A female nurse who sometimes tries to save time by putting medications in her uniform pocket to deliver to clients, confides that after arriving home she
... [Show More] found a hydrocodone (Vicodin) tablet in her pocket. Which possible outcome of this situation should be the nurse's greatest concern?
A.) Accused of diversion.
B.) Reported for stealing.
C.) Reported for a HIPAA violation.
D.) Accused of unprofessional conduct.
A
Rationale: Even if this is only one incident, the nurse may be suspected of taking medications on a regular basis and the incident could be interpreted as diversion (A), or diverting narcotics for her own use, which should be reported to the peer review committee and to the State Board of Nursing. (B, C, and D) are also of concern, but (A) is the most serious possible outcome.
A male client has a nursing diagnosis of "spiritual distress." What intervention is best for the nurse to implement when caring for this client?
A.) Use distraction techniques during times of spiritual stress and crisis.
B.) Reassure the client that his faith will be regained with time and support.
C.) Consult with the staff chaplain and ask that the chaplain visit with the client.
D.) Use reflective listening techniques when the client expresses spiritual doubts.
D
Rationale: The most beneficial nursing intervention is to use nonjudgmental reflective listening techniques, to allow the client to feel comfortable expressing his concerns (D). (A and B) are not therapeutic. The client should be consulted before implementing (C).
The nurse removes the dressing on a client's heel that is covering a pressure sore one-inch in diameter and finds that there is straw-colored drainage seeping from the wound. What description of this finding should the nurse include in the client's record?
A.) Stage 1 pressure sore draining sero-sanguineous drainage.
B.) Pressure sore at bony prominence with exudate noted.
C.) One-inch pressure sore draining serous fluid.
D.) Pressure sore on heel with a small amount of purulent drainage.
C
Rationale: Serous drainage is clear watery plasma, so (C) provides accurate documentation based on the information provided. Information to stage this pressure score (A) is not provided, and sero-sanguineous drainage is pale and watery with a combination of plasma and red cells, and may be blood-streaked. Exudate (B) is fluid such as pus and serum. Purulent drainage (D) is thick, yellow, green, or brown indicating the presence of dead or living organisms and white blood cells.
The nurse is preparing to give a client dehydration IV fluids delivered at a continuous rate of 175 ml/hour. Which infusion device should the nurse use?
A.) Portable syringe pump.
B.) Cassette infusion pump.
C.) Volumetric controller.
D.) Nonvolumetric controller.
B
Rationale: A cassette pump (B) should be used to accurately deliver large volumes of fluid over longer periods of time with extreme precision, such as ml/hour. A syringe pump (A) is accurate for low-dose continuous infusion of low-dose medication at a basal rate, but not large fluid volume replacement. Volumetric (C) and nonvolumetric (D) controllers count drops/minute to administer fluid volume and are inherently inaccurate because of variation in drop size.
How should the nurse handle linens that are soiled with incontinent feces?
A.) Put the soiled linens in an isolation bag, then place it in the dirty linen hamper.
B.) Place an isolation hamper in the client's room and discard the linens in it.
C.) Place the soiled linens in a pillow case and deposit them in the dirty linen hamper.
D.) Ask the housekeeping staff to pick up the soiled linen from the dirty utility room.
C
Rationale: The nurse should be careful to keep the soiled linens from contaminating the fresh linens, and should handle the soiled linens like any other dirty linen (C). (A, B, and D) are not indicated.
A low-sodium, low-protein diet is prescribed for a 45-year-old client with renal insufficiency and hypertension, who gained 3 pounds in the last month. The nurse determines that the client has been noncompliant with the diet, based on which report from the 24-hour dietary recall? (Select all that apply.)
A.) Snack of potato chips, and diet soda.
B.) Lunch of tuna fish sandwich, carrot sticks, fresh fruit, and coffee.
C.) Breakfast of eggs, bacon, toast, and coffee.
D.) Dinner of vegetable lasagna, tossed salad, sherbet, and iced tea.
E.) Bedtime snack of crackers and milk.
A, B, C, E
Rationale: Potato chips (A) are high in sodium. Tuna (B) is high in protein. Bacon (C) and crackers (E) are high in sodium. Only (D) is a meal that is in compliance with a low sodium, low protein diet.
Which technique is most important for the nurse to implement when performing a physical assessment?
A.) A head-to-toe approach.
B.) The medical systems model.
C.) A consistent, systematic approach.
D.) An approach related to a nursing model.
C
Rationale: The most important factor in performing a physical assessment is following a consistent and systematic technique (C) each time an assessment is performed to minimize variation in sequence which may increase the likelihood of omitting a step or exam of an isolated area. The method of completing a physical assessment (A, B, and D) may be at the discretion of the examiner, but a consistent sequence by the examiner provides a reliable method to ensure thorough review of the clients' history, complaints, or body systems.
The nurse is evaluating client learning about a low-sodium diet. Selection of which meal would indicate to the nurse that this client understands the dietary restrictions?
A.) Tossed salad, low-sodium dressing, bacon and tomato sandwich.
B.) New England clam chowder, no-salt crackers, fresh fruit salad.
C.) Skim milk, turkey salad, roll, and vanilla ice cream.
D.) Macaroni and cheese, diet Coke, a slice of cherry pie.
C
Rationale: Skim milk, turkey, bread, and ice cream, while containing some sodium, are considered low-sodium foods. Bacon, canned soups, especially those with seafood, hard cheeses, macaroni, and most diet drinks are very high in sodium.
Which step in the nursing process would involve promoting a safe environment for the client?
A.) Planning
B.) Diagnosis
C.) Assessment
D.) Implementation
D
Rationale: The nurse promotes a safe environment during the implementation stage of the nursing process. During the planning stage, the nurse develops an individualized care plan for the client. The plan contains strategies and alternatives to achieve specific outcomes. During the diagnosis stage, the nurse analyzes the assessment data to determine the health care issues. The nurse collects comprehensive data pertinent to the client's health and situation during the assessment stage.
Which healthcare system focuses solely on palliative care?
A.) Hospice
B.) Rehabilitation
C.) Assisted Living
D.) Extended care facilities
A
Rationale: A hospice is a system of family-centered care that allows clients to live and remain at home with comfort, independence, and dignity while easing the pain of terminal illness. The focus of hospice care is palliative care, not curative treatment. Rehabilitation restores a person to his or her fullest physical, mental, social, vocational, and economic potential possible. Assisted living offers an attractive long-term care setting with an environment reminiscent of home and with some resident autonomy. An extended care facility provides intermediate medical, nursing, or custodial care to clients recovering from acute illnesses or clients with chronic illnesses or disabilities.
Which statement is applicable to Watson's theory of transpersonal caring?
A.) Watson's theory views the client as an adaptive system.
B.) Watson's theory is based on stress and the client's reaction to the stressor.
C.) Watson's theory focuses on providing the client with culturally specific nursing care.
D.) Watson's theory defines the outcome of nursing activity in relation to the humanistic aspects of life.
D
Rationale: Watson's theory of transpersonal caring defines the outcome of nursing activity in relation to the humanistic aspects of life. The Roy adaptation model views the client as an adaptive system. The Neuman systems model is based on stress and the client's reaction to the stressor. Leininger's theory focuses on cultural diversity; the goal of nursing care should be to provide the client with culturally specific nursing care.
Which statement is true about Betty Neuman's theory?
A.) Betty Neuman's theory is based on anthropology.
B.) Betty Neuman's theory views the client as an adaptive system.
C.) Betty Neuman's theory is based on stress and the client's reaction to the stressor.
D.) Betty Neuman's theory defines the outcomes of the nursing based on humanistic aspects of life.
C
Rationale: Betty Neuman's theory is based on stress and the client's reaction to the stressor. In this model, the client is the individual, group, family, or community. The system is composed of five concepts that interact with one another: physiologic, psychologic, sociocultural, developmental, and spiritual. Leininger's theory is based on anthropology. Roy's adaptation model views the client as an adaptive system. Jean Watson's theory of transpersonal caring defines the outcome of the nursing activity with regard to the humanistic aspects of life.
A hospital needs to hire a nursing staff for the intensive care of cancer clients. Which of these positions is most likely to be filled by the nurse?
A.) Nurse practitioner
B.) Nurse administrator
C.) Certified nurse-midwife
D.) Clinical nurse specialist
D
Rationale: The hospital will most likely hire a clinical nurse specialist. A clinical nurse specialist is an expert in a specific area of practice and in a particular setting such as an intensive care unit. A nurse practitioner has expertise in taking care of clients in an outpatient, ambulatory care, or community care setting. A nurse administrator looks after the management of the care provided to clients within a health-care agency. A certified nurse-midwife provides care to women during their pregnancy, labor or delivery.
Which statement defines "information" gathered by the nurse?
A.) It is an individual piece of reality.
B.) It is a combination of pieces of reality.
C.) It is the organization and interpretation of data.
D.) It is the identification of relationship of various data.
C
Rationale: Information is defined as the organization and interpretation of data or pieces of reality. Datum is an individual piece of reality. When data are combined and relationships among data are identified, the nurse obtains knowledge. [Show Less]