1. A nurse is talking with a client who has major depressive disorder. The client states, "Nobody cares if I'm around or not." Which of the following
... [Show More] responses should the nurse take?
• It sounds as though you’re feeling hopeless
• Rationale: This statement by the nurse is an example of restating, which is a therapeutic response. This technique restates the main idea the client has expressed and allows the client to clarify any misunderstanding.
2. A nurse is preparing to administer a unit of packed RBCs to a client. In adherence with the Joint Commission National Patient Safety Goals regarding blood administration, which of the following actions should the nurse plan to take?
• Verify the client and blood component using a two-person process
• Rationale: The Joint Commission National Patient Safety Goals regarding blood transfusions includes improving the accuracy of client identification. The nurse should eliminate transfusion errors related to client misidentification by using a two-person verification process to identify the client and the blood component.
3. A nurse on a medical-surgical unit is caring for a group of clients. Which of the following clients should the nurse monitor for the development of reflex urinary incontinence?
• A client who has a T12 spinal cord injury
• Rationale: The nurse should identify that a client who has a C1 to S2 spinal cord injury is at risk of developing reflex urinary incontinence. With this type of incontinence, the client is unaware that the bladder is full and therefore lacks the urge to void, resulting in the involuntary loss of urine. The nurse should monitor for this form of incontinence and implement interventions such as intermittent catheterization.
4. A nurse is documenting an assessment in a client's electronic health record when an assistive personnel (AP) asks to enter the morning blood glucose for the client. Which of the following actions should the nurse take?
• Request that the AP use another computer to enter the data
• Rationale: The nurse should request that the AP to go to another computer that is not in use to enter the morning blood glucose from the client. This is time- sensitive data that needs to be entered in the computer as soon as possible.
5. A nurse is preparing to administer acetaminophen 120 mg PO to a toddler. Available is acetaminophen drops 80mg/0.8 mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
• 1.2 mL
• Rationale:
Ratio and Proportion
• STEP 1: What is the unit of measurement the nurse should calculate? mL
• STEP 2: What is the dose the nurse should administer? Dose to administer = Desired 120 mg
• STEP 3: What is the dose available? Dose available = Have 80 mg
• STEP 4: Should the nurse convert the units of measurement? No
• STEP 5: What is the quantity of the dose available? 0.8 mL
• STEP 6: Set up an equation and solve for X.
• Have/Quantity = Desired/X
• 80 mg/0.8 mL = 120 mg/X mL
• X = 1.2
• STEP 7: Round if necessary.
• STEP 8: Reassess to determine whether the amount to give makes sense. If there are 80 mg/0.8 mL and the amount prescribed is 120 mg, it makes sense to administer 1.2 mL. The nurse should administer acetaminophen 1.2 mL PO. Desired Over Have
• STEP 1: What is the unit of measurement the nurse should calculate? mL
• STEP 2: What is the dose the nurse should administer? Dose to administer = Desired 120 mg
• STEP 3: What is the dose available? Dose available = Have 80 mg
• STEP 4: Should the nurse convert the units of measurement? No
• STEP 5: What is the quantity of the dose available? 0.8 mL
• STEP 6: Set up an equation and solve for X.
• Desired x Quantity/Have = X
• 120 mg x 0.8 mL/80 mg = X mL
• 1.2 = X
• STEP 7: Round if necessary.
• STEP 8: Reassess to determine whether the amount to give makes sense. If there are 80 mg/0.8 mL and the amount prescribed is 120 mg, it makes sense to administer 1.2 mL. The nurse should administer acetaminophen 1.2 mL PO. Dimensional Analysis
• STEP 1: What is the unit of measurement the nurse should calculate? mL
• STEP 2: What is the quantity of the dose available? 0.8 mL
• STEP 3: What is the dose available? Dose available = Have 80 mg
• STEP 4: What is the dose the nurse should administer? Dose to administer = Desired 120 mg
• STEP 5: Should the nurse convert the units of measurement? No
• STEP 6: Set up an equation and solve for X.
• X = Quantity/Have x Conversion (Have)/Conversion (Desired) x Desired/
• X mL = 0.8 mL/80 mg x 120 mg/
• X = 1.2
• STEP 7: Round if necessary.
• STEP 8: Reassess to determine whether the amount to give makes sense. If there are 80 mg/0.8 mL and the amount prescribed is 120 mg, it makes sense to administer 1.2 mL. The nurse should administer acetaminophen 1.2 mL PO
6. A nurse is preparing to administer 0.9% sodium chloride 1,000 mL over 8 hr IV to a client. The nurse should set the infusion pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
• 125 mL/hr
• Rationale:
• Follow these steps to calculate the infusion rate:
• STEP 1: What is the unit of measurement the nurse should calculate? mL/hr
• STEP 2: What is the volume the nurse should infuse? 1,000 mL
• STEP 3: What is the total infusion time? 8 hr
• STEP 4: Should the nurse convert the units of measurement? No
• STEP 5: Set up an equation and solve for X.
• Volume (mL)/Time (hr) = X mL/hr
• 1,000 mL/8 hr = X mL/hr
• X = 125
• STEP 6: Round if necessary.
• STEP 7: Reassess to determine if the amount to administer makes sense. If the amount prescribed is 1,000 mL to infuse over 8 hr, it makes sense to administer 125 mL/hr. The nurse should set the IV pump to deliver 0.9% sodium chloride at 125 mL/hr for 8 hr.
7. A nurse is providing teaching about nutrition management to the parent of an 18- month-old toddler who has phenylketonuria. Which of the following foods should the nurse recommend?
• Baked potato
• Rationale: The nurse should recommend low-protein foods to the parent of a toddler who has phenylketonuria. The nurse should also recommend the parent offer the toddler fruits, juices, and cereals with limited phenylalanine.
8. A nurse is preparing to extinguish a small fire in a client's room. Which of the following actions should the nurse take when using the fire extinguisher?
• Slide the pin on top of the fire extinguisher straight put
• Rationale: The nurse should pull the pin on the top of the fire extinguisher to allow for use to extinguish the fire.
9. A nurse is planning meals for a client who practices Judaism and reports that she strictly adheres to orthodox dietary laws. The nurse should recognize that which of the following dietary practices applies to the client's beliefs?
• The client is permitted to eat fish that have scales:
• Rationale: The nurse should recognize that Orthodox Jewish dietary laws permit the client to eat fish that have fins and scales, such as tuna. However, fish that do not have scales, such as catfish, are considered unclean and are not permitted.
10. A nurse is caring for a client who has a Clostridium difficile infection and is incontinent of stool following long-term antibiotic therapy. Which of the following actions should the nurse take?
• Wear a gown while providing care for the client
• Rationale: The nurse should wear a gown when providing care for a client who has a C. difficile infection and is incontinent of stool. Applying a clean, water- resistant gown prior to entering the client's room prevents the nurse's clothing from becoming contaminated while caring for the client. The nurse should remove the gown prior to exiting the client's room.
11. A nurse is admitting a client who has pulmonary tuberculosis. Which of the following transmission-based precautions should the nurse initiate?
• Airborne
• Rationale: Pulmonary tuberculosis is an infection that is transmitted by airborne droplets smaller than 5 microns in diameter. Therefore, this client requires airborne precautions to prevent communicating this infection to others
12. A nurse in a mental health facility is preparing an educational program for a group of staff nurses about the proper use of restraints. Which of the following information should the nurse plan to include?
• An adult client may be in a mechanical restraint for up to 4 hours
• Rational: The nurse should specify that a client who is 18 years or older may be in a restraint for no more than 4 hr. Children who are 9 to 17 years old are limited to 2 hr and children who are younger than 9 years old are limited to 1 hr
13. A nurse is teaching sleep hygiene to a client who has insomnia. Which of the following statements should the nurse make?
• Exercise in the morning after arising
• Rationale: Daily exercise has many benefits, including enhancing cardiovascular, psychological, and musculoskeletal health. The nurse should recommend that the client avoid exercising within 2 hr of bedtime to limit stimulation and enhance sleep
14. A nurse is preparing to leave the room of a client who is on isolation precautions. Which of the following actions should the nurse take when removing a tied surgical mask?
• Remove the mask by securely holding the ties and moving it away from the face
• Rationale: The nurse should untie the bottom strings and then the top strings. Finally, while still holding the strings, the nurse should remove the mask from her face. This action prevents the nurse from touching the front of the mask, which is contaminated
15. A nurse is caring for an adolescent client who is in critical condition following a motor vehicle crash in which he was the passenger. The client's parent shouts at the nurse, asking why her son is dying instead of the driver. Which of the following actions should the nurse take to provide emotional support to the parent?
• Inform the parent that anger is a natural response when dealing with loss
• Rationale: The nurse should identify that the parent is in the anger stage of grief. The nurse should assist the parent to understand that anger is a natural response to loss and encourage her to talk about her feelings
16. A community health nurse is planning prevention strategies for hypertension among members of her community. The nurse should identify that which of the following ethnic groups in the community is at greatest risk of developing hypertension?
• African Americans
• Rationale: Evidence-based practice indicates that individuals of African-American ethnicity have the highest prevalence of hypertension. Therefore, the nurse should identify community members of this ethnicity are at greatest risk of developing hypertension.
17. A community health nurse is planning interventions to promote Healthy People 2020 initiatives in the community. Which of the following actions should the nurse plan to take first?
• Determine the level of health equity among groups in the community
• Rationale: Health equity among all groups in the community is a Healthy People 2020 initiative. Using the nursing process, the first action the nurse should take is to assess the needs of the community. By identifying disparities in community health, the nurse can develop interventions targeted at the community's specific needs.
18. A nurse is reviewing a client's new prescriptions that were just documented in the client's medical record by the provider. Which of the following abbreviations should the nurse clarify with the provider?
• Enoxaparin 40 mg SQ QD
• Rationale: The nurse should clarify this prescription with the provider. The abbreviations "SQ" and "QD" are considered error-prone and should not be used in documentation. The nurse should clarify that the provider intends the prescription to be administered subcutaneously once daily. "Subcutaneous" or "subcut" should be used instead of "SQ" and "daily" should be used instead of "QD."
19. A nurse is planning the menu for a client who practices Seventh-Day Adventism. Which of the following food selections should the nurse make?
• Scrambled eggs
• Rationale: The nurse should select scrambled eggs in the client's dietary meal plan for a client who practices Seventh-Day Adventism. Most clients who practice Seventh-Day Adventistism are lacto-ovo vegetarians who consume vegetables, eggs, and dairy, but not meat. Clients who practice this religion also do not consume caffeine or alcohol.
20. A nurse in a long-term care facility discovers a small fire in a client's trash can. After moving the client to safety, which of the following actions should the nurse take next?
• Pull the alarm to notify emergency services
• Rationale: Evidence-based practice indicates the nurse should first rescue and remove clients in immediate danger and then activate the alarm to notify authorities of the situation.
21. A community health nurse is developing a brochure about the use of smokeless tobacco. Which of the following information should the nurse plan to include?
• Smokeless tobacco provides a higher dose of nicotine than cigarettes
• Rationale: Smokeless tobacco is placed in the mouth, where nicotine is then absorbed sublingually. A higher dose of nicotine is delivered with the use of smokeless tobacco compared to smoking cigarettes, because heat destroys nicotine.
22. A nurse is preparing to administer three medications to a client who has an NG tube: a levothyroxine tablet, an ibuprofen gel cap, and a delayed-release omeprazole capsule. Which of the following actions should the nurse take?
• Crush the levothyroxine tablet into a powder and dissolve it in 30 mL of warm sterile water
• Rationale: The nurse should prepare simple tablets for NG administration by
crushing them into a fine powder and dissolving them in at least 30 mL of warm sterile water. Cold water can cause discomfort. Sterile water eliminates the possible problem of chemicals in tap water interacting with the medication.
23. A nurse is caring for a child who has contact dermatitis due to poison ivy. The parent asks the nurse how to prevent further reactions. Which of the following responses should the nurse make?
• Wash your child’s exposed clothing with hot water and detergent
• Rationale: The nurse should instruct the parent to wash the child's clothing in hot water and detergent after exposure to the poison ivy plant. This will remove the oil, urushiol, which causes the skin reaction.
24. A nurse is planning care for a client who has an indwelling urinary catheter. Which of the following interventions should the nurse include in the plan to prevent the development of a catheter-associated urinary tract infection (CAUTI)?
• Secure the catheter tubing to the client’s leg
• Rationale: The nurse should assess the client's need for urinary catheterization and should follow evidence-based practice to prevent or reduce the risk of CAUTI development. This includes securing the catheter tubing to the client's leg so that the catheter does not move, reducing the risk of urethral trauma and introduction of bacteria into the urinary system
25. A nurse in a long-term care facility is admitting a new client following a brief stay in acute care. In adherence with the Joint Commission National Patient Safety Goals regarding medication administration, which of the following actions should the nurse take?
• Compare a list of the client’s current medications with the ones he will take in long-term care
• Rationale: The Joint Commission National Patient Safety Goals regarding
medication reconciliation includes maintaining and communicating accurate
client medication information. The nurse should complete a medication reconciliation to identify and resolve any discrepancies by comparing the client's list of current medications with the medications he will take in the long-term care facility and addressing any duplications, omissions, or interactions.
26. A nurse is creating a plan of care for a client who is non-ambulatory and has bladder and bowel incontinence. Which of the following interventions should the nurse include to prevent skin breakdown?
• Offer the client a glass of water every 2 hr when reposition
• Rationale: The nurse should offer the client a glass of water every 2 hr on the client's repositioning schedule. This helps prevent dehydration, which increases the risk of skin breakdown.
27. A home health nurse is providing teaching to the parent of a child who is receiving chemotherapy and experiencing nausea. Which of the following statements should the nurse make?
• Have your child rest with his head elevated after meals
• Rationale: The nurse should instruct the parent to have the child rest with his head elevated after meals. This will allow for easier digestion and help to decrease the nausea associated with eating
28. A nurse is caring for a client who has cancer and is planning discharge to go home with hospice care. Which of the following statements by the client indicates that he is experiencing spiritual distress?
• I wish God had not allowed this cancer to invade my body
• Rationale: The nurse should identify that this statement indicates the client is experiencing spiritual distress, which occurs when there is a disturbance in a client's belief system. This client is expressing spiritual anger and not accepting his condition.
29. A nurse is beginning nutrition counseling with a client who has a BMI of 34.2. Which of the following questions should the nurse ask first to address the client's excessive nutrition and obesity?
• Are you ready to make a lifelong commitment to a healthier lifestyle?
• Rationale: The first action the nurse should take when using the nursing process is to assess the client. The nurse should ask questions to determine the client's level of motivation for making the lifestyle changes that will result in weight loss and maintaining a healthy weight over time. Without motivation, the client is unlikely to lose weight.
30. A nurse is administering enoxaparin subcutaneously to a client who is postoperative and is at risk of thromboembolic events. Which of the following actions should the nurse take?
• Pull up a small amount of skin using the thumb and forefinger of the nondominant hand.
• Pulling up or pinching the skin brings the subcutaneous tissue upward and helps
reduce the pain of the injection.
31. A nurse is searching electronic databases for clinical research about behavioral indicators of pain in an infant. Which of the following online sources should the nurse select to research this infant care issue?
• Cumulative Index to Nursing and Allied Health Literature (CINAHL)
• The nurse should select the Cumulative Index to Nursing and Allied Health Literature (CINAHL) to locate clinical research about health-related client care issues. CINAHL is a cumulative index that the nurse can search electronically to locate reliable data related to the specific topic being researched.
32. A nurse is planning to use an interpreter to assist her when interviewing a client who does not speak the same language as the nurse. Which of the following actions should the nurse plan to take?
• Ensure the client and the interpreter are compatible
• The nurse should ensure that the client is comfortable with the interpreter. The nurse should consider the client's age, gender, and culture when using an interpreter.
33. A nurse is planning a community health program about substance use disorders. Which of the following information should the nurse include when discussing the guidelines for safe limits of alcohol consumption?
• A healthy woman of any age should consume no more than seven drinks in a week
• Recommendations for safe limits of alcohol consumption for a healthy woman
include consuming no more than seven drinks in a week
34. A nurse is caring for a client who is 2 days postoperative following an above-the-knee amputation. The client states he is experiencing a dull, burning pain in the leg that was amputated. Which of the following actions should the nurse take to treat the client's neuropathic pain?
• Administer a beta-blocking medication to the client
• Rationale: The nurse should administer a beta-blocking medication to the client. This classification of medication has been shown to relieve the phantom limb pain manifestations of constant dull and burning type pain.
35. A nurse is developing a plan of care for an older adult who is experiencing functional incontinence following hip arthroplasty. Which of the following interventions should the nurse include?
• Place grab bars by the toilet
• Rationale: The nurse should place grab bars by the toilet and install a raised toilet seat. These aid the client in reaching and sitting on the toilet, decreasing the chance of incontinence.
36. A nurse is preparing to administer morphine 5 mg IM form a 10 mg/mL vial to help manage a client's acute pain. Which of the following actions should the nurse plan to take after administering a controlled substance?
• Have the second nurse witness and initial the disposal of the remaining medication
• When nurses administer a portion of a vial's amount of a controlled substance, they must discard the rest safely, such as by injecting it out of the syringe into a sink or toilet, while a second nurse witnesses the first nurse discarding it. The second nurse must then initial the waste of the medication in the client's medication administration record. [Show Less]