Detailed Answer Key
HW-3
1. A nurse is caring for a client who has had an allogeneic hematopoietic stem-cell transplant. Which of the
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infection-control precautions should the nurse use while caring for this client?
A. Airborne
Rationale: Clients who have varicella and other infections such as rubeola and tuberculosis require
airborne precautions.
B. Protective
Rationale: Clients whose immune system is compromised, such as from chemotherapy, AIDS, or after a
stem-cell transplant, require a protective environment.
C. Contact
Rationale: Clients who have infections such as herpes simplex, respiratory syncytial virus, and
methicillin-resistant Staphylococcus aureus require contact precautions.
D. Droplet
Rationale: Clients who have streptococcal pharyngitis and other infections such as rubella and diphtheria
require droplet precautions.
2. A nurse is creating a discharge plan. Which of the following nursing statements indicates the nurse understands
when discharge planning should be implemented?
A. “I will begin 48 hr before the client’s discharge.”
Rationale: Effective discharge planning must begin upon admission of the client, not 48 hr before
discharge.
B. “I will begin once the client’s discharge order is written.”
Rationale: Effective discharge planning must begin upon admission of the client, not once the discharge
order is written.
C. “I will begin upon the client’s admission to the facility.”
Rationale: Effective discharge planning must begin upon admission of the client to the facility.
D. “I will begin once the client’s insurance company approves discharge coverage.”
Rationale: Effective discharge planning must begin upon admission of the client, not once the client’s
insurance company approves discharge coverage.
3. A nurse has completed an informed consent form with a client. The client then states, “I have changed my mind and
do not want to have the procedure done.” Which of the following actions should the nurse take?
A. Remind the client that a signed informed consent form is a legally binding document.
Rationale:
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The client has the right to withdraw informed consent; therefore, informing the client the consent
is a legal document is not an appropriate response.
B. Notify the surgeon that the client wishes to withdraw informed consent for the procedure.
Rationale: The client has the right to withdraw informed consent; therefore, the surgeon who is the one to
obtain the informed consent should be notified of the request.
C. Inform the surgical team to cancel the client’s surgery.
Rationale: The client has the right to withdraw informed consent; however, the surgeon who is the one to
obtain the informed consent should be notified first to determine if the surgery will be cancelled.
D. Proceed with preparation of the patient for the surgical procedure.
Rationale: The client has the right to withdraw informed consent; therefore, proceeding with the preparation
for surgery is not an appropriate response.
4. A nurse in a community health clinic is caring for a client who has a new diagnosis of plantar warts. The nurse
should include which of the following in the teaching plan for this client?
A. Soak feet in an antiseptic solution daily.
Rationale: Plantar warts are a result of an infection with the human papillomavirus; therefore, antiseptic
solutions are ineffective as a means of treatment.
B. They may be painful with ambulation.
Rationale: Plantar warts are painful with ambulation.
C. They are related to excessive foot perspiration.
Rationale: Foot odors are a result of excessive perspiration of the feet. This is not a finding associated with
plantar warts.
D. A biopsy will be prescribed to rule out malignancy.
Rationale: Plantar warts are a result of an infection with the human papillomavirus and are benign growths
of the skin. A biopsy is not necessary unless obvious changes in the appearance of the wart are
present.
5. A nurse is assisting with transferring a client from the bed to a wheelchair. Which of the following actions should the
nurse take?
A. Place the wheelchair at a 90° angle to the bed.
Rationale: The nurse should place the wheelchair as close to the bed as possible to prevent the client from
falling.
B. Lock the wheels of the bed and the wheelchair.
Rationale:
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The nurse should keep the wheels of the bed and the wheelchair in the locked position to
prevent them from moving when transferring a client.
C. Acquire the help of several people to lift the client.
Rationale: There is no indication that the client is so weak that the staff must lift him. If the client requires
lifting, the nurse should use the appropriate lifting device to keep the client and the staff safe.
D. Elevate the bed to a position of comfort for the nurse.
Rationale: When assisting the client out of bed, the nurse should lower the bed to its lowest position.
6. A nurse is assisting a client during ambulation when the client begins to fall. Which of the following actions should
the nurse take?
A. Provide support by holding the client’s arm.
Rationale: This is not an appropriate action. Holding the client’s arm does not allow the nurse to easily
support the client, and can cause the shoulder joint to dislocate during a fall.
B. Lean the client toward the wall.
Rationale: This is not an appropriate action. Leaning the client to one side alters the center of gravity,
causing distorted balance and making the fall more difficult to control.
C. Lower the client to the floor.
Rationale: This is an appropriate action. The nurse should gently lower the client to the floor.
D. Assume a narrow base of support.
Rationale: This is not an appropriate action. The nurse should assume a wide base of support.
7. A nurse is documenting information in a computerized health record. Which of the following nursing actions
jeopardizes client confidentiality?
A. Logging out of the computer before leaving a terminal
Rationale: Legal guidelines for a nurse include logging out of the computer before leaving a terminal.
B. Sharing computer passwords with coworkers
Rationale: This action violates client confidentiality by allowing coworkers to access information which they
may not be authorized to view.
C. Using a computer terminal in a non-public area
Rationale: Legal guidelines for a nurse include using a computer terminal that is not accessible for public
viewing.
D. Preventing an unidentified health care worker from viewing a health record on the computer screen
Rationale:
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This action follows legal guidelines as not all health care personnel have access to client health
records.
8. A nurse is planning to discharge a client who has quadriplegia to his home. The nurse suggests that the family
might need respite care services. When a family member asks how respite care can help, which of the following
responses should the nurse provide?
A. “Respite care allows the primary caregiver time away from day-to-day care responsibilities.”
Rationale: A client who has quadriplegia requires support for many activities of daily living. Primary
caregivers need time to meet their own personal needs as well. Respite care allows primary
caregivers time away from their day-to-day care responsibilities for the client.
B. “Respite care provides holistic support and care for a client who is terminally ill.”
Rationale: Hospice care provides holistic support and care for clients who are terminally ill and their
families.
C. “Respite care helps relieve pain and promote comfort.”
Rationale: Palliative care or hospice care helps relieve pain and promote comfort.
D. “Respite care is a continuation of psychological support after a family member dies.”
Rationale: Hospice care continues psychological support after a family member dies.
7, A nurse in a long-term care facility is planning care for several clients. Which of the following activities should
the nurse delegate to the licensed practical nurse (LPN)?
?, Admission assessment of a new client
Rationale: Delegation of the admission assessment as part of the nursing process is not appropriate, as
this requires nursing judgment.
B. Scheduling a diagnostic study for a client
Rationale: The LPN can schedule a diagnostic study as this does not involve assessment or nursing
judgment as part of the nursing process.
C. Evaluating changes to a client's pressure ulcer
Rationale: Delegation of assessing changes to a pressure ulcer is not appropriate, as this requires
specialized knowledge and judgment as part of the nursing process.
D. Teaching a client insulin injection technique
Rationale: Delegation of teaching is not appropriate, as this requires evaluation as part of the nursing
process. A LPN can reinforce prior teaching.
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10.A nurse is transcribing a client’s medication prescriptions and is having difficulty reading a written prescription by
the provider. Which of the following nursing actions should the nurse take?
A. Clarify the prescription with the client’s family.
Rationale: The nurse should not clarify the medication prescription with the client’s family, because this
action could be a breach of confidentiality.
B. Interpret the prescription based on the client’s health history.
Rationale: The nurse should not interpret the medication prescription based on the client’s health history,
because incorrect information may result.
C. Ask the pharmacist for clarification of the prescription.
Rationale: The nurse should not ask the pharmacist for clarification of the prescription, because incorrect
information may result.
D. Contact the provider to clarify the prescription.
Rationale: The nurse should contact the provider for clarification of the prescription to confirm the correct
interpretation of the prescription.
11.A nurse is administering an IM injection to a client who has hepatitis C. Before placing the syringe and needle in a
puncture-resistant container, which of the following actions should the nurse take?
A. Recap the needle.
Rationale: Recapping the needle increases the risk for a needle stick.
B. Place the cap on the bedside table and slide the needle into the cap.
Rationale: Recapping the needle after use using the slider recapping method increases the risk for a
needle stick.
C. Wrap the needle with gauze.
Rationale: Wrapping the needle with gauze is unnecessary and increases the risk for a needle stick.
D. Dispose of the needle uncapped.
Rationale: The nurse should immediately place the uncapped needle in a puncture-resistant container to
prevent a needle stick with the contaminated needle.
12.A nurse is teaching a newly licensed nurse about transcribing prescriptions. Which of the following examples
should the nurse include in the instructions?
A. Losartan 50.0 mg, PO, QD
Rationale: This prescription should not have a trailing zero. The decimal point can be missed and QD can
be mistaken for QOD, causing a medication error.
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B. Metformin 500mg,1 tablet, PO, daily
Rationale: This prescription is written correctly.
C. Desmopressin .1 mL, intranasal, qd
Rationale: This prescription requires a leading zero. The decimal point can be missed and qd can be
mistaken for qod, causing a medication error.
D. Zolpidem, 5 mg PO, HS
Rationale: Hour of sleep should be written out to prevent mistaking it for half-strength.
13.A nurse is planning to perform a sterile dressing change for a client. Which of the following actions should the
nurse plan to take?
A. Hold gauze packages 7.6 cm (3 in) above the sterile field.
Rationale: When adding sterile items to a sterile field from a package, such as gauze for a dressing, the
nurse should hold the items 15 cm (6 in) above the sterile field to prevent the outside wrapper
from contaminating the field.
B. Place sterile supplies within the 2.54 cm (1 in) border of the sterile field.
Rationale: The outer 2.54 cm (1 in) border of a sterile drape is contaminated. The nurse should place
objects towards the center of the sterile field, away from the contaminated edges.
C. Use sterile forceps to move the sterile items on the sterile field.
Rationale: A sterile object remains sterile only if the nurse touches it with another sterile object. This
principle guides the nurse in placement of sterile objects and how she should handle them such
as using sterile forceps or wearing sterile gloves to handle objects on a sterile field.
D. Position the wrapped package on the bedside table so the outer flap opens towards her.
Rationale: The nurse should position the wrapped package so that the outer flap is on top and opens
away from her. This allows the nurse to open the top flap away from her, reaching around the
package and grasping the outer wrapper, then opening the side flaps with two hands, and
opening the inner most flap towards her as she steps away.
14.A nurse is administering nasal decongestant drops for a client. Which of the following actions should the nurse
take?
A. Tell the client to blow her nose gently before the instillation.
Rationale: Prior to instillation, the nurse should instruct the client to blow her nose gently. This action will
help remove any secretions or crusts that could interfere with the distribution and absorption of
the medication.
B. Assist the client to a side-lying position.
Rationale:
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The nurse should assist the client to lie supine for a nasal instillation.
C. Hold the dropper 2 cm (1 in) above the naris.
Rationale: The nurse should hold the dropper 1 cm (1/2 in) above each naris before instilling the drops.
D. Instruct the client to stay in the same position for 2 min.
Rationale: The client should stay in the same position for 5 min to make sure the drops do not run out
when the she sits or stands up.
15.A nurse is teaching a class of older adults about the expected physiologic changes of aging. Which of the following
changes should the nurse include in the discussion? (Select all that apply.)
A. More difficulty seeing due to a greater sensitivity to glare
B. Decreased cough reflex
C. Decreased bladder capacity
D. Decreased systolic blood pressure
E. Dehydration of intervertebral discs [Show Less]