers. Adolescent males commit suicide at a higher rate than adolescent females. Options 1 and 2 are true; however, neither would be as high a priority as preventing suicide. Option 4 is not true. A driver’s education course does not ensure safe practice.

Cognitive Level: Analysis.
Client Need: Safe, Effective Care Environment.
Nursing Process: Planning.

Question 10

The nurse, at change-of-shift report, learns that one of the clients in his care has bilateral soft wrist restraints. The client is confused, is trying to get out of bed, and had pulled out the IV line, which was subsequently reinserted. Which action(s) by the nurse is appropriate? Select all that apply.

1. Document the behavior(s) that require continued use of the restraints.
2. Ensure that the restraints are tied to the side rails.
3. Provide range-of-motion exercises when the restraints are removed.
4. Orient the client.
5. Assess the tightness of the restraints.

Answer 10

Document the behavior(s) that require continued use of the restraints.

Provide range-of-motion exercises when the restraints are removed.

Orient the client.

Assess the tightness of the restraints.
Rationale: Standards require documentation of the necessity for restraints. The implementation of range-of-motion exercises prevents joint stiffness and pain from disuse. Orienting the client helps the nurse determine the necessity of the restraint. Option 2 is inappropriate because it may cause injury if the side rail is lowered without untying the restraint.

Question 11

A client can bathe most of her body except for the back, hands, and feet. She also can walk to and from the bathroom and dress herself when given clothing. Which functional level describes this client?
Totally dependent (+4)
Moderately dependent (+3)
Semidependent (+2)
Independent (0)

Answer 11

Semidependent (+2)
Rationale: The client fits the descriptors for semi-dependent functional level (see Table 33-2).

Cognitive Level: Applying.
Client Need: Physiological Integrity.
Nursing Process: Assessment.

Question 12

The client is unresponsive and requires total care by nursing staff. Which assessment does the nurse check first before providing special oral care to the client?

Presence of pain
Condition of the skin
Gag reflex
Range of motion

Answer 12

Gag reflex
Rationale: The client will be positioned in a side-lying position with the head of the bed lowered because the client is at risk for aspiration. The absence of the gag reflex lets the nurse know that the client has no natural defense (cough) and is at a higher risk for aspiration. All other answers are assessments more appropriate prior to bathing the client.

Cognitive Level: Applying.
Client Need: Physiological Integrity.
Nursing Process: Assessment.

Question 13

A client with diabetes has very dry skin on her feet and lower extremities. The nurse plans to inform the client to do which of the following to maintain intact skin?

Soak her feet frequently.
Use a nonperfumed lotion.
Apply foot powder.
Avoid knee-high elastic stockings.

Answer 13

Use a nonperfumed lotion.
Rationale: A lotion will help moisten the skin. Perfumed lotions contain alcohol, which is drying to the skin. Soaking the feet for a long time or frequently also causes dry skin (option 1). Applying foot powder is appropriate to prevent or control unpleasant foot odor (option 3). Elastic stockings may decrease circulation (option 4).

Cognitive Level: Applying.
Client Need: Physiological Integrity.
Nursing Process: Implementation.

Question 14

The client wears an in-the-ear (ITE) hearing aid and because of arthritis needs someone to insert the hearing aid. Which action does the nurse teach the unlicensed assistive personnel (UAP) to do before inserting the client’s hearing aid?

Turn the hearing aid off.
Soak the hearing aid in soapy solution to clean it.
Turn the volume all the way up.
Remove the batteries.

Answer 14

Your Answer:
Turn the hearing aid off.
Rationale: Turn off the hearing aid. Option 2 is incorrect because an in-the-ear hearing aid is cleaned with a damp cloth. Option 3 is incorrect; make sure the volume is turned all the way down because a too loud volume is distressing. Check that the battery is in the hearing aid; do not remove the batteries (option 4).

Cognitive Level: Applying.
Client Need: Physiological Integrity.
Nursing Process: Implementation.

Question 15

The client is in surgery and will be returning to his bed via a stretcher. Which bed option reflects that the nurse appropriately planned ahead for this client?

Open bed in low position.
Occupied bed in low position.
Closed bed in high position.
Surgical bed in high position.

Answer 15

Surgical bed in high position.
Rationale: Both the placement of the linens for a surgical bed and placing the bed in a high position facilitate the client’s transfer from a stretcher into the bed. The linens for a closed bed are drawn up to the top of the bed and under the pillows (option 3).

Cognitive Level: Remembering.
Client Need: Physiological Integrity.
Nursing Process: Implementation.

Question 16

The nurse is discussing strategies with the unlicensed assistive personnel (UAP) for bathing a client with dementia. Which strategies would be appropriate for the client? Select all that apply.

Cover the client as much as possible.
Sing or talk to the client.
Complete the bath as quickly as possible.
Be organized.
Expect the client to protest—finish quickly.

Answer 16

Cover the client as much as possible.

Sing or talk to the client.

Be organized.
Rationale: Moving quickly may agitate the client (option 3). Protesting, screaming, and crying are not normal. Stop the bath and approach again later (option 5).

Cognitive Level: Applying.
Client Need: Physiological Integrity.

Question 17

The nurse is observing the unlicensed assistive personnel (UAP) perform perineal care for a client. Which action indicates that the nurse needs to discuss additional teaching with the UAP?

Uses a clean portion of the washcloth for each stroke.
Wipes from the pubis to the rectum.
Uses clean gloves.
Does not retract the foreskin.

Answer 17

Does not retract the foreskin.
Rationale: It is important to retract the foreskin to remove the smegma that collects under the foreskin and can cause bacterial growth.

Cognitive Level: Analyzing.
Client Need: Physiological Integrity.
Nursing Process: Evaluation.

Question 18

The nurse is planning a presentation on oral health at an intergenerational community center. Which statements will be important to include? Select all that apply.

Using a bottle during naps and bedtime can cause dental caries in a toddler.
Schedule a visit to the dentist when your child is ready to go to school.
It is important for parents to supervise a child’s brushing of their teeth.
Most older adults have dentures and don’t need to worry about oral care.
Older adults are at risk for periodontal disease.

Answer 18

Using a bottle during naps and bedtime can cause dental caries in a toddler.

It is important for parents to supervise a child’s brushing of their teeth.

Older adults are at risk for periodontal disease.
Rationale: The developmental level warrants supervision. If the bottle is given during naps or bedtime, the solution has continuous contact with the toddler’s teeth. The first visit to the dentist should occur between the ages of 2 and 3 (option 2). More than 50% of older adults have their own teeth (option 4).

Question 19

The nurse is discussing foot care with a client who was recently diagnosed with diabetes. Which statement by the client indicates a need for further teaching?

“I am going to use a mirror to check my feet.”
“I enjoy walking barefoot around the house.”
“I will file my nails.”
“I will increase the time that I wear new shoes each day.”

Answer 19

“I enjoy walking barefoot around the house.”
Rationale: The client needs to avoid walking barefoot because that could cause injury that may result in an infection. Also, neurologic impairment is likely as a result of the diabetes, which may result in decreased sensation. The client would be unaware of an injury.

Cognitive Level: Analyzing.
Client Need: Health Promotion and Maintenance.
Nursing Process: Evaluation.

Question 20

The client is complaining of shortness of breath. His respirations are 28 and labored. The bed is currently in the flat position. The nurse puts the bed in which position?

Fowler’s
Semi-Fowler’s
Trendelenburg
Reverse Trendelenburg

Answer 20

Fowler’s
Rationale: Fowler’s is a semisitting position that should ease the client’s breathing. The head of the bed (HOB) in semi-Fowler’s is lower (option 2). The HOB is lowered in the Trendelenburg position (option 3). Although the HOB is raised in the reverse Trendelenburg position, it is a straight tilt and may not be as comfortable as Fowler’s (option 4).

Cognitive Level: Applying.
Client Need: Safe, Effective Care Environment.
Nursing Process: Implementation.