NUR 1600 Maternity (Prioritization) EXAM (GRADED A) plus Rationales | 100% Guaranteed ACE

Question 1 See full question Several hours into a shift, a nurse on a very busy medical-surgical unit privately asks the charge nurse to change her assignment. She is frustrated because she has had t o devote so much time and energy to helping a newly licensed nurse provide discharge teaching for clients with diabetes mellitus. The charge nurse should: Correct response: • offer to assist with the discharge teaching needs. Explanation: Staff members need to know the charge nurse is a supportive leader who respects their honesty and stands behind them. By offering to help with discharge teaching, the charge nurse is actively engaging with her staff at a time of need. Changing all the assignments on this extremely busy floor would be counterproductive. Insisting that the staff member follow through with her assignment disrespects her request and genuine need. Providing a float nurse could help, but there are no guarantees a float nurse is available. Remediation: • Discharge Question 2 See full question During chemotherapy, an oncology client has a nursing diagnosis of Impaired oral mucous membrane related to decreased nutrition and immunosuppression secondary to the cytotoxic effects of chemotherapy. Which nursing intervention is most likely to decrease the pain of stomatitis Correct response: • Providing a solution of viscous lidocaine for use as a mouth rinse Explanation: To decrease the pain of stomatitis, the nurse should provide a solution of hydrogen viscous lidocaine for the client to use as a mouth rinse. (Commercially prepared mouthwashes contain alcohol and may cause dryness and irritation of the oral mucosa.) The nurse also may administer systemic analgesics as ordered. Stomatitis occurs 7 to 10 days after chemotherapy begins; thus, stopping chemotherapy wouldn't be helpful or practical. Instead, the nurse should stay alert for this potential problem to ensure prompt treatment. Monitoring platelet and leukocyte counts may help prevent bleeding and infection but wouldn't decrease pain in this highly susceptible client. Checking for signs and symptoms of stomatitis also wouldn't decrease the pain. Remediation: • Impaired Oral Membrane Question 3 See full question A nurse has been caring for an adolescent client in a residential facility. The child has been through a series of foster placements since infancy with no success in any placement until the age of 7 when placed with a middle-aged single woman. The client thrived there until the woman was killed in a car accident. The client attempted suicide after her foster mother died in response to the loss and the child was placed in the residential facility. The nurse has become close to this client and wants to help her address her issues and move on with her life. Which comment to the manager demonstrates that the nurse understands the client’s issues and is able to respond appropriately to the client’s needs? You Selected: • "It is difficult for her to love and trust again after her losses. In this facility, she can learn to deal with her loss in a less emotionally charged environment than a foster home." Explanation: The severe emotional trauma the girl has experienced will likely make it difficult for her to be successful in an adoptive placement at the present time, whether that placement is with someone she knows (the nurse) or another adoptive family. Additionally, adoption by the nurse is inappropriate because it blurs the lines between her professional and personal life and is likely to confuse the client. It is clear that the client has many issues and that love alone is not likely to solve all her problems. Treatment at the residential facility will allow her to work through emotional issues in a more therapeutic environment. Though not currently ready for adoption, she may be ready for adoption in the future after sufficient treatment. Question 4 See full question A client is about to undergo cardiac catheterization for which he signed an informed consent. As the nurse enters the room to administer sedation for the procedure, the client states, "I'm really worried about having this open heart surgery." Based on this statement, how should the nurse proceed? Correct response: • Withhold the medication and notify the physician immediately. Explanation: The nurse should withhold the medication and notify the physician that the client does not understand the procedure. The physician then has the obligation to explain the procedure better to the client and determine whether or not the client understands. If the client does not understand, he cannot give a true informed consent. If the medication is administered before the physician explains the procedure, the sedation may interfere with the client's ability to clearly understand the procedure. The nurse may not just medicate the client and document the finding; the physician must be notified. The procedure does not need to be cancelled, only postponed until the client receives more education and is able to give informed consent. Remediation: • Decisional Conflict Question 5 See full question Which action associated with restraint use on a confused client can be delegated to an unlicensed healthcare worker/nursing assistant? • Completion of range of motion on limbs restrained Question 1 See full question Four clients have been admitted to the cardiac intensive care unit after experiencing acute myocardial infarctions. Each client has sustained a percentage of cardiac damage. Which client is most in need of interventions to prevent the development of cardiogenic shock? Correct response: • The client with 40% damage Explanation: At least 40% of the heart muscle must be involved for cardiogenic shock to develop. In most circumstances, the heart can compensate for up to 25% damage. An infarction involving 70% of the heart would have likely already caused cardiogenic shock. Question 2 See full question The nurse is providing postoperative care to a client with sickle cell anemia. What is the most important intervention for the nurse to include in the plan of care? Correct response: • Increasing fluids Explanation: The main surgical risk of anesthesia is hypoxia. Emotional stress, demands of wound healing, and the potential for infection can each increase the sickling phenomenon. Increased fluids are encouraged because hydration promotes hemodilution, and decreases sickling. Preparing the child psychologically to decrease fear will minimize undue emotional stress, but is not a priority. Deep coughing is encouraged to promote pulmonary hygiene and prevent respiratory tract infection. Analgesics are used to control wound pain and to prevent abdominal splinting and decreased ventilation. Remediation: A hospitalized client, with a productive cough, chills, and night sweats is suspected of having active tuberculosis (TB). What is the nurse’s most important intervention? You Selected: • Maintain the client on respiratory isolation Correct response: • Maintain the client on respiratory isolation Explanation: This client is showing signs and symptoms of active TB and, because of the productive cough, is highly contagious. He should be admitted to the hospital and placed in respiratory isolation. Three sputum cultures should be obtained to confirm the diagnosis. Question 4 See full question The nurse is caring for a client with type 1 diabetes mellitus. At 3:00 AM, the nurse finds the client disoriented to time and place, diaphoretic, and complaining of palpitations. What is the nurse’s priority intervention? You Selected: • Check blood glucose level Correct response: • Check blood glucose level Explanation: Check the blood glucose level first when symptoms arise, then proceed with treatment according to the results. If the client is hypoglycemic, administration of a simple carbohydrate is appropriate. If the client is conscious, the carbohydrate may be given orally. If consciousness is altered, subcutaneous or intramuscular glucagon is appropriate. This client is showing symptoms of hypoglycemia, additional insulin would further lower the blood glucose. Remediation: • Diabetes Mellitus (Type 1), Long-Term Care Question 5 See full question A two-month-old infant arrives with a heart rate of 180 bpm and a temperature of 103.1° F (39.5° C) rectally. What is the most appropriate initial nursing intervention? You Selected: • Give acetaminophen Correct response: • Give acetaminophen Explanation: Acetaminophen should be given to decrease the temperature. A heart rate of 180/bpm is normal in an infant with a fever. A tepid sponge bath may be given to help decrease the temperature and calm the infant. Carotid massage, and placing the infant’s hands in cold water are attempts to decrease the heart rate through vagal maneuvers. This will not work because the source of the increased heart rate is fever. Fluid intake is encouraged after the acetaminophen is given to help replace insensible fluid losses. Remediation: • Acetaminophen Question 6 See full question A 19-month-old child with croup is crying as a nurse tries to auscultate breath sounds. What is the nurse’s most appropriate intervention? You Selected: • Hand the stethoscope to the child to examine before auscultating his lungs Correct response: • Hand the stethoscope to the child to examine before auscultating his lungs Explanation: Children at this age are very curious. Encouraging the child to play with the stethoscope will distract him and help gain trust so that the nurse will be able to auscultate the lungs. Ignoring the child’s crying may only upset him more, and will not help the nurse gain his trust. The nurse should ask the parents to help quiet and comfort the child. Asking the parents to leave may only upset the child more. The nurse should speak to the child in a soft, comforting tone of voice. Question 7 See full question A client in early labor tells the nurse that she has a thick, yellow discharge from both of her breasts. What is the nurse’s most appropriate intervention? You Selected: • Inform the client that the discharge is colostrum, and a normal finding Explanation: After the fourth month, colostrum may be expressed. The breasts normally produce colostrum for the first few days after birth. Milk production begins one to three days postpartum. A clinical breast examination isn’t usually indicated in the intrapartum setting. Although a culture may be indicated, it requires advanced assessment as well as a medical order. Remediation: • Breast Care For Non-Nursing Mothers Question 8 See full question Which nursing intervention is priority for an infant during the first 24 hours following surgery for cleft lip repair? Correct response: • Carefully clean the suture line after feedings to reduce the risk of infection Explanation: The suture line must be carefully cleaned with a sterile solution after each feeding to reduce the risk of infection, which could adversely affect the healing and cosmetic results. The infant shouldn’t be placed in the prone position, because this puts pressure on the incision and may affect healing. Anticipatory care should be provided to reduce the risk of the infant crying, which puts strain on the incision. Pacifiers and other firm objects should not be placed in the infant’s mouth because they can disrupt the suture line. Remediation: Question 9 See full question A nurse on a maternity unit witnesses a mother slapping the face of her crying neonate. What is the nurse’s priority action? Correct response: • Take the neonate to the nursery, inform the health care provider of what was witnessed, and notify social services Explanation: The neonate’s safety and protection are the nurse’s first priority. The nurse should immediately take the neonate to the nursery and inform the health care provider of the abuse. As an advocate for the neonate, the nurse provides the health care provider with an opportunity to examine the child for injuries. The nurse should not confront the client. Observing the mother for further incidents may be part of the revised care plan, however this incident requires immediate intervention. Question 10 See full question Two hours after starting total enteral nutrition (TEN) through a nasogastric tube, a client starts to have abdominal distention. Which action should the nurse take first? Correct response: • Stop the feeding Explanation: Clients receiving TEN are at risk for abdominal distention due to rapid feeding or delayed emptying of the stomach contents. The nurse should stop the feeding to prevent further distention and then continue to assess the cause of the distention. Aspirating the stomach contents and repositioning the tube may be necessary but are not the priority. A client receiving a nasogastric tube feeding should be placed in an upright or Fowler’s position to prevent the risk of aspiration. Question 1 See full question Which client would benefit most from information explaining the importance of receiving an annual Papanicolaou (PAP) test? Correct response: • A client infected with the human papillomavirus (HPV) Explanation: HPV causes genital warts, which are associated with an increased incidence of cervical cancer. Recurrent candidiasis, pregnancy before age 20, and the use of oral contraceptives have not been shown to increase the risk of cervical cancer. Remediation: Question 2 See full question A client with schizophrenia has been stable for some time. What action is most important for preventing relapse? Correct response: • Consistently taking prescribed medications Explanation: Although all of the choices are important for preventing relapse, compliance with the medication regimen is the priority in the treatment of schizophrenia. Remediation: Question 3 See full question The nurse is caring for a client struggling with alcohol dependence. It is most important for the nurse to: Correct response: • avoid blaming or preaching to the client. Explanation: Blaming or preaching to the client causes negativity and prevents the client from hearing what the nurse has to say. Speaking briefly to the client may not allow time for adequate communication. Perfectionism doesn’t tend to be an issue. Determining if nonverbal communication will be more effective is better suited to a client with cognitive impairment. Remediation: Question 4 See full question A client is admitted to the labor and delivery unit for birth of a known anencephalic fetus. What is the most appropriate intervention by the nurse? You Selected: • Provide privacy and emotional support Correct response: • Provide privacy and emotional support Explanation: Providing privacy and support is an appropriate therapeutic intervention for the client and family to grieve their loss. Fetal heart tones are rarely assessed in a client with an anencephalic fetus. Most fetuses will not survive due to a lack of cerebral function. Reassuring the client that she will get pregnant again dismisses how she feels about her current loss, and also provides false reassurance. Question 5 See full question The nurse is assessing a client 22 hours after a cesarean birth. Which assessment finding would require immediate action by the nurse? You Selected: • Heart rate of 132 beats/min and blood pressure of 84/60 mmHg Correct response: • Heart rate of 132 beats/min and blood pressure of 84/60 mmHg Explanation: Tachycardia and hypotension may be signs of hemorrhage. An oral temperature of 100.2° F (37.9º C) may be due to dehydration, if it occurs on the first postpartum day. A gush of blood from the vagina when a client stands is a normal finding on the first postpartum day. Reports of abdominal pain and cramping are expected following cesarean birth. Question 1 See full question A client displays signs associated with a possible ruptured aortic aneurysm. What is the priority nursing intervention? Correct response: • Prepare the client for surgical intervention Explanation: When the vessel ruptures, prompt surgery is required for it’s repair. Antihypertensive medications and beta-adrenergic blockers can help control hypertension, reducing the risk of rupture. An aortogram is a diagnostic tool used to detect an aneurysm. Remediation: Question 2 See full question A 22-year-old client with quadriplegia in supine position is apprehensive and flushed, with a blood pressure of 210/100 mmHg and heart rate of 50 bpm. Which nursing intervention should be done first? Correct response: • Raise the head of the bed immediately to 90 degrees Explanation: Anxiety, flushing above the level of the lesion, piloerection, hypertension, and bradycardia are symptoms of autonomic dysreflexia, typically caused by such noxious stimuli as a full bladder, fecal impaction, or pressure ulcer. Putting the client flat will cause the blood pressure to increase more. The indwelling urinary catheter should be assessed immediately after the head of the bed is raised. Nitroglycerin is given to relieve chest pain and reduce preload. It isn’t used for hypertension or dysreflexia. Question 3 See full question A nurse is instructing an unlicensed assistive personnel (UAP) on the proper care of a client in Buck’s extension traction following a fracture of the left fibula. Which observation would indicate that teaching has been effective? Correct response: • The weights are allowed to hang freely over the end of the bed. Explanation: In Buck’s traction, the weights should hang freely without touching the bed or floor. Lifting the weights would break the traction. The client should be moved up in bed, allowing the weight to move freely along with the client. The leg should be kept in straight alignment. Performing ankle rotation exercises could cause the leg to go out of alignment. • ) Question 4 See full question The nurse is planning care for a child admitted to the pediatric unit with neonatal bronchopulmonary dysplasia (chronic lung disease). Which intervention should the nurse perform first? You Selected: • Provide humidified oxygen Correct response: • Provide humidified oxygen Explanation: Tachypnea, dyspnea, and wheezing are intermittently or chronically present, secondary to airway obstruction and increased airway resistance. Giving humidified oxygen will help keep the airways moist and liquefy secretions. Fluid restriction may be ordered to decrease secondary problems such as heart failure, but it is not in all cases. The palivizumab vaccine is recommended in children with chronic lung disease to prevent respiratory syncytial viral (RSV) infection. It is typically given during RSV season. The ambient air temperature should be kept in a neutral thermal zone to decrease oxygen consumption. Question 5 See full question A three-year-old child is given a preliminary diagnosis of acute epiglottitis. Which initial nursing intervention is most appropriate? • Have emergency airway equipment readily available Explanation: With acute epiglottitis, the glottal structures become edematous. Emergency airway equipment and humidified oxygen should be readily available. The nurse should not attempt to visualize the epiglottis, use tongue blades or throat culture swabs, which can cause the epiglottis to spasm, and totally occlude the airway. Throat inspection should only be attempted when immediate intubation or tracheostomy can be performed in the event of further or complete obstruction. The child should always remain in a position that provides the most comfort, security and ease of breathing. The child will often assumes a classic tripod posture with the trunk leaning forward, neck hyperextended, and chin thrust forward. Question 6 See full question Which nursing intervention is priority for a pregnant adolescent during her first trimester? Correct response: • Refer the client to a dietitian for nutritional counseling Explanation: Adolescents are at risk for delivering low-birth-weight neonates. Nutritional counseling should be a priority for these clients to ensure proper fetal development. A pregnant adolescent is not likely to deliver a macrosomic neonate. The final head size of the fetus is unknown at this time. Adolescents are not at increased risk for developing gestational diabetes or placenta previa. Question 7 See full question A client is admitted to the labor and delivery unit in labor with blood flowing down her legs. What would be the priority nursing intervention? Correct response: • Monitor fetal heart tones Explanation: Monitoring fetal heart tones would be the priority, due to a possible placenta previa or abruptio placentae. Although an indwelling catheter may be placed, it is not a priority intervention. Remediation: Question 8 See full question A nurse is teaching a group of parents about recurrent urinary tract infections (UTIs) in their children. What is the priority educational goal for this group of parents? Correct response: • Parents will identify ways of preventing UTIs Explanation: Prevention is the most important goal of teaching about primary and recurrent UTIs. The most preventive measures are simple hygienic practices that should be a routine part of daily care. Treatment, detection, and testing are all important, but are not the priority goal. Question 9 See full question A client with a panic disorder is having difficulty falling asleep. Which nursing intervention should be performed first? Correct response: • Teach the client progressive relaxation Explanation: Relaxation techniques work very well with a client showing anxiety. If this doesn’t work, then contacting the psychotherapist, diversionary activities, and pharmacological interventions would be in order. Remediation: Question 10 See full question A nurse finds a client crying after she was told by the health care provider that she is to start hemodialysis to treat her acute renal failure. What is the nurse’s most important intervention? Correct response: • Sit quietly with the client Explanation: Sitting with the client shows compassion and concern and may help the nurse establish therapeutic communication. Making a referral doesn’t allow the client to explore feelings with the nurse. The nurse can’t guarantee the acute renal failure is temporary. Discussing the client’s other abilities diverts the emphasis from the client’s primary issue. Question 1 See full question In which circumstance may the nurse legally and ethically disclose confidential information about a client? • A taxi driver's diagnosis of an uncontrolled seizure disorder to a state agency Explanation: Question 2 See full question A charge nurse tells a new nurse, "You really need to get your skills up to speed." The statement hurts and embarrasses the new nurse. How can she best handle the situation? Correct response: • Ask for a private meeting to explore the charge nurse's concerns in detail. Explanation: Question 3 See full question Which nursing diagnosis takes highest priority for a child in the early stages of burn recovery? Correct response: • Risk for infection Question 4 See full question A nurse feels that a 5-year-old boy in her care is showing signs and symptoms of diabetes mellitus. The nurse should: Correct response: • gather supporting evidence and contact the physician with her concerns. Explanation: Remediation: Question 5 See full question A nurse is caring for a school-age child with cerebral palsy. The child has difficulty eating using regular utensils and requires a lot of assistance. Which referral is most appropriate? Correct response: • Occupational therapist Explanation: Remediation: Question 6 See full question A nurse-manager for a community health organization is planning for the home health needs of an 8-year-old child who requires around-the-clock care by nursing assistants. The nurse-manager knows that when working with a nursing assistant, she must: Correct response: • provide written instructions, education, and ongoing supervision. Explanation: Question 8 See full question A nurse caring for a client who had a stroke is using the unit's new computerized documentation system. The nurse uses the information technology appropriately when she: . Correct response: • documents medications after administration. Question 9 See full question When creating a program to decrease the primary cause of disability and death in children, the nurse should: Correct response: • teach health and safety practices to children and their parents. Explanation: Question 10 See full question During a home visit to an elderly client with mild dementia, the client's daughter reports that she has one major problem with her mother. She says, "She sleeps most of the day and is up most of the night. I cannot get a decent night's sleep anymore." Which suggestions should the nurse make to the daughter? Select all that apply. Correct response: • Establish a set routine for rising, hygiene, meals, short rest periods, and bedtime. • Engage the client in simple, brief exercises or a short walk when she gets drowsy during the day. • Promote relaxation before bedtime with a warm bath or relaxing music. Question 11 See full question An elderly client is being admitted to same-day surgery for cataract extraction. The client has several diamond rings. The nurse should explain to the client that: Correct response: • the rings will be placed in an envelope, the client will sign the envelope, and the envelope will be placed in a safe. Question 13 See full question Nurse researchers have proposed a study to examine the efficacy of a new wound care product. Which of the following aspects of the methodology demonstrates that the nurses are attempting to maintain the ethical principle of nonmaleficence? Correct response: • The nurses are taking every responsible measure to ensure that no participants experience impaired wound healing as a result of the study intervention. Explanation: Question 16 See full question A client is discharged to a heart rehabilitation program. What lifestyle changes would be appropriate for the nurse to review? Correct response: • Reduced cholesterol levels, progressive activity levels, and coping strategies Question 17 See full question A woman who delivered her last infant by caesarean section is admitted to the hospital at term with contractions every 5 minutes. The health care provider (HCP) intends to have her undergo “a trial labor.” The nurse explains to the client that: Correct response: • labor progress will be evaluated continually to determine appropriate progress for a vaginal delivery. Explanation: A trial labor in this context means that the woman is allowed to go into labor, and her progress is assessed by cervical dilation and effacement as well as fetal descent evaluated to determine whether to allow the labor to progress to delivery. If there are indications that labor is not progressing, other means of delivery are considered. Labor stimulation is used cautiously and may not be safe. The presence of contractions every 5 minutes indicates true labor. If fetal distress is noted and an emergency cesarean section cannot be done immediately, tocolytic agents may be considered to stop contractions. Question 18 See full question A nurse admitted a client with ulcerative colitis. A case manager is visiting the client and wants to discuss care. What is the nurse’s understanding of the case manager? Correct response: • The case manager collaborates care among all health care partners with the client in the center. Question 20 See full question Which statement is a correct reason for nurses to become culturally sensitive and develop their cultural competency skills? . Correct response: • Cultural sensitivity and consideration of client diversity are necessary to provide ethical nursing care. Question 1 See full question A nurse is caring for a 14-month-old infant being treated for an upper respiratory infection. The physician would like to order a series of X-rays for the infant, who has been in a foster home for 4 months. How should the nurse obtain consent? Correct response: • Obtain consent from the foster parents. Explanation: Foster parents have the right to consent to medical care of minors in their care. The parents of a minor in foster care don't have authority to make decisions regarding his care. The nurse should call Child Protective Services only if she has concerns about a foster parent's authenticity. The nurse needn't notify the director of nursing unless complications occur. Question 2 See full question Which action is the priority when assessing a suicidal client who has ingested a handful of unknown pills? Correct response: • Determining if the client's physical condition is life-threatening Explanation: If the client's physical condition is life-threatening, the priority is to treat the medical condition. Any compromise to the client's airway, breathing, or circulation must be addressed immediately. It's also imperative to determine the time of ingestion because this may determine treatment. The psychiatric evaluation, which includes intent to harm oneself, adequate support system, and history, can be performed after the client is medically stable. Question 3 See full question A client is scheduled to undergo an exploratory laparoscopy. The registered nurse (RN) asks the licensed practical nurse (LPN) to prepare the client for surgery. The RN must confirm that the LPN has specialized training before delegating which task? Correct response: • Initiating I.V. therapy, as ordered Explanation: The RN must confirm that the LPN has specialized I.V. training before asking her to begin I.V. therapy for this client. Initiating I.V. therapy is beyond the usual scope of practice for an LPN. Weighing the client, teaching coughing and deep breathing exercises, and teaching the client how to collect a urine specimen are within the scope of LPN practice and don't require additional training. Question 4 See full question A nurse caring for a group of clients on the neurological floor is working with a nursing assistant and a licensed practical nurse (LPN). Their client care assignment consists of a client with new-onset seizure activity, a client with Alzheimer's disease, and a client who experienced a stroke. While administering medications, the registered nurse receives a call from the intensive care unit (ICU), saying a client who underwent a craniotomy 24 hours ago must be transferred to make room for a new admission. The ancillary staff is providing morning care and assisting clients with breakfast. How should the nurse direct the staff to facilitate a timely transfer? Correct response: • Ask the nursing assistant to finish providing care to the clients and the LPN to administer the remaining medications so the registered nurse can accept the client from the ICU. Explanation: Question 5 See full question A 17-year-old unmarried primigravida at 10 weeks’ gestation tells the nurse that her family does not have much money and her dad just got laid off from his job. What should the nurse do? Correct response: • Refer the client to a social worker for enrollment in a food assistance program. Explanation: The nurse should refer the client to a social worker for assistance in enrolling in a food assistance program. Question 6 See full question The client has returned to the surgery unit from the postanesthesia care unit (PACU). The client’s respirations are rapid and shallow, the pulse is 120 bpm, and the blood pressure is 88/52 mm Hg. The client’s level of consciousness is declining. The nurse should first: Correct response: • call the rapid response team (RRT)/medical emergency team. Explanation: The nurse should first call the rapid response team (RRT) or medical emergency team that provides a team approach to evaluate and treat immediately clients with alterations in vital signs or neurological deterioration. The client’s vital signs have changed since the client was in the PACU, and immediate action is required to manage the changes; Question 7 See full question A nurse is caring for a client who is receiving hospice care at home. The client’s neighbors have been calling the nurse to inquire about the client’s condition. The nurse should tell the callers: Correct response: • "Please call the client's sister" Explanation: The family is in the best position to give the information they elect to disclose to friends and community members. The hospice nurse and the oncologist must maintain client confidentiality and follow privacy guidelines for release of confidential information. Therefore, disclosing any information about the client’s condition would be inappropriate. Question 8 See full question A child with meningococcal meningitis is being admitted to the pediatric unit. In preparation for the child's arrival, the nurse should first? Correct response: • institute droplet precautions. Explanation: The child with meningococcal meningitis requires droplet precautions for at least the first 24 hours after effective therapy is initiated to reduce the risk of transmission to others on the unit. After the child has been placed on droplet precautions, other actions, such as taking the child’s vital signs, asking about medication allergies, and inquiring about the health of siblings at home, can be performed. Question 9 See full question A nurse is caring for a client who is well known in society. A person inquires about the medical details of the client, saying that he is a family member. The nurse reveals the requested information. Later, the nurse comes to know that the inquirer was not a family member. Which of the following ethical rules of professional–client relationships has the nurse violated? You Selected: • Confidentiality. Correct response: • Confidentiality. Explanation: The nurse has violated the principle of confidentiality by revealing the client’s personal medical information to a third person. Confidentiality is a professional duty and a legal obligation. What is documented in the client’s record is accessible only to those providing care to that client. The nurse’s action does not violate rules of veracity, fidelity, and privacy. Fidelity means being faithful to one’s commitments and promises. Veracity means telling the truth, which is essential to the integrity of the client–provider relationship. Remediation: Question 10 See full question A client who just underwent a mastectomy is due to arrive at the post-surgical care unit. Which of the following actions should the nurse prioritize when attempting to establish an effective relationship with the client? You Selected: • Assess the client's knowledge of her activity limitations. Correct response: • Recognize and address the client's anxiety. Explanation: An early priority when admitting a client to a unit and establishing a relationship is to recognize and take steps to reduce anxiety. Assessing and addressing learning needs are important goals but should be addressed after the client has been settled on the unit. HIPAA should have been explained to the client earlier in her admission. Remediation: • General Patient Care, PACU Question 11 See full question Professional regulations and laws that govern nursing practice are in place for which of the following reasons? You Selected: • To protect the safety of the public Correct response: • To protect the safety of the public Explanation: Question 12 See full question During a taped shift report, the evening nurse reports that a client has been “annoying all evening, and has been demanding and on the call bell constantly.” The nurse manager of the unit overhears this part of the report. Which of the following statements represents the best response by the nurse manager to the evening nurse? You Selected: • “Your report was subjective and did not address the cause of the behavior.” Correct response: • “Your report was subjective and did not address the cause of the behavior.” Explanation: The nurse’s report was subjective regarding the observed behavior of the client. It was value laden and did not establish the cause of the behavior, which could have been anything from anxiety to uncontrolled pain. The other options are incorrect because the report was not informative or constructive. It was subjective and inappropriate. Question 13 See full question A client on the palliative unit discusses treatment with the nurse. The client wants to refuse further chemotherapy and request pain management strategies only. What is the most appropriate action by the nurse in relation to the client’s requests? You Selected: • Acknowledge the client’s right to make the choices regarding treatment. Correct response: • Acknowledge the client’s right to make the choices regarding treatment. Explanation: Remediation: Question 14 See full question The nurse is educating parents of a child diagnosed with seasonal allergies. The nurse discusses therapeutic management of the child’s allergies and works with the parents to set goals that best support a quality childhood experience. Which of the following goals is most important for the nurse to set with the parents? You Selected: • Identifying ways to reduce the child’s exposure to the allergens Correct response: • Identifying ways to reduce the child’s exposure to the allergens Explanation: Remediation: Question 15 See full question The nurse manager is holding a meeting with the nursing team to discuss management’s decision to reduce staffing on the nursing unit. During the discussion, one of the staff nurses stands up and yells at the nurse manager, using profanity, and threatening “to take this decision further.” To defuse this situation, which of the following would be the best step for the nurse manager to take? You Selected: • Call a break in the meeting and talk to the nurse in a private place. Correct response: • Call a break in the meeting and talk to the nurse in a private place. Explanation: Question 16 See full question The client and her husband are very distressed and state that they feel their nurse has been negligent in providing care during their labor. Which of the following is the nurse’s best defense against an accusation of negligence? You Selected: • The national standards of practice were met when providing care. Correct response: • The national standards of practice were met when providing care. Explanation: Question 17 See full question A client visits the mental health clinic and tells the nurse that she is lethargic, experiences pain in her back, cannot concentrate, and is depressed. The nurse observes patches of hair loss on the client’s scalp. Which referral should the nurse make first? You Selected: • a health care provider (HCP) Correct response: • a health care provider (HCP) Explanation: Remediation: Question 18 See full question Which action associated with restraint use on a confused client can be delegated to an unlicensed healthcare worker/nursing assistant? You Selected: • Completion of range of motion on limbs restrained Correct response: • Completion of range of motion on limbs restrained Explanation: Question 19 See full question A client is scheduled for a laparoscopic cholecystectomy and is surprised to learn that he will be discharged later the same day, provided there are no complications. When caring for a client who will be discharged shortly after a procedure, the nurse must: You Selected: • ensure that health education is begun as early as possible. Correct response: • ensure that health education is begun as early as possible. Explanation: Remediation: Question 20 See full question A client underwent insertion of a nasogastric (NG) tube for partial bowel obstruction the previous evening. The nurse notes that the tube is not secured to the client’s face. How will the nurse precede? You Selected: • Securely tape the tube in place Correct response: • Verify placement of the tube Explanation: The NG tube placement should be verified prior to re-taping the NG tube; the other options require verification of the NG tube placement first and the healthcare provider will need to know. Remediation: Question 1 See full question ? You Selected: • Inform the nurses who work in the facility that client education should be implemented as soon as the client is admitted to either the hospital or the outpatient surgical center. Correct response: • Work with the surgeons' staff and the nursing staff in the hospital and outpatient surgical center to evaluate current client education practices and make revisions as needed. Explanation: Every nurse who provides client care should provide client education. Nurses must work together to establish the best methods of educating clients. The most appropriate response is to contact the facility's nurse-manager, not the nursing staff. Evaluating client education in only the surgeon's office doesn't consider the entire client education process and all of the staff providing it. Client education is an important nursing responsibility and every complaint deserves attention. Question 2 See full question A nurse-manager has decided to delegate responsibility for the review and revision of the surgical unit's client-education materials. Which statement illustrates the best method of delegation? You Selected: • Ask the two most proficient staff nurses to form a task force to review and revise client-education materials within the next 6 weeks. Have these nurses solicit input from clients and staff members. Correct response: • Ask the two most proficient staff nurses to form a task force to review and revise client-education materials within the next 6 weeks. Have these nurses solicit input from clients and staff members. Explanation: Question 3 See full question A nurse is conducting a physical assessment on an adolescent who doesn't want her parents informed that she had an abortion in the past. Which statement best describes the information security measures the nurse can implement in this situation? You Selected: • Before agreeing to maintain confidentiality, determine whether the adolescent is an emancipated minor. Correct response: • Respect the adolescent's wishes and maintain her confidentiality. Explanation: The nurse should respect the rights of minors who don't want parents informed of medical problems; she shouldn't tell parents about an adolescent's past procedures. Many states have laws that emancipate minors for health care visits involving pregnancy, abortion, or sexually transmitted diseases. Question 4 See full question Parents tell a nurse that they have not met their goal of home management of their son with schizoaffective disorder. They report that the client poses a threat to their safety. Based on this information, what recommendation should the nurse make? You Selected: • Arrange for respite care; family members could be aggravating the client's condition. Correct response: • Evaluate the client for voluntary admission to a mental health facility. Explanation: A voluntary admission is the preferred approach because it involves having the client recognize existing problems and facilitates the client's involvement in treatment. Chemical restraints would violate the client's rights to freedom from the use of restraints and seclusion. The duty of care is a legal concept that applies only to the nurse-client relationship, not to family relationships. Respite care isn't an appropriate recommendation at this time. The nurse must address the safety issue and institute effective treatment and care. At a later time, it would be prudent for the nurse to talk with the client's family about caregiver burden and the option of using respite care. Remediation: Question 5 See full question Accompanied by her partner, a client seeks admission to the labor and delivery area. She states that she's in labor and says she attended the facility clinic for prenatal care. Which question should the nurse ask her first? You Selected: • "What is your expected due date?" Correct response: • "What is your expected due date?" Explanation: When obtaining the history of a client who may be in labor, the nurse's highest priority is to determine her current status, particularly her due date, gravidity, and parity. Gravidity and parity affect the duration of labor and the potential for labor complications. Later, the nurse should ask about chronic illnesses, allergies, and support persons. Remediation: Question 6 See full question A client tells a nurse that she's in a nontraditional same-sex relationship. The woman's partner is the health care surrogate for the client and her fetus. The sperm donor, who is their best friend, has waived parental rights. If the client can't make health care decisions for the fetus, who's responsible for making them? You Selected: • The client's partner Correct response: • The client's partner Explanation: A legal document stating that the client's partner is the health care surrogate for the client and the fetus authorizes the partner to make decisions on behalf of the client or the fetus if the client isn't able to do so. Before insemination, a donor signs a legal document waiving rights to the child; therefore, the donor has no authority to make health care decisions on behalf of the client or the fetus. Pregnancy at any age results in emancipation; parents don't have rights to make health care decisions for pregnant adolescents. The court system wouldn't make the decision if the client has designated a legal health care surrogate. Remediation: Question 7 See full question A client and her boyfriend of 5 months are celebrating the birth of a healthy baby boy when the client's estranged partner arrives to visit the baby he believes is his son. The nurse caring for the client knows that the estranged partner has the right to: You Selected: • hold the neonate after the mother gives permission. Correct response: • hold the neonate after the mother gives permission. Explanation: The neonate's mother has legal control over the neonate. Therefore, the mother must grant permission for her estranged partner to hold him. The neonate commonly stays in the mother's room, not in the nursery. Therefore, looking through the nursery window isn't an option. The estranged partner can't ask to have the boyfriend removed because the client wants him to remain. The mother must sign the consent for circumcision. Remediation: Question 8 See full question A group of nursing assistants hired for the medical-surgical floors are attending hospital orientation. Which topic should the educator cover when teaching the group about caring for clients with diabetes mellitus? You Selected: • Obtaining, reporting, and documenting fingerstick glucose levels Correct response: • Obtaining, reporting, and documenting fingerstick glucose levels Explanation: The educator should teach the nursing assistants how to obtain and document a fingerstick glucose level. She should also teach them normal and abnormal results and the importance of reporting them to the registered nurse caring for the client. Treating hypoglycemia, teaching clients about dietary changes, and assessing clients experiencing hypoglycemic reactions are outside the scope of practice for a nursing assistant. They are the responsibility of the registered nurse. Remediation: Question 9 See full question The nurse is planning care for a group of pregnant clients. Which client should be referred to a health care provider (HCP) immediately? You Selected: • a woman at 32 weeks' gestation who is preeclamptic with +3 proteinuria Correct response: • a woman at 32 weeks' gestation who is preeclamptic with +3 proteinuria Explanation: The nurse should refer the preeclamptic client with 3+ proteinuria to a HCP. The 3+ urine is significant, indicating there is much protein circulating. The woman who is 37 weeks’ gestation with insulin-dependent diabetes who has experienced hypoglycemic episodes in the past week can be managed with food and glucose tablets until the client can obtain an appointment with the care provider. The client at 10 weeks’ gestation with nausea and vomiting and +1 ketones should also be seen by a HCP, but at this point although this client is uncomfortable, her life is not in danger. The 15-week client would not be expected to feel her baby move this soon in the pregnancy, and this would not be considered a problem that requires immediate referral to a HCP. Remediation: Question 10 See full question A client has undergone a laparoscopic cholecystectomy. Which instruction should the nurse include in the discharge teaching? You Selected: • Report bile-colored drainage from any incision. Correct response: • Report bile-colored drainage from any incision. Explanation: There should be no bile-colored drainage coming from any of the incisions postoperatively. A laparoscopic cholecystectomy does not involve a bile bag. Breathing deeply into a paper bag will prevent a person from passing out due to hyperventilation; it does not alleviate nausea. If the adhesive dressings have not already fallen off, they are removed by the surgeon in 7 to 10 days, not 6 weeks. Remediation: Question 11 See full question Which task should a nurse choose to delegate to a nursing assistant? Select all that apply. You Selected: • Documenting a client's oral intake • Performing a blood glucose check • Taking a client's vital signs Correct response: • Taking a client's vital signs • Documenting a client's oral intake • Performing a blood glucose check Explanation: Registered nurses are responsible for all phases of the nursing process. These responsibilities include assessing a client's pain and evaluating a client's response to treatment. A nurse may delegate tasks such as taking vital signs, documenting intake and output, and performing blood glucose checks if she follows the five rights of delegation. The five rights of delegation include: right task (the task is within the delegate's scope of practice), right person (the person is competent to perform the task), right communication (the nurse gives the right directions to complete the task), right feedback (the nurse works collaboratively with the delegate), and right follow-up (the nurse follows-up on the task after it has been completed). Question 12 See full question The nurse assigns an unlicensed assistive personnel (UAP) to the care of a client who has just returned from surgery for repair of a fractured right wrist and application of an arm cast. The nurse should stress to the UAP the importance of reporting: You Selected: • the client cannot move the fingers on the right hand. Correct response: • the client cannot move the fingers on the right hand. Explanation: The UAP should report immediately to the nurse any sign that the client cannot move the fingers on the casted arm, numbness or tingling, or feelings of tightness because these may indicate impaired neurovascular status. The nurse, not the UAP, is responsible for neurovascular assessments. Intake and output would usually not be particularly significant in a client with a fractured arm. It is normal for the client to feel heat immediately after application of a plaster cast. Remediation: Question 13 See full question When recording data regarding the client's health record, the nurse mentions the analysis of the subjective and objective data in addition to detailing the plan for care of the client. Which of the following styles of documentation is the nursing implementing? You Selected: • SOAP charting. Correct response: • SOAP charting. Explanation: The nurse is using the SOAP charting method to record details about the client. In SOAP charting, everyone involved in a client's care makes entries in the same location in the chart. SOAP charting acquired its name from the four essential components included in a progress note: S = subjective data; O = objective data; A = analysis of the data; P = plan for care. Hence, it involves mentioning the analysis of the subjective and objective data in addition to detailing the plan for care of the client. Narrative charting is time-consuming to write and read. In narrative charting, the caregiver must sort through the lengthy notation for specific information that correlates the client's problems with care and progress. Focus charting follows a DAR model. PIE charting is a method of recording the client's progress under the headings of problem, intervention, and evaluation. Remediation: Question 14 See full question A physician's order for a client states the administration of a medication “b.i.d.” How many times should the nurse administer the medication to the client? You Selected: • Twice a day. Correct response: • Twice a day. Explanation: Remediation: Question 15 See full question A nurse observes a physician providing care to an infectious client without the use of personal protective equipment. What should the nurse do first? You Selected: • Complete an incident report. Correct response: • Discuss the breach of practice with the physician. Explanation: The nurse should first discuss the breach of infection control procedures with the physician and discuss the practices that should be followed. The other options may be followed subsequently, but discussing with the physician is the first step. Remediation: • Contact Precautions • Standard Precautions Question 16 See full question After being seen in the oncology clinic, a client with severe bone marrow suppression is admitted to the hospital. The client's cancer therapy consisted of radiation and chemotherapy. When developing the care plan for this client, the nurse prioritizes which nursing intervention? You Selected: • Allowing time for the client to talk about his/her condition Correct response: • Monitoring temperature and blood cell count Explanation: Risk for infection takes highest priority in clients with severe bone marrow depression. This is because they have a decrease in the number of white blood cells, which are the cells that fight infection. Therefore, the nurse should monitor temperature and blood cell count. While the other interventions are helpful in the care of this client, the risk for infection takes precedence. Remediation: Question 17 See full question A client is upset to learn that corticosteroids need to be taken to control symptoms of systemic lupus erythematosus (SLE). While the nurse is preparing to administer medication, the client refuses to take it, stating, “This is turning me into an old woman before my time.” What is the best response by the nurse? You Selected: • Ask about the medication side effects that are a concern and explain why suddenly stopping the drug can cause problems. Correct response: • Ask about the medication side effects that are a concern and explain why suddenly stopping the drug can cause problems. Explanation: It is important to explore the client’s concerns regarding the side effects. As a follow-up, it is important to reinforce what is the desired effect of the drug. It is critical to explain the importance of not suddenly discontinuing its use. Explaining the symptoms of the disease does not identify the reasons for the client's concern. Encouraging the client to take the medication or documenting the refusal does not identify the concerns. Remediation: Question 18 See full question A nurse is caring for a client who has left homonymous hemianopsia following a recent cerebral vascular accident (CVA). Which nursing diagnosis should take the highest priority? You Selected: • Risk for injury Correct response: • Risk for injury Explanation: Left homonymous hemianopsia causes loss of vision in half of the right visual field so clients cannot see past the midline without turning the head to that side, leaving the client at risk for injury. The client who has had a stroke may have impaired physical mobility, activity intolerance, and impaired verbal communication but these are not the priority according to Maslow’s hierarchy of needs. Remediation: Question 19 See full question An alert and oriented client states that he does not want chemotherapy. His family believes that he should receive it. Which is the nurse’s best response to the client? You Selected: • “Have you discussed this with your religious advisor?” Correct response: • “You understand that this decision is ultimately yours to make.” Explanation: A competent client has the right to refuse care. The role of the nurse is to advocate for the client and respect the client’s decision. In that role, it is essential for the nurse to make sure that the client is informed regarding the outcome of any choices made. The nurse should not offer advice or attempt to influence the client with personal beliefs or family influence. Remediation: Question 20 See full question A nurse is working on a unit that is short staffed for the shift and is delegating client care to a licensed practical nurse. Which activity would be appropriate for the nurse to delegate? Select all that apply. You Selected: • administering a sitz-bath to a client who has had perineal surgery 2 days ago • assistance with range of motion exercises for a client diagnosed with Alzheimer’s disease • education about how to administer a heparin injection to a client diagnosed with deep vein thrombosis • vital sign monitoring of a client who is 3 days postsurgical repair of a fractured hip Correct response: • vital sign monitoring of a client who is 3 days postsurgical repair of a fractured hip • assistance with range of motion exercises for a client diagnosed with Alzheimer’s disease • administering a sitz-bath to a client who has had perineal surgery 2 days ago Explanation: The nurse, when delegating tasks, needs to keep in mind the scope of practice for the licensed practical nurse (LPN). Vital sign monitoring, assistance with range of motion exercises, and administering a sitz-bath are within the scope of practice for an LPN. The LPN can collect or gather data and reinforce teaching, but the assessment and education are outside the LPN’s scope of practice. Question 1 See full question When a nurse enters a client's room, the client frowns and states, "I've had my damn light on for 20 minutes. It's about time you got here. I'm sick of this place and the staff." The nurse's best response would be: You Selected: • "You seem upset this morning." Correct response: • "You seem upset this morning." Explanation: To be therapeutic, the nurse should always comment on the client's statements. The client's words are strong, and it's obvious that he's angry. By introducing herself or apologizing, the nurse ignores the client's problem. Repeating the client's statement would only add to his anger. Remediation: Question 2 See full question A nurse is caring for a severely depressed client who is barely functioning. The priority nursing goal for this client would be to: You Selected: • assess for and maintain adequate nutrition and hydration. Correct response: • assess for and maintain adequate nutrition and hydration. Explanation: Food and fluid intake may be compromised in a client who is severely depressed. The nurse must ensure that the client is adequately hydrated and is receiving proper nutrition. Although the client's psychological needs are important, physiological needs are the priority in this case. Assessing the client's depression level, continuing the client's ordered medication, and maintaining the client's hygiene needs are lower priorities at this time. The nurse should be aware that family involvement may not be indicated in this client's care. Remediation: Question 3 See full question A nurse explains the guidelines for the unit's seclusion room to a client with an impulse control disorder. Which client statement indicates that the nurse has adequately communicated the client's rights? You Selected: • "Although I don't think I will, I can ask to go into seclusion, but I know you can make me go into the seclusion room." Correct response: • "Although I don't think I will, I can ask to go into seclusion, but I know you can make me go into the seclusion room." Explanation: As a proactive part of the treatment plan, clients may request to go into seclusion to prevent disruptive or destructive actions. In addition, the staff may use seclusion for a client whose behavior is out of control. A client who loses his temper can be guided by staff to modify his behavior. It's possible that this staff intervention can make the seclusion option unnecessary. When a client is placed in seclusion, a physician must perform a clinical assessment within 24 hours. Consequences of a client's decision not to attend a unit group meeting are related to what's written in the treatment plan. The client shouldn't be placed in seclusion unless he's a danger to himself or to others. Remediation: Question 4 See full question The nurse refers the parents of a child with cystic fibrosis to an organization that helps families with children who have this disease. Such organizations are especially beneficial for parents by helping them: You Selected: • meet with other parents of children with cystic fibrosis for mutual support. Correct response: • meet with other parents of children with cystic fibrosis for mutual support. Explanation: An important function of support organizations for any health problem is to put parents of children with the condition in touch with each other. Other parents can commonly offer support and help. In some instances, organizations can offer assistance, such as providing equipment required for home care of their child with cystic fibrosis. These organizations do not obtain tutors for children, nor do they provide medications, financial assistance, or genetic counseling for parents. Remediation: Question 5 See full question An unlicensed assistive personnel (UAP) is providing care to a client with left-sided paralysis. Which action by the UAP requires the nurse to provide further instruction? You Selected: • elevating the foot of the bed to reduce edema Correct response: • pulling up the client under the left shoulder when getting the client out of bed to a chair Explanation: Pulling the client up under the arm can cause shoulder displacement. A belt around the waist should be used to move the client. Passive range-of-motion exercises prevent contractures and atrophy. Raising the foot of the bed assists in venous return to reduce edema. High top tennis shoes are used to prevent foot drop. Question 6 See full question A nurse on the gynecologic surgery unit observes a respiratory therapist (RT) take a medication cup with pills that was sitting in the medication room. What course of action should the nurse take? You Selected: • Tell the RT that you saw her take the pills from the medication room. Correct response: • Report the situation to the nursing supervisor. Explanation: The nurse should follow the line of authority or chain of command by reporting the observation immediately to the nursing supervisor. The nurse should not confront the person or the medication nurse because the line of authority for reporting incidents should be followed. The RT supervisor may subsequently be involved in the incident, but the nursing supervisor should initiate and follow the policy and procedure. Question 7 See full question Because of an outbreak of influenza among the nursing staff, the hospital is very short staffed. The nurse manager prioritizes client needs on the surgical unit by which strategy? You Selected: • ensuring that clients receive medications but omitting full bathing when possible Correct response: • ensuring that clients receive medications but omitting full bathing when possible Explanation: Daily bathing is not required to meet standards of care. Rescheduling surgeries is not a strategy for meeting nursing care needs of clients. Medications are required to be given as prescribed to maintain standards of care and efficacy of the medication. UAPs are not licensed to administer analgesics. Question 8 See full question The nurse uses which part of the SBAR acronym when stating, “I think the client is dry.” You Selected: • Situation. Correct response: • Assessment. Explanation: SBAR stands for Situation, Background, Assessment, and Recommendation. It is a proven standardized method of communication between members of the health care team and a client’s condition. SBAR is used as a standardized method of hand-off communication. A hand-off is a transfer of responsibility from one caregiver to another caregiver. The information communicated during a hand-off must be accurate, with minimal interruptions, in order to meet client safety needs. Remediation: Question 9 See full question A nurse is caring for an elderly bedridden adult in the long t