NCLEX-RN CRITICAL CARE-with 100% verified solutions- 2024.docx, Exams of Nursing

Download NCLEX-RN CRITICAL CARE-with 100% verified solutions- 2024.docx and more Exams Nursing in PDF only on Docsity! NCLEX-RN CRITICAL CARE-with 100% verified solutions- 2024 a - The nurse is providing postprocedure care to a client who had a cardiac catheterization. The client begins to manifest signs and symptoms associated with embolization. Which action should the nurse take? a. Notify the primary healthcare provider immediately b. Apply a warm, moist compress to the incision site c. Increase the intravenous fluid rate by 20 mL/hr d. Monitor vital signs more frequently b - A nurse observes a window washer falling 25 feet (7.6 m) to the ground. The nurse rushes to the scene and determines that the person is in cardiopulmonary arrest. What should the nurse do first? a. Feel for a pulse b. Begin chest compressions c. Leave to call for assistance d. Perform the abdominal thrust maneuver d - A client reports left-sided chest pain after playing racquetball. The client is hospitalized and diagnosed with left pneumothorax. When assessing the client's left chest area, the nurse expects to identify which finding? a. Dull sound on percussion b. Vocal fremitus on palpation c. Rales with rhonchi on auscultation d. Absence of breath sounds on auscultation c - A client is admitted to the hospital with partial- and full-thickness burns of the chest and face sustained while trying to extinguish a brush fire. Which is the nurse's priority concern? a. Loss of skin integrity caused by the burns b. Potential infection as a result of the burn injury c. Inadequate gas exchange caused by smoke inhalation d. Decreased fluid volume because of the depth of the burns b - During the first 48 hours after a client has sustained a thermal injury, which conditions should the nurse assess for? a. Hypokalemia and hyponatremia b. Hyperkalemia and hyponatremia c. Hypokalemia and hypernatremia d. Hyperkalemia and hypernatremia b. Unrelated c. Inversely related d. Directly proportional c - A burn client is receiving the open method for wound treatment. Which information will the nurse explain to the client? a. Bathing will not be permitted. b. Dressings will be changed daily. c. Personal protective equipment will be worn by staff. d. Room temperature will be kept below 72° F (22.2° C). a - A client presents to the emergency department with weakness and dizziness. The blood pressure is 90/60 mm Hg, pulse is 92 and weak, and body weight reflects a 3-pound (1.4 kilogram) loss in two days. The weather has been hot. Which condition should the nurse conclude is the priority for this client? a. Deficient fluid volume b. Impaired skin integrity c. Inadequate nutritional intake d. Decreased participation in activities b - A client is admitted with severe burns. The nurse is caring for the client 36 hours after the client's admission and identifies the client's potassium level of 6.0 mEq/L (6.0 mmol/L). Which drink will the nurse recommend be included in the client's diet? a. Milk b. Tea c. Orange juice d. Tomato juice a - A woman comes to the office of her healthcare provider reporting shortness of breath and epigastric distress that is not relieved by antacids. To which question would a woman experiencing a myocardial infarction respond differently than a man? a. "Do you have chest pain?" b. "Are you feeling anxious?" c. "Do you have any palpitations?" d. "Are you feeling short of breath?" b - During a vertex vaginal birth the nurse notes meconium-stained amniotic fluid. What is the priority nursing intervention for the newborn? a. Stimulating crying b. Suctioning the airway c. Using an Ambu bag with oxygen support d. Placing the infant in the reverse Trendelenburg position c - While receiving a blood transfusion, the client suddenly shouts, "I feel like someone is lowering a heavy weight on my chest. I feel like I'm going to die!" Which actions are priority? a. Administer nitroglycerin and aspirin b. Slow the rate and monitor the vital signs c. Stop the transfusion and administer normal saline through new IV tubing d. Ask the client to further describe the feeling and rate the pain d - A client who was hospitalized with partial- and full-thickness burns over 30% of the total body surface area is to be discharged. The client asks the nurse, "How will my spouse be able to care for me at home?" How should the nurse interpret this statement? a. Readiness to discuss the client's deformities b. Indication of a change in family relations c. Need for more time to think about the future d. Beginning realization of implications for the future b - A nurse is assessing a client with a cast to the extremity. Which assessment finding is the priority? a. Warmth b - A client was admitted with full-thickness burns 2 weeks ago. Since admission, the client has lost an average of 1 lb (0.5 kg) of weight each day. Which action will the nurse most likely take based upon the adjusted dietary plan? a. Provide low-sodium milk. b. Provide high-protein drinks. c. Provide foods that are low in potassium. d. Provide 10% more calories in the form of fats. d - A burn victim has waxy white areas interspersed with pink and red areas on the anterior trunk and all of both arms. The nurse calculates the percentage of total body surface area (TBSA). Which percentage will the nurse report? a. 20 b. 25 c. 30 d. 36 d - A nurse places a client with severe burns on a circulating air bed. Which goal is the nurse trying to achieve? a. Increasing mobility b. Preventing contractures c. Limiting orthostatic hypotension d. Preventing pressure on peripheral blood vessels a - Which noninvasive assessment and management skills certification would the nurse be required to use for airway maintenance and cardiopulmonary resuscitation (CPR)? a. Basic Life Support (BLS) b. Certified Emergency Nurse (CEN) c. Advanced Cardiac Life Support (ACLS) d. Pediatric Advanced Life Support (PALS) b - The nurse is caring for different clients in a mass casualty event. Which client is assigned the lowest priority for care? a. Client with red tag b. Client with black tag c. Client with green tag d. Client with yellow tag b - On the morning of surgery a client is admitted for resection of an abdominal aortic aneurysm. While awaiting surgery, the client suddenly develops symptoms of shock. Which nursing action is priority? a. Prepare for blood transfusions. b. Notify the surgeon immediately. c. Make the client nothing by mouth (NPO). d. Administer the prescribed preoperative sedative. a - A nurse understands that value clarification is a technique useful in therapeutic communication because initially it helps clients do what? a. Become aware of their personal values b. Gain information related to their needs c. Make correct decisions related to their health d. Alter their value systems to make them more socially acceptable b - An Asian client arrives at the mental health clinic with symptoms of anxiety and panic. While speaking with the client, the nurse notes that the client makes very little eye contact. What does this assessment data suggest? a. Shyness b. Cultural variation c. Symptom of depression d. Shame regarding treatment d - Before effectively responding to a sexually abused victim on the phone, it is essential that the nurse in the rape crisis center do what? d. Increased cultural competence a - A client who only speaks Spanish is being cared for at a hospital in which nursing personnel only speak English. What communication technique would be appropriate for the nurse to use when discussing healthcare decisions with the client? a. Contact an interpreter provided by the hospital. b. Contact the client's family member to translate for the client. c. Communicate with the client using Spanish phrases the nurse learned in a college course. d. Communicate with the client with the use of a hospital-approved Spanish dictionary. b - During a routine checkup a patient reports concerns over weight gain despite trying juice cleanses and other trend diets. The nurse records the patient's weight and BMI at a healthy range, but the patient states, "I wish I were as thin as my co- workers." The patient is at risk for what culturally-bound condition? a. Neurasthenia b. Anorexia nervosa c. Shenjing shuairuo d. Ataque de nervios a - The nurse is caring for an Asian client who had a laparoscopic cholecystectomy six hours ago. When asked whether there is pain, the client smiles and says, "No." What should the nurse do? a. Monitor for nonverbal cues of pain b. Check the pressure dressing for bleeding c. Assist the client to ambulate around his room d. Irrigate the client's nasogastric tube with sterile water a - A 5-year-old child who is newly arrived from Latin America attends a nursery school where everyone speaks English. The child's mother tells the nurse that her child is no longer outgoing and has become very passive in the classroom. What is the probable reason for the child's behavior? a. Culture shock b. Social immaturity c. Experience of discrimination d. Lack of interest in school activities d - A nurse manager works on a unit where the nursing staff members are uncomfortable taking care of clients from cultures that are different from their own. How should the nurse manager address this situation? a. Assign articles about various cultures so that they can become more knowledgeable. b. Relocate the nurses to units where they will not have to care for clients from a variety of cultures. c. Rotate the nurses' assignments so they have an equal opportunity to care for clients from other cultures. d. Plan a workshop that offers opportunities to learn about the cultures they might encounter while at work. a - A mother brings her 9-month-old infant to the clinic. The nurse is familiar with the mother's culture and knows that belly binding to prevent extrusion of the umbilicus is a common practice. The nurse accepts the mother's cultural beliefs but is concerned for the infant's safety. What variation of belly binding does the nurse discourage? a. Coin in the umbilicus b. Tight diaper over the umbilicus c. Binder that encircles the umbilicus d. Adhesive tape across the umbilicus c - What should a nurse consider about the past experiences of clients who have immigrated to this country? a. It affects all of their inherited traits. b. There will be little impact on their lives today. c. It is important that their values be assessed first. d. How they will interact is permanently established. a - Which behavior is seen in children at the undifferentiated stage of spiritual development, as propounded by Fowler? a. Children have no concept of right or wrong to guide their behaviors. d. The patient is of Latin American culture. c - As the nurse is discussing psychiatric care with an older adult client, the client says, "When I was growing up I was taught to accept my lot in life and not complain. I'm proud of the fact that despite my issues I can still function independently. I don't want to be just put away." The nurse understands that the factors that influence the client's mental health are examples of what? a. Setting of care b. Anxiety disorder c. Attitudes and beliefs d. Cultural and ethnic disparities d - The nurse is caring for an Asian-American client with a diagnosis of depression. While interviewing this client the nurse notes that the client maintains traditional cultural beliefs and values. What is the most important information for the nurse to obtain about the client? a. Dietary practices b. Concept of space c. Immigration status d. Role within the family c - How can the lines of communication be improved in a healthcare organization during the process of delegation? a. By considering all aspects of client care b. By selecting experienced nursing assistants as delegatees c. By appreciating and valuing each other's cultural perspectives d. By selecting a delegatee having similar strengths as that of the delegator b - During a survey, the community nurse meets a client who has not visited a gynecologist after the birth of her second child. The client says that her mother or sister never had annual gynecologic examinations. Which factor is influencing the client's health practice? a. Spiritual belief b. Family practices c. Emotional factors d. Cultural background d - The nurse is caring for an African American client with renal failure. The client states that the illness is a punishment for sins. Which cultural health belief does the client communicate? a. Yin/Yang balance b. Biomedical belief c. Determinism belief d. Magicoreligious belief a - A pregnant immigrant notices cultural differences in the way that pregnant women are cared for where she now lives. Which component of cultural competence is being demonstrated when the nurse motivates the immigrant to accept these differences? a. Cultural desire b. Cultural awareness c. Cultural knowledge d. Cultural encounters a - A nurse notices that a client is in spiritual distress. Which nursing action establishes the nurse as a caregiver? a. The nurse provides therapeutic treatment to the client. b. The nurse teaches the client about signs of spiritual distress. c. The nurse communicates the wishes of the client to family members. d. The nurse collaborates with the agency chaplain to pursue the best treatment plan. a,b,c - Which nursing interventions are examples of the nurse as a caregiver? (Select all that apply) a. Encouraging the client to exercise daily b. Setting goals for the client to reduce weight c. Arranging for the client to meet a spiritual advisor d. Evaluating the client's understanding of prescribed diet a. Bulimia nervosa b. Anorexia nervosa c. Shenjing shuairuo d. Ataque de nervios a - A foreign language-speaking client needs to undergo chemotherapy; a signed consent form is required. What should the nurse do to explain the terms of the consent to the client? a. Seek the help of an official interpreter. b. Seek the help of the primary healthcare provider to assist the client. c. Seek help from the client's family friend who speaks the client's language. d. Seek help from the client's caregiver who speaks the same language as the client. c - A hospice nurse is caring for a dying client and the client's family members during the developing awareness stage of grief. What is the most important thing about the family that the nurse should assess before providing care? a. Cohesiveness b. Educational level c. Cultural background d. Socioeconomic status c - A nurse is caring for an adult client who immigrated to this country 5 years ago. What does the nurse know about the past experiences of clients who have immigrated to this country? a. They affect their inherited traits. b. They have little effect on their lives today. c. They are important in assessment of their values. d. They establish personal interactions throughout life. a - When caring for a client who adheres to a kosher diet, which important thing should the nurse make sure to exclude from the client's meals? a. Pork and shellfish b. Blood-containing food c. All meat, fish, and poultry d. Animal and dairy products during Lent d - A recent immigrant from mainland China is critically ill and dying. What question should the nurse ask when collecting information to meet the emotional needs of this client? a. "Do you like living in this country?" b. "When did you come to this country?" c. "Is there a family member who can translate for you?" d. "Which family member do you prefer to receive information?" a - A client says "Do not cut the thread on my wrist before sending me for surgery because the thread is a blessing from God." Which internal variable influences the client's health belief in this scenario? a. Spiritual factors b. Emotional factors c. Developmental stage factors d. Intellectual background factor b - A pregnant client states, "Abortion is banned in our community because it interferes with God's creative work." According to the nurse, which variable influences the client's health belief? a. Emotional factors b. Cultural background c. Socioeconomic factors d. Perception of functioning d - A school nurse works with adolescents who recently immigrated to the U.S. and are adjusting to life in the public schools. What characteristics help the nurse differentiate students who are assimilating from students who are acculturating? a. Students who acculturate shun all aspects of their new culture. e. "It depends on the patterns and needs of an individual." b - A patient with a terminal illness is grateful for the care received in the hospital and has slowly started to come to terms with imminent death. The nurse recognizes that the patient's behavior and attitude is most consistent with which cultural group? a. German culture b. Somalian culture c. Ukrainian culture d. More secular culture d - A patient who does not understand English requires an interpreter. Which nursing student action may exacerbate health disparities? a. The student expects the interpreter to act as the patient's advocate. b. The student expects the interpreter to have a health care background. c. The student maintains steady eye contact with the patient. d. The student talks only to the interpreter about the patient. b - While talking with a 60-year-old patient, the nurse learns that the patient emigrated 15 years ago from China and likes to live independently away from the patient's grown children. The patient eats only Chinese foods at home. What should the nurse infer from these findings? a. The patient has undergone assimilation. b. The patient has undergone biculturalism. c. The patient has undergone acculturation. d. The patient has undergone enculturation. b - Which instruction would be most beneficial for an aging African-American client with hypertension? a. "Check the pulse daily." b. "Have an annual urinalysis." c. "Record blood pressure weekly." d. "Visit an ophthalmologist monthly." c - An elderly adult suffered an injury after falling down in the washroom. The primary healthcare provider performed a surgical procedure on the client and orders a blood transfusion. A family member of the client mentions that blood transfusions are not permitted in their community. What should the nurse do in order to handle the situation? a. The nurse should wait for the court's order to give blood to the client. b. The nurse should proceed with the transfusion in order to save the client's life. c. The nurse should inform the primary healthcare provider and not give blood to the client. d. The nurse should explain to the family member that the client needs this transfusion. a,b,c - What points should a nurse keep in mind when caring for a client who belongs to a different culture? (Select all that apply). a. The nurse should be aware of his or her own cultural values and behavior patterns. b. The nurse should focus on understanding the client's traditions, values, and beliefs. c. The nurse should understand that unique cultural perceptions exist regarding health practices. d. The nurse should know that every client strictly adheres to his or her cultural beliefs and traditions. e. The nurse should know that a client's cultural background does not influence the nurse-client relationship. a - An elderly client states, "Disease occurs when supernatural elements enter the body." Which variable influences the client's health beliefs in this scenario? a. Spiritual factors b. Emotional factors c. Intellectual background d. Perception of functioning c - In order to provide ideal therapeutic communication to patients, a health care facility provides interpreter services. Which statement regarding an interpreter is correct? a. Interpreters can be relatives or friends of the patient as well. b. The interpreter should be able to make literal, word-for-word translations. c. The interpreter should be able to interpret not only the language but also the culture. e. Radiation therapy c - A patient with chronic renal failure stops responding to the treatment. On examination, the primary healthcare provider determines that the patient is terminally ill. What is the best nursing intervention in this situation? a. Suggest that the family members get a second opinion. b. Suggest that the family members continue to try different treatments. c. Encourage the family members to provide pallative care to the patient. d. Inform the family members that the disease is no longer curable and the patient will die shortly. b,d,e - After reviewing a patient's reports, the primary healthcare provider suggests palliative care for the patient. Which conditions would qualify the patient for this type of care? (Select all that apply). a. Peptic ulcer b. Chronic renal failure c. Cognitive impairment d. Congestive heart failure e. Chronic obstructive lung disease c - A terminally ill patient has died in the hospital and it is time to inform the patient's family members. The nurse is unsure how to console the family members. Which member of the interprofessional team is appropriate for the nurse to ask for support in informing and consoling the family? a. Primary health care provider b. Pharmacist c. Social worker d. Occupational therapist c - A terminally ill client in a hospice unit for several weeks is receiving a morphine drip. The dose is now above the typical recommended dosage. The client's spouse tells the nurse that the client is again uncomfortable and needs the morphine increased. The prescription states to titrate the morphine to comfort level. What should the nurse do? a. Add a placebo to the morphine to appease the spouse. b. Discuss with the spouse the risk for morphine addiction. c. Assess the client's pain before increasing the dose of morphine. d. Check the client's heart rate before increasing the morphine to the next level. c,e - What interventions should the nurse perform while caring for an actively dying patient? (Select all that apply). a. Admit the patient in hospice care. b. Perform aggressive laboratory tests. c. Provide patient and family reassurance. d. Keep the patient undisturbed for long time. e. Perform symptom management in the patient. a - A client with advanced bone cancer is experiencing cachexia. The nurse discusses the nutritional aspect of palliative care with the family. What is the importance of the nurse explaining these nutritional interventions to the family? a. Enhances the quality of the client's life b. Reduces the likelihood of a respiratory infection c. Prevents the malabsorption syndrome from occurring d. Cures the cachexia that results from bone cancer and chemotherapy 0.2 - A client with terminal bone cancer is to receive 2 mg of hydromorphone intravenously (IV) every 4 hours as needed for severe breakthrough pain. The vial contains 10 mg/mL. When the client reports severe pain, how much solution of hydromorphone should the nurse administer? Record your answer using one decimal place. Include a leading zero if applicable. mL c - The primary healthcare provider instructs the nurse to manage fluid replacement therapy in a patient with cancer. What type of care is the patient receiving? a. Palliative care b. Comfort care c. Supportive care d - A family has decided to withhold extraordinary care for a newborn with severe abnormalities. How should the nurse interpret this decision? a. The newborn has no rights. b. It is the same as euthanasia. c. It is illegal professional practice. d. The newborn is being allowed to die. d - A 76-year-old widower is terminally ill. He is very quiet and is unwilling to have visitors. During the initial contact with this client, what should the nurse do? a. Assess what the client knows about death and the dying process. b. Avoid talking about his condition unless he initiates the discussion. c. Encourage him to accept phone calls from those who wish to visit with him. d. Explore the extent to which he understands his situation and what the information means to him. a - A client with terminal cancer says to the nurse, "If I could just be free of pain for a few days, I might be able to eat more and regain strength." Which stage of grieving does the nurse concludes the client is experiencing? a. Bargaining b. Frustration c. Depression d. Rationalization b - According to Kübler-Ross, during which stage of grieving are individuals with serious health problems most likely to seek other medical opinions? a. Anger b. Denial c. Bargaining d. Depression a - What childhood problem has legal as well as emotional aspects and cannot be ignored? a. School phobia b. Fear of animals c. Fear of monsters d. Sleep disturbances a - A registered nurse is educating a nursing student about the process of resolving an ethical dilemma. What information should the nurse provide regarding negotiation of outcomes? a. "A nurse should provide a personal point of view." b. "Negotiations should be held in formal settings only." c. "Negotiation takes place immediately after gathering information." d. "The group agrees to a statement of the problem during the negotiation process." b - A nurse who promotes freedom of choice for clients in decision-making best supports which principle? a. Justice b. Autonomy c. Beneficence d. Paternalism d - Which nursing action indicates that the nurse is actively listening to the client? a. The nurse states his or her own opinions when the client is speaking. b. The nurse refrains from telling his or her own story to the client. c. The nurse reads the client's health record during the conversation. d. The nurse interprets what the client is saying and reiterates in his or her own words. a, b - What is true about psychosocial changes observed in adolescents? Select all that apply. a. "They search for personal identity." d. Defamation of character a - A nurse on the medical-surgical unit tells other staff members, "That client can just wait for the lorazepam; I get so annoyed when people drink too much." What does this nurse's comment reflect? a. Demonstration of a personal bias b. Problem solving based on assessment c. Determination of client acuity to set priorities d. Consideration of the complexity of client care d - What stage of Kohlberg's theory of moral development defines "right" by the decision of the conscience? a. Social contract orientation b. Society-maintaining orientation c. Instrumental relativist orientation d. Universal ethical principle orientation c - The nurse is caring for a client who is in pain following surgery. The nurse informs the primary health care provider about the client's request for pain medication. What is the role of the nurse in this situation? a. Educator b. Manager c. Advocate d. Administrator b - Two 14-year-old girls are best friends and always eat lunch together at school. One of the girls eats rapidly and then immediately leaves to go to the girls' restroom. After a week or so the other girl begins to suspect that her friend is using self-induced vomiting to keep her weight down. Because the friend is not sure what to do, she speaks with a relative who is a nurse. What should the nurse encourage her to do? a. Confront her friend with her suspicions. b. Talk to the school nurse about her concerns. c. Inform the girl's mother about her daughter's behavior. d. Watch a while longer before doing anything that might ruin the friendship. c - A client is presented with the treatment option of electroconvulsive therapy (ECT). After discussion with staff members, the client requests that a family member be called to help make the decision about this treatment. What ethical principle does the nurse consider when supporting the client's request? a. Justice b. Veracity c. Autonomy d. Beneficence a - The professional obligation of a nurse to assume responsibility for actions is referred to as what? a. Accountability b. Individuality c. Responsibility d. Bioethics d - A nurse is caring for a client with renal failure. The client wants to go back home but the family members want the client to undergo a kidney transplant. The nurse gives details about the possible threats and benefits of the surgery to the family and informs them that the client wants to stay home. What role does the nurse play here? a. Educator b. Manager c. Caregiver d. Advocate a - A nonviolent client on the psychiatric unit suddenly refuses to take the prescribed antipsychotic medication. What should the nurse do? a. Honor the client's decision and document the behavior and all interventions. b. Use an authoritarian approach to induce the client to take the prescribed medication. d. A proxy is a legal document that directs treatment in accordance with the client's wishes in case of a terminal illness or condition. b - The nurse is providing restraint education to a group of nursing students. The nurse should include that it is inappropriate to use a restraint device to do what? a. Prevent a client from pulling out an intravenous (IV) when there is concern that the client cannot follow instructions or is confused. b. Prevent an adult client from getting up at night when there is insufficient staffing on the unit. c. Maintain immobilization of a client's leg to prevent dislodging a skin graft. d. Keep an older adult client from falling out of bed following a surgical procedure. a - The nurse finds that an 80-year-old client's family is not caring for the client properly. Which action of the nurse indicates leadership quality? a. Advocating on behalf of the client b. Discussing the client's problem with the other nurse c. Arranging a permanent accommodation in the hospital d. Suggesting the family join the client in a long-term healthcare facility c - How would the student nurse describe a quasi-intentional tort occurring during the practice of nursing? a. It is a willful act violating a client's rights. b. It is a civil wrong made against a person or property. c. It is an act that lacks intent but involves volitional action. d. It is an unintentional act that includes negligence and malpractice. c - Which ethical principles govern a nurse's behavior when making difficult decisions about a patient's care at the point of care? a. Bioethics b. Metaethics c. Clinical ethics d. Research ethics b - Which ethical principle is violated when the nurse forgets to give a painkiller to a patient as promised? a. Justice b. Fidelity c. Veracity d. Nonmaleficence b - A nursing instructor provides teaching about the ethical principle of nonmaleficence to a group of nursing students. What is appropriate for the nurse to include in the education? a. Treat all patients equitably and fairly. b. Act in ways to prevent harm to patients. c. Tell the patient the truth about their health. d. Help the patients to make informed choices. a - What should a nurse do in order to comply with the ethic of nonmaleficence in the healthcare setting? a. The nurse should focus on doing no harm. b. The nurse should keep promises made to clients. c. The nurse should respect the autonomy of clients. d. The nurse should keep the best interests of the client in mind. c - A pregnant woman is admitted with a tentative diagnosis of placenta previa. The nurse implements prescriptions to start an intravenous (IV) infusion, administer oxygen, and draw blood for laboratory tests. The client's apprehension is increasing, and she asks the nurse what is happening. The nurse tells her not to worry, that she is going to be alright, and that everything is under control. What is the best interpretation of the nurse's statement? a. Adequate, because the preparations are routine and need no explanation b. Effective, because the client's anxieties would increase if she knew the danger involved c. Questionable, because the client has the right to know what treatment is being given and why d. Incorrect, because only the primary healthcare provider should offer assurances about management of care a. Answer the questions softly so other people will not hear. b. Decline to discuss the friend's medical condition. c. Give the coworker the name of the client's primary healthcare provider, so the coworker can contact the provider instead. d. To provide reassurance, tell the coworker of the friend's test results that are within normal limits. a - An older client is treated in the emergency department for soft-tissue injuries that the medical team suspects might be caused by physical abuse. An adult child states that the client is forgetful and confused and falls all the time. A mini-mental examination indicates that the client is oriented to person, place, and time, and the client does not comment when asked directly how the bruises and abrasions occurred. What is the next appropriate nursing action? a. Interview the client without the presence of family members. b. Report the abuse to the appropriate state agency for investigation. c. Accept the adult child's explanation until more data can be collected. d. Refer the client's clinical record to the hospital ethics committee for review. c - A nurse assisting in a research study calculates the risk-benefit ratio and concludes that there were no harmful effects associated with a survey of diabetic clients. This researcher was applying which principle? a. Human dignity b. Human rights c. Beneficence d. Utilitarianism c - A visitor says to the nurse, "Can I read my client's progress record? I am the sponsor from an alcohol recovery program." How should the nurse respond? a. Allow the visitor to review the record; sponsors have access to privileged information. b. Ask the primary healthcare provider about granting permission to the sponsor. c. Do not allow the sponsor to review the record. d. Allow the visitor to review the record; clients with alcoholism need reassurance from sponsors. b - A registered nurse is teaching a nursing student about malpractice insurance. Which statement by the nursing student requires correction? a. "Malpractice insurance provides for a defense when a nurse is alleged to have committed professional negligence or medical malpractice." b. "Most private insurance policies for nurses are primary policies that begin covering the nurse even before all hospital insurance coverage has been exhausted." c. "If both the employing institution and the nurse are sued, the nurse needs to notify his or her private insurance carrier of the lawsuit, even though the nurse has insurance through the hospital." d. "If both the hospital policy and the private policy are considered primary and the hospital loses as a result of the nurse's act, the hospital may sue the nurse's private insurer to recover its losses." c - It is determined that a staff nurse has a drug abuse problem. What approach to the staff nurse's addiction should be taken as an initial intervention? a. Counseled by the staff psychiatrist b. Dismissed from the job immediately c. Referred to the employee assistance program d. Forced to promise to abstain from drugs in the future c - A nursing team leader identifies that a nurse is coming to work after drinking alcohol. What is the most appropriate way for the team leader to approach this ethical situation? a. Counsel the nurse about the problem. b. Ignore the problem until it happens again. c. Notify the nurse manager about the problem. d. Resolve the problem by sending the nurse home. d - A child admitted to the hospital is in need of a life-saving heart transplant surgery. However, the parents refuse to allow the surgery stating that such surgeries are against their belief system. The nurse in charge of the client recognizes the situation as an ethical dilemma. What first step should the nurse take in order to resolve the dilemma? a. Evaluate the outcome of the plan of action over time. b. Verbalize the problem and agree to a statement as a group. c. Examine his or her own values critically to formulate an opinion about the issue. c - A nurse fails to act in a reasonable, prudent manner. Which legal principle is most likely to be applied? a. Malice b. Tort law c. Malpractice d. Case law a - A nurse needs to obtain consent for the medical treatment of a child whose parent is a minor. What appropriate step should the nurse take to obtain consent? a. The nurse should ask the minor to give consent. b. The nurse should wait for the consent of the court. c. The nurse should ask any adult siblings of the minor to give consent. d. The nurse should ask a legal guardian of the minor to give consent. b - A client is scheduled for skin cancer surgery and has not signed the consent form. Which situation will cause the nurse to legally delay signing the operative consent? a. Ambivalent feelings are present and acknowledged. b. A sedative type of medication has been given recently. c. A complete history and physical has not been performed and recorded. d. A discussion of alternatives with two primary healthcare providers has not occurred. c - The nurse is having difficulty understanding a client's decision to have hospice care rather than an extensive surgical procedure. Which ethical principle does the client's behavior illustrate? a. Justice b. Veracity c. Autonomy d. Beneficence a - A state's Nurse Practice Act (Canada: Provincial/Territorial Registered Nurse Act) does not allow a registered nurse (RN) to suture wounds. The primary healthcare provider offers to teach the RN how to suture and tells the RN that minor wounds may be sutured without supervision. Which action should the nurse take? a. Refuse to suture wounds b. Follow the primary healthcare provider's instructions c. Agree to suture wounds in the primary healthcare provider's presence d.Report the situation to the state board of nursing (Canada: Provincial/Territorial RN Association) d - The nurse informs a client's family that the client is in pain and does not wish to proceed with chemotherapy. What is the role of the nurse in this situation? a. Manager b. Educator c. Caregiver d. Advocate c - A client who is admitted to the hospital and requires a colon resection states, "I want to be a do not resuscitate (DNR)." The nurse questions the client's understanding of a DNR order. Which response by the client best indicates to the nurse an understanding of a DNR order? a. "My doctor will know what to do." b. "My family can make the decisions for me." c. "If something happens to me, I would rather die." d. "If I have a heart attack, I do not want any medication." b - While having a group discussion in an organization, one of the team members criticizes an idea of another team member. Which strategy should the leader apply to resolve the issue? a. Focus group b. Brainstorming c. Delphi technique d. Nominal group technique request without waiting for the client's consent. What legal charge may be brought against the nurse? a. Slander b. Negligence c. Invasion of privacy d. Defamation of character b - A parent objects to the child's getting vaccinated because she believes that vaccinations can cause autism. However, a nurse gives the child the vaccination injection against the wishes of the mother. What legal charge may be brought against the nurse? a. Assault b. Battery c. Invasion of privacy d. False imprisonment c - A nurse notes that the primary healthcare provider has scheduled a surgery for an unconscious client. An informed consent has not yet been obtained. What course of action does the nurse expect to be taken to deal with the situation? a. The client's spouse will give informed consent for the surgery. b. The procedure will be postponed till the client is able to give consent. c. The surrogate decision maker designated by the client will give consent. d. The primary healthcare provider will perform the procedure without waiting for consent. a - A nursing student is listing the different aspects of obtaining informed consent from clients. Which point mentioned by the nursing student needs correction? a. "Informed consent is an important part of the nurse-client relationship; it is a vital part of the nursing duty." b. "Informed consent should be obtained in all situations except during extraordinary circumstances." c. "Informed consent is provided by clients based on the full disclosure of risks, benefits, alternatives, and consequences of refusal." d. "The primary healthcare provider legally has to disclose facts in terms that the client is able to understand to make an informed choice." d - What should the nurse do initially when obtaining consent for surgery? a. Describe the risks involved in the surgery. b. Explain that obtaining the signature is routine for any surgery. c. Witness the client's signature, which the nurse's signature will document. d. Determine whether the client's knowledge level is sufficient to give consent. b - An adult client with mobility problems wishes to become an organ donor. Which act allows the client to donate his or her organs? a. Mental Health Parity Act b. Uniform Anatomical Gift Act c. National Organ Transplant Act d. Americans with Disabilities Act a, b, c - A nurse signs as a witness to informed consent provided by the client. What does the signature of the nurse imply? Select all that apply. a. That the client's signature is authentic b. That the client has given consent voluntarily c. That the client appears to be competent to give consent d. That the client cannot refuse treatment after its initiation e. That the client has received a proper explanation of procedures from the nurse d - An older, confused client is being cared for at home by an adult child who works full-time. The client has lost weight and is wearing soiled and inappropriate clothing. The home care nurse suspects elder neglect. What should the nurse do? a. Discuss the situation with the adult child. b. Ask the client whether the adult child is neglectful. c. Avoid reporting the situation to prevent alienation of the adult child. a. Improving social skills b. Getting out of the house for a few hours daily c. Maintaining gains achieved during hospitalization d. Avoiding direct confrontation with the community d - A nurse is preparing to care for a client who engages in ritualistic behavior. What is the most appropriate intervention to include in the plan of care? a. Redirecting the client's energy into activities to help others b. Teaching the client that the behavior is not serving a realistic purpose c. Administering antianxiety medications that block out the memory of internal fears d. Helping the client understand that the behavior is caused by maladaptive coping with increased anxiety d - A client who is taking an oral hypoglycemic daily for type 2 diabetes develops the flu and is concerned about the need for special care at home. What should the nurse instruct the client to do? a. Skip the oral hypoglycemic pill, drink plenty of fluids, and stay in bed b. Avoid food, drink clear liquids, take a daily temperature, and stay in bed c. Eat as much as possible, increase fluid intake, and call the office again the next day d. Take the oral hypoglycemic pill, drink warm fluids, and check your blood sugar before meals and at bedtime c - A client has Clostridium difficile. The nurse is providing discharge instructions related to decreasing the risk of transmission to family members. What would be appropriate to include in the client's teaching? a. Increase fluids. b. Increase fiber in the diet. c. Wash hands with soap and water. d. Wash hands with an alcohol-based hand sanitizer. a, b, c, e - Which colors are often included in an organizational disaster plan for use during triage? Select all that apply. a. Red b. Black c. Green d. White e. Yellow c - Which health care team member is a first responder when an emergency or mass casualty incident (MCI) occurs? a. Medical unit nurse b. Police officer c. Critical care nurse d. Unlicensed assistive personnel a - What should the nurse teach a client who is taking warfarin? a. Report episodes of spontaneous bleeding. b. Increase the dose with prolonged inactivity. c. Take antibiotics, if injured, to prevent infection. d. Eat a diet with an increased quantity of green vegetables. d - During change of shift report the night nurse indicates that a client cannot tolerate the prescribed intermittent tube feedings. Which action should the receiving nurse take first? a. Suggest that an antiemetic be prescribed b. Change the feeding schedule to omit nights c. Request that the type of solution be changed d. Gather more data from the night nurse about the technique used a - Which response by the nurse during a client interview is an example of back channeling? c. Contractility of the heart decreases. d. The parasympathetic nervous system is triggered. c - Which hospital department plays a primary role in disaster preparedness? a. Medical department b. Surgical department c. Emergency department d. Mental health department a - A client with hyperthyroidism is to receive methimazole. What instructions does the nurse provide? a. Initial improvement will take several weeks. b. There are few side effects associated with this drug. c. This medication may be taken at any time during the day. d. Large doses are used to quickly correct the functions of the thyroid. a - A client has a diskectomy and fusion for a herniated nucleus pulposus. When getting out of the bed for the first time since surgery, the client reports feeling faint and lightheaded. What should the nurses assisting with the ambulation have the client do? a. Sit on the edge of the bed so they can hold the client upright. b. Slide to the floor so the client will not be injured as a result of a fall. c. Bend forward so that blood flow to the brain is increased. d. Lie down immediately so they can take the client's blood pressure. a - A client is admitted to the hospital for an adrenalectomy. The nurse is providing postoperative care before the client's replacement steroid therapy is regulated fully. The nurse should monitor the client for which complication? a. Hypotension b. Hypokalemia c. Hypernatremia d. Hyperglycemia d - A client is undergoing diagnostic testing to determine if the client has myasthenia gravis. The nurse understands that the test that is most specific for determining the presence of this disease is what? a. Electromyography b. Pyridostigmine test c. History of physical deterioration d. Edrophonium chloride test c - Which method of delivering client care works well in disaster situations? d. "Were you aware of anything different or unusual just before your seizure began?" a - Which member of the health care team is accountable for initial assessment and ongoing evaluation of client care? a. Registered nurse b. Licensed practical nurse c. Primary health care provider d. Unlicensed nursing personnel d - A client is having a tonic-clonic seizure. Which is a priority nursing action? a. Elevating the head of the bed b. Restraining the client's arms and legs c. Placing a tongue blade in the client's mouth d. Taking measures to prevent injury b - A client with an abdominal wound infected with methicillin-resistant Staphylococcus aureus (MRSA) is scheduled for a computed tomography (CT) scan of the abdomen. To ensure client and visitor safety during transport, the nurse should implement which precaution? a. No special precautions are required. b. Cover the infected site with a dressing. c. Drape the client with a covering labeled biohazardous. d. Place a surgical mask on the client. d - Two nurses are planning to help a client with one-sided weakness move up in bed. What should the nurses do to conform to a basic principle of body mechanics? a. Instruct the client to position one arm on each shoulder of the nurses. b. Direct the client to extend the legs and remain still during the procedure. c. Have both nurses shift their weight from the front leg to the back leg as they move the client up in bed. d. Position the nurses on either side of the bed with their feet apart, gather the pull sheet close to the client, turn toward the head of the bed, and then move the client. a - Which description by the nurse is a correct explanation of delegation? a. The transfer of responsibility for the performance of an activity b. The person's responsibility and accountability for individual actions or omissions c. The active process of directing, guiding, and influencing the outcome of an individual d. The transfer of both the accountability and responsibility from one person to another 18 - A healthcare provider prescribes lidocaine HCl, 1.5 mg per minute, for a client whose ECG tracing reveals multiple premature ventricular complexes (PVCs). The nurse adds 500 mg of lidocaine HCl to 100 mL of D5W. To administer the correct amount of medication, at what rate should the nurse set the intravenous (IV) infusion pump? Record your answer using a whole number. mL/hr d - Which caring intervention helps to provide comfort, dignity, respect, and peace to a client? a. Listening b. Spiritual caring c. Providing presence d. Relieving pain and suffering d - A client with arterial insufficiency of both lower extremities is visited by the home healthcare nurse. What client teaching is an essential nursing intervention? a. "Maintain elevation of both legs." b. "Massage the legs when they are painful." c. "Apply a hot water bottle to the legs." d. "Check pulses in the legs regularly." b - The nurse is assessing a client after surgery. Which assessment finding does the nurse obtain from the primary source? a. X-ray reports e. Administering intravenous antibiotics d - A nurse is developing a teaching plan for a client with lower extremity arterial disease (LEAD). Which information will the nurse include in the teaching plan? a. Trimming toenails so that they are short and rounded b. Checking bathwater temperature by putting the toes in first c. Using alcohol to rub hands, feet, legs, and arms at least two times a day d. Seeking professional treatment for any minor injuries to the extremities d - Which step in the nursing process would involve promoting a safe environment for the client? a. Planning b. Diagnosis c. Assessment d. Implementation d - A client presents to the healthcare facility with abdominal pain. Which question should the nurse ask the client to obtain information about concomitant symptoms? a. "Can you describe the pain?" b. "Where exactly do you feel the pain?" c. "Which activities make the pain worse?" d. "What other discomfort do you experience?" b - In which role does the nurse oversee the budget of a specific nursing unit or agency? a. Nurse educator b. Nurse manager c. Nurse researcher d. Nurse practitioner a - A nurse is caring for a client with the diagnosis of schizophrenia. What should the nurse plan to do to increase the self-esteem of this client? a. Reward healthy behaviors. b. Explain the treatment plan. c. Identify various means of coping. d. Encourage participation in community meetings. a - A client is receiving patient-controlled analgesia (PCA) after surgery. What does the nurse identify as the primary benefit with this type of therapy? a. Client is able to self-administer pain-relieving drugs as necessary b. Amount of medication received is determined entirely by the client c. Amount of drug used for analgesia matches sleep-wake cycles d. Self-administration relieves the nurse of monitoring the client for pain relief b - A client diagnosed with tuberculosis is taking isoniazid. To prevent a food and drug interaction, the nurse should advise the client to avoid which food? a. Hot dogs b. Red wine c. Sour cream d. Apple juice b - A nurse is preparing to teach a client to apply a nitroglycerin patch as prophylaxis for angina. Which instruction should the nurse include in the teaching plan? a. Apply the patch on a distal extremity. b. Remove a previous patch before applying the next one. c. Massage the area gently after applying the patch to the skin. d. Apply a warm compress to the site before attaching the patch. a - When caring for a client who is receiving enteral feedings, the nurse should take which measure to prevent aspiration? a. Elevate the head of the bed between 30 and 45 degrees. a - What should the associate nurse use to provide client care within the primary nursing delivery model? a. Plan of care b. Nurse's notes c. Physician's orders d. Direction from the charge nurse c - Tissue plasminogen activator (t-PA) is to be administered to a client in the emergency department. Which is the priority nursing assessment? a. Apical heart rate b. Electrolyte levels c. Signs of bleeding d. Tissue compatibility d - A client in a nursing home is diagnosed with urethritis. What should the nurse plan to do before initiating antibiotic therapy prescribed by the primary healthcare provider? a. Start a 24-hour urine collection. b. Prepare for urinary catheterization. c. Teach the client how to perform perineal care. d. Obtain a urine specimen for culture and sensitivity. a - A client with a leg prosthesis and a history of syncopal episodes is being admitted to the hospital. When formulating the plan of care for this client, the nurse should include that the client is at risk for what? a. Falls b. Impaired cognition c. Imbalanced nutrition d. Impaired gas exchange d - While organizing a community health care program for polio vaccinations, the registered nurse delegates the task of administering vaccines to the members of the health care team. Who among the health care team is most suitable to carry out the task? a. Technician b. Patient care associate c. Certified nursing aide d. Licensed practical nurse b - Which team member acts as a liaison between the health care facility and the media? a. Triage officer b. Public information officer c. Medical command physician d. Hospital incident commander b - Immediately after a bilateral adrenalectomy a client is receiving corticosteroids that are to be continued after discharge from the hospital. Which statement by the client indicates to the nurse that additional education is needed? a. "I need to have periodic tests of my blood for glucose." b. "I am glad that I only have to take the medication once a day." c. "I must take the medicine with meals while I have food in my stomach." d. "I should tell the doctor if I am overly restless or have trouble sleeping." b - In preparation for discharge, a client who had a total hip replacement is taught wound care by the nurse. Which statement from the client indicates a correct understanding of the nurse's instructions? a. "I will sit in a chair for several hours every day." b. "I will inspect the incision for healing when I change the dressing." c. "I will check to see whether the staples have dissolved within a few days." d. "I will call the health care clinic if I see any clear drainage coming from the incision." a - Which is essential for ensuring disaster readiness in a community? a. Two b. Three c. Four d. Five d - A nurse performs full range-of-motion exercises on a client's extremities. When putting an ankle through range-of-motion exercises, what must the nurse perform? a. Flexion, extension, and rotation b. Abduction, flexion, adduction, and extension c. Pronation, supination, rotation, and extension d. Dorsiflexion, plantar flexion, eversion, and inversion c - During a home visit, a nurse discovers that a child in the household has a disability and has been experiencing seizures. In addition, the child's parent is indifferent to the child's physical, emotional, or medical needs and seems to provoke seizure episodes by harsh verbal exchanges with the child. The nurse believes that an intervention by an appropriate community resource is indicated. Where should the nurse direct the referral? a. Outpatient clinic b. Hospital pediatric unit c. Child Protective Services d. Bureau of the handicapped a, b, d - Which threats, included in the term "NBC", lead to the implementation of improved emergency medical services (EMS) and hospital safety programs? Select all that apply. a. Nuclear b. Biologic c. Botulism d. Chemical e. Nipha virus a - A client with achalasia is scheduled to have a bougienage to dilate the lower esophagus and cardiac sphincter. After the procedure the nurse assesses the client for what complications related to esophageal perforation? a. Tachycardia and abdominal pain b. Faintness and feelings of fullness c. Diaphoresis and cardiac palpitations d. Increased blood pressure and urinary output a - A nurse is providing postoperative care for a client one hour after an adrenalectomy. Maintenance steroid therapy has not begun yet. The nurse should monitor the client for which complication? a. Hypotension b. Hyperglycemia c. Sodium retention d. Potassium excretion b - A nurse is working with an unlicensed assistive personnel (UAP) in caring for a group of clients. Which statement by the UAP indicates a correct understanding of the UAP's role? a. "I will turn off clients' IVs that have infiltrated." b. "I will take clients' vital signs after their procedures are over." c. "I will use unit written materials to teach clients before surgery." d. "I will help by giving medications to clients who are slow in taking pills." a - A client is admitted with a closed head injury sustained in a motor vehicle accident (MVA). The nursing assessment indicates increased intracranial pressure (ICP). Which intervention should the nurse perform first? a. Place the head and neck in alignment. b. Administer 1 gram mannitol intravenously (IV) as prescribed. c. Increase the ventilator's respiratory rate to 20 breaths/minute. d. Administer 100 mg of pentobarbital IV as prescribed.