NURSING DE MSN5410
HESI PRACTICE TEST COMPREHENSIVE EXAM 1
A nurse is planning to teach self-care measures to a female
... [Show More] client about prevention of yeast infections. Which instructions should the nurse provide?
Use a douche preparation no more than once a month. Increase daily intake of fiber and leafy green vegetables.
Select nylon underwear that is loose-fitting, white, and comfortable.
Avoid tight-fitting clothing and do not use bubble-bath or bath salts.
Rationale
A common genital tract infection in females is candidiasis, which is an overgrowth of the normal vaginal flora of Candida albicans that thrives in an environment that is warm and moist and is perpetuated by tight-fitting clothing, underwear, or pantyhose made of nonabsorbent materials. The client should wear clothing that is loose fitting and absorbent, such as cotton underwear, and avoid using bubble-bath or bath salts which further irritate sensitive genital tissue. Douching is not recommended because it can irritate vaginal tissue, alter pH, and contribute to fungal growth. While increasing dietary fiber intake encourages healthy, nutritional guidelines, it is not the focus of the teaching. Cotton, not nylon undergarments, provide absorbancy and reduce moisture in the perineal area.
Which information should the nurse provide a client who has undergone cryosurgery for Stage 1A cervical cancer?
Notify the healthcare provider if heavy vaginal discharge occurs. Use condoms for sexual intercourse during the next week.
Flat subclinical mucosal lesions are a common harmless side effect.
Use a sanitary napkin instead of a tampon.
Rationale
Clients should avoid the use of tampons for 3 to 6 weeks after the procedure to reduce the risk of infection. A heavy, watery vaginal discharge is expected during this time, so the healthcare provider notification is not necessary. Sexual intercourse should be avoided for up to 6 weeks. Mucosal lesions are not a side effect of the procedure but may indicate human papillomavirus or a cancerous lesion and should be reported.
The nurse determines that a client's body weight is 105% above the standardized height-weight scale. Which related factor should the nurse include in the nursing problem, "Imbalanced nutrition: more than body requirements?"
Morbidly obese. Markedly obese.
Inadequate lifestyle changes in diet and exercise.
Increased morbidity and mortality risks.
Rationale
Obesity is a body weight that is 20% above desirable weight for a person's age, sex, height, body build, and calculated body mass index (BMI). Focusing on diet and exercise best identifies factors that contribute to the formulation of the nursing diagnosis. Markedly and morbid obesity are both medical classifications for a client's weight. Although the client is at an increased risk for several chronic illnesses, such as heart disease, diabetes mellitus, hypertension, coronary artery disease and hyperlipidemia, this is not a contributing cause or related factor that supports the nursing diagnosis.
A client with metastatic cancer is preparing to make decisions about end-of-life issues. When the nurse explains a durable power of attorney for health care, which description is accurate?
"It allows you to document your wishes regarding life-sustaining treatment if you can't speak for yourself."
"It will identify someone that can make decisions for your health care if you are in a coma or vegetative state."
"It is not legally binding, but helps the healthcare provider know exactly what medical treatments you want."
"It is a form that all people must sign before admission to the hospital so that individualized treatment plans can be developed."
Rationale
This is a legal document that allows individuals to identify someone to make decisions for health care, identifies how aggressive treatment should be if the client should ever be in a coma or persistent vegetative state, and lists any medical treatments they would never want performed. Documents about life sustaining treatments is the definition of the "Living Will"--some states and Canada do not consider Living Wills legal documents. A durable power of attorney is a legal document but is not a hospital form.
Which approach should the nurse use when preparing a toddler for a procedure?
Demonstrate the procedure using a doll. Avoid asking the child to make choices.
Plan a teaching session to last about 20 minutes. Show equipment but prevent child from handling it.
Rationale
Imitation is one of the most distinguishing characteristics of toddler play, so demonstration of a procedure on a doll enables a non-threatening, dramatic experience that can help prepare the toddler for the actual procedure. The primary developmental task in toddlerhood is acquiring a sense of autonomy, so giving choices whenever possible to a toddler is recommended, not avoiding asking the toddler to make a choice. Since the toddler's attention span is short, teaching sessions should be brief and can be repeated for reinforcement. Showing the equipment before its use helps relieve anxiety, but the child should be allowed to handle some of the equipment to prevent frustration and alleviate fear.
A child with bacterial conjunctivitis receives a prescription for erythromycin eye drops. Which information is most important for the nurse to include in the teaching plan?
Apply warm compresses to reduce swelling. Wear sunglasses to protect eyes from sunlight.
Take acetaminophen (Tylenol) for any eye discomfort.
Avoid sharing towels and washcloths with siblings.
Rationale
All of the information is important to include in the teaching plan, but it is most important to avoid spreading the bacterial infection. The child should avoid sharing towels and washcloths and should stay home from school for the first 24 hours after antibiotics are started, to prevent contamination of others. The other choices are important measures to reduce the child's discomfort, but inhibiting the spread of the infection is the priority intervention.
The scope of professional nursing practice is determined by rules promulgated by which organization?
State's Board of Nursing.
State Nursing Associations.
American Nurses Association (ANA).
National Labor Relations Board (NLRB).
Rationale
Each state's Board of Nursing is authorized to promulgate rules and regulations that carry the weight of law. The State Legislature delegates its law-making authority to this administrative law body. State nursing organizations and the ANA are
influential in defining and describing nursing standards of care, but neither have the authority to pass laws that legally define the professional scope of nursing practice. Although NLRB may rule on issues important to nursing practice, the scope of professional nursing practice is determined by the laws, rules, and regulations promulgated by state Boards of Nursing.
A client is admitted to the hospital for alcohol dependency. What is the priority nursing intervention during the first 48 hours following admission?
Administer thiamine (B1) to prevent Korsakoff's syndrome.
Monitor for increased blood pressure and pulse.
Administer a PRN benzodiazepine as needed for anxiety. Encourage fluid intake of non-caffeinated beverages.
Rationale
Clients with alcohol dependency experience withdrawal symptoms, which include elevated blood pressure, pulse, and temperature, so monitoring these physical parameters has the highest priority. Administering thamine will prevent Korsakoff's syndrome (secondary dementia caused by thiamine deficiency, associated with malnutrition secondary to excessive alcohol intake, but this intervention does not have the priority of monitoring vital signs.
Prior to transferring a client to a chair using a mechanical lift, what is the most important client characteristic the nurse should assess?
Ability to grasp objects. Ability to bear weight.
Upper body muscle strength.
Tolerance of exertion.
Rationale
Awareness of the client's ability to tolerate exertion allows the nurse to plan how to prepare the client for the use of the lift. The other assessments are not needed when using a lift.
A low potassium diet is prescribed for a client. What foods should the nurse teach this client to avoid?
Dried prunes.
Cottage cheese. Mashed potatoes. Mustard greens.
Rationale
A serving of dried prunes contains more than 300 mg of potassium, and should be avoided. The richest dietary sources of potassium are unprocessed foods (especially fruits), many vegetables, and some dairy products, so the client should avoid these food groups. Servings of foods containing less than 150 mg of potassium, such as cottage chees, mashed potatoes and mustard greens, are good choices for a low potassium diet.
The nurse is planning to conduct nutritional assessments and diet teaching to clients at a family health clinic. Which individual has the greatest nutritional and energy demands?
A pregnant woman.
A teenager beginning puberty. A 3-month-old infant.
A school-aged child.
Rationale
A pregnant woman's metabolic demands are 20 to 24% more than the basic metabolic rate. The other cilients require only 15 to 20% more than the basic metabolic rate.
When documenting assessment data, w hich statement should the nurse record in the narrative nursing notes?
Hair is within normal limits.
Most all permanent teeth are present.
S1 murmur auscultated in supine position. Slight tenderness in the left upper quadrant.
Rationale
Documentation of subjective and objective data obtained from the physical assessment should be communicated using precise, descriptive, clear, and accurate information, such as auscultated heart sounds while the client is in a specified position. The other choices do not demonstrate specific documentation.
The nurse obtains a heart rate of 92 and a blood pressure of 110/76 prior to administering a scheduled dose of verapamil (Calan) for a client with atrial flutter. Which action should the nurse implement?
Administer the dose as prescribed.
Withhold the drug and notify the healthcare provider. Give intravenous (IV) calcium gluconate.
Recheck the vital signs in 30 minutes and then administer the dose.
Rationale
Verapamil slows sinoatrial (SA) nodal automaticity, delays atrioventricular (AV) nodal conduction, which slows the ventricular rate, and is used to treat atrial flutter, so the drug should be administered, based on the client's heart rate and blood pressure. Withholding the medication or giving IV calcium are not indicated by the data presented. Rechecking vital signs delays the administration of the scheduled dose.
During a client assessment, the client says, "I can’t walk very well." Which action should the nurse implement first?
Choose the most successful approach.
Identify the problem. Consider alternatives.
Predict the likelihood of the outcome.
Rationale
The sequential steps in problem-solving are to first identify the problem, then consider alternatives, consider outcomes of the alternatives, predict the likelihood of the outcomes occurring, and choose the alternative with the best chance of success.
A female client reports to the nurse that her sleep was interrupted by "thoughts of anger toward my husband." What type of thoughts is the client having?
Obsessive.
Phobic.
Delusional. Paranoid.
Rationale
Obsessive thoughts are thoughts that the client is unable to control. Phobic thoughts are irrational fears. Delusional thoughts are false beliefs. Paranoid thoughts are suspicious thoughts.
Following an emergency Cesarean delivery, the nurse encourages the new mother to breastfeed her newborn. The client asks why she should breastfeed now. Which information should the nurse provide?
Initiate the lactation process. Prevent neonatal hypoglycemia.
Stimulate contraction of the uterus. Facilitate maternal-infant bonding.
Rationale
When the infant suckles at the breast, oxytocin is released by the posterior pituitary to stimulates the "letdown" reflex, which causes the release of colostrum, and contracts the uterus to prevent uterine hemorrhage. Initiating lactation or preventing low
blood glucose levels in the newborn do not support the client's need in the immediate period after the emergency delivery. Although maternal-newborn bonding is facilitated by early breastfeeding, the priority is uterine contraction stimulation.
Which nursing intervention is an example of a competent performance criterion for an occupational and environmental health nurse?
Serves as a consultant to businesses and management. Implements health programs for construction workers.
Designs quality improvement methods that measure health outcomes. Conducts research studies that enhance health safety.
Rationale
Implementing health programs for construction workers is an example of a competent performance criterion in management, which includes monitoring of the quality and effectiveness of vendor services. Serving as a consultant is an example of an expert performance criterion for case management. Designing quality improvment methods and conducting research studies are examples of a proficient performance criteria for management.
Which finding should the nurse identify as an early clinical manifestation of neonatal encephalopathy related to hyperbilirubinemia?
Mental retardation.
Rigid extension of all extremities.
Lethargy or irritability.
Increased or unstable temperature.
Rationale
Hyperbilirubinemia causes severe brain damage, encephalopathy (kernicterus), that results from the deposition of unconjugated bilirubin in brain cells. Prodromal clinical manifestations of central nervous system involvement include decreased activity, a loss of interest in feeding, and lethargy or irritability. Without treatment, progressive signs of neurologic damage include mental retardation, rigid extremities and unstable temperature.
A client with asthma receives a prescription for high blood pressure during a clinic visit. Which prescription should the nurse anticipate the client to receive that is least likely to exacerbate asthma?
Pindolol (Visken). Carteolol (Ocupress).
Metoprolol tartrate (Lopressor).
Propranolol hydrochloride (Inderal).
Rationale
The best antihypertensive agent for clients with asthma is metoprolol (Lopressor), a beta-2 blocking agent which is also cardioselective and less likely to cause bronchoconstriction. Pindolol is a beta-2 blocker that can cause bronchoconstriction and increase asthmatic symptoms. Although carteolol is a beta blocking agent and an effective antihypertensive agent used in managing angina, it can increase a client's risk for bronchoconstriction due to its nonselective beta blocker action. Propranolol also blocks the beta-2 receptors in the lungs, causing bronchoconstriction, and is not indicated in clients with asthma and other obstructive pulmonary disorders.
During the physical assessment, which finding should the nurse recognize as a normal finding?
Regular pulsation at the epigastric area when the client is supine.
Apical pulse noted over an area 4 to 5 centimeters with a duration of 2 seconds. Jugular venous pressure palpable with the client in an upright position.
Point of maximal impulse at the third intercostal space in the right midclavicular line.
Rationale
Recognizing normal findings in the physical exam is a necessity. The regular and recurrent expansion and contraction of an artery produced by waves of pressure caused by the ejection of blood from the left ventricle as it contracts is a normal finding. All other choices are abnormal findings that require further assessment.
A client is brought into the emergency department following a sudden cardiac arrest. A full code is started. Five minutes later the family arrives with a durable power of attorney signed by the client requesting that no extraordinary measures be taken, including intubation, to save the client's life. What action should the nurse take?
Stop the code immediately.
Continue the code according to protocol.
Ask the legal department if the code should be continued. Assess the family's support for the durable power of attorney.
Rationale
A durable power of attorney documents the client's wishes and supersedes the wishes of the medical staff. The client's wishes are most important.
After eye drops are instilled, which instruction should the nurse provide to the client?
"Tilt your head back." "Look to each side."
"Close your eyelids." "Blink quickly 3 times."
Rationale
Gently closing the eyelids without blinking allows the medication to spread over the eye. It is usually helpful for the client to tilt their head back while the eye drops are being instilled. Instructing the client to look to each side will not assist in medication distribution or absorption.
A dyspneic male client refuses to wear an oxygen face mask because he states it is "smothering" him. What oxygen delivery system is best for this client?
Rebreather mask. Venturi mask.
Nasal cannula.
Hand-held nebulizer.
Rationale
The nasal cannula will provide oxygen without covering the client's face. The Venturi and rebreather masks are also masks and will not alleviate the problem of feeling "smothered." A hand-held nebulizer is used for medication administration rather than oxygen.
When engaging in planned change on the unit, what should the nurse-manager establish first?
Goals for achieving the change are established.
Options for accomplishing the change are explored. Resources needed for the change are available.
Staff members are aware of the need for change.
Rationale
The first step in planned change involves establishing a relationship with those involved in the change process and instilling knowledge and awareness of the need for change. The nurse-manager should next implement looking at resources needed, and then set goals and options on how to accomplish the change.
The nurse plans to suction a male client who has just undergone right pneumonectomy for cancer of the lung. Secretions can be seen around the endotracheal tube and the nurse auscultates rattling in the lungs. What safety factors should the nurse consider when suctioning this client?
Suction for only 5 seconds since the client has only one lung and cannot hold his breath for very long.
Use a soft-tip rubber suction catheter and avoid deep vigorous suctioning.
Have another person available to hold the client's hands to prevent inadvertent removal of the suction tube.
Suction deeply and vigorously to ensure that all secretions are removed in order to prevent atelectasis.
Rationale
A soft rubber catheter with a blunt tip is preferable and deep, vigorous suctioning should be avoided. The client should not hold his breath whether he has one or two lungs and 5 seconds of suctioning is not enough to justify the trauma caused by suctioning. Having another person available for restraint is a good idea if the client is combative or confused, but having a person hold his hands is not the best answer to this question. It is important to avoid deep suctioning to avoid perforating the sutures on the bronchial stump following a pneumonectomy.
An older client who has been bedridden for a month is admitted with a pressure ulcer on the left trochanter area. The nurse determines that the ulcer extends into the subcutaneous tissue. At which stage should the nurse document this finding?
Stage 1.
Stage 2.
Stage 3.
Stage 4.
Rationale
Pressure ulcers develop over skin surfaces usually covering bony prominences and are caused by external pressure that impedes blood flow, causing ischemia of the skin and underlying tissue. The stage of the pressure area is determined by the depth of tissue damage, and this client's lesion should be documented as a Stage 3 because it is a full-thickness tissue loss with visible subcutaneous fat that does not expose bone, tendon, or muscle. Stage 1 is a nonblanchable pressure point over intact skin. Stage 2 is a partial thickness ulcer, such as a ruptured blister or shallow open ulcer with a pink wound bed. Stage 4 is a full thickness tissue loss with exposed bone, tendon or muscle, slough or eschar, and often includes undermining and tunneling.
The nurse is assessing a client and identifies the presence of petechiae. Which documentation best describes this finding?
Purplish-red pinpoint lesions of the skin. Purple to bluish discoloration of the skin.
Small circumscribed elevations containing purulent fluid. Generalized reddish discoloration of an area of skin.
Rationale
Petechiae are described as purplish to red, non-blanchable, pinpoint lesions that are tiny hemorrhages within the dermal or submucosal layers. Purplish skin discoloration describes ecchymosis caused by trauma to the underlying blood vessels. Small elevations conting pus describes pustules. Generalize red skin area is nonspecific and incomplete.
After receiving report, the nurse prioritizes the client care assignment. Which client should the nurse assess first?
The client who has a new onset of difficult breathing.
An anxious client who is 3 days post myocardial infarction.
The client with type 2 diabetes mellitus who has a call light on. A client whose blood transfusion is near completion.
Rationale
Based on Maslow's hierarchy of needs and the need to address airway, breathing, and circulation (ABCs), the client with a new onset of difficulty breathing should be assessed first. The other clients need care but arevnot the priority of over a client who needs airway/breathing assessment and management.
The nurse is inspecting the external eye structures for a client. Which finding is a normal racial variation?
A Hispanic client may have inward-turned eyelashes. An Asian client may have a horizontal palpebrale fissure.
An African-American client may have slightly yellow sclerae.
A Caucasian client may have a slightly protruding eyeball.
Rationale
Recognizing normal variations that are common in different racial groups helps the nurse differentiate an early sign of pathology, such as yellow sclerae. A slightly yellow color of the sclera is a normal racial variation found in the African-American population. The other choices are findings not related to one racial group.
What nursing delivery of care provides the nurse to plan and direct care of a group of clients over a 24-hour period?
Team nursing.
Primary nursing.
Case management.
Functional nursing.
Rationale
Primary nursing is a model of delivery of care where a nurse is accountable for planning care for clients around the clock. Functional nursing is a care delivery model that provides client care by assignment of functions or tasks. Team nursing is a care delivery model where assignments to a group of clients are provided by a mixed-staff team. Case management is the
delivery of care that uses a collaborative process of assessment, planning, facilitation, and advocacy for options and services to meet an individual's health needs and promote quality cost-effective outcomes.
A work group is to be formed to determine a care map for a new surgical intervention that is being conducted at the hospital. Which group is likely to be most effective in developing the new care map?
Nurse-manager group. Multidisciplinary group.
Single-discipline group. Surgical staff group.
Rationale
In a multidisciplinary work group, a number of individuals from a variety of disciplines are involved in developing the care map, but each works independently to implement the care plan. Single-discipline work groups, such as nurse manager group or surgical group, are likely to focus on the aspects of the care map related only to their specific discipline.
A nurse whose tuberculosis (TB ) skin test result reveals an 8 mm induration obtains a negative chest radiograph, which indicates latent tuberculosis. The employee-health
nurse should implement which intervention for this nurse?
Repeat the skin test and chest radiograph in three weeks.
Administer isoniazid (INH) daily for 6 to 9 months.
Give combination therapy of antitubercular drugs for 6 months.
Recommend the bacille Calmette-Gu rin (BCG) vaccine.
Rationale
Latent TB infection (LTBI) occurs when an individual becomes infected with Mycobacterium tuberculosis but does not become acutely ill, so isoniazid (INH) drug therapy once daily for 6 to 9 months should be implemented to prevent transmission and the development of clinical disease. The nurse is infected and should be treated, not retested. Combination therapy is the recommended treatment for active TB. Vaccination is not indicated with infection.
A nurse is answering questions about breast cancer at a hospital-sponsored community health fair. A woman asks the nurse to explain the use of tamoxifen (Nolvadex). Which response should the nurse provide?
Low doses of tamoxifen prevent menopausal hot flashes.
An option used to reduce the risk of breast cancer for all women.
This anti-estrogen drug inhibits malignancy growth.
Part of a combination of chemotherapeutic agents used to treat tumors.
Rationale
Tamoxifen (Nolvadex) is used in postmenopausal women with breast cancer to prevent and treat recurrent cancer and inhibit the growth-stimulating effects of estrogen by blocking estrogen receptor sites on malignant cells. A side effect of tamoxifen is hot flashes, which is related to the decreased estrogen. Tamoxifen is used for women with estrogen receptor-positive breast cancer, not all women, and is classified as a hormonal agent, not a chemotherpeutic agent, used to suppress malignant cell growth.
The nurse is planning a teaching program about prenatal care for a diverse ethnic group of clients. Which factor is most influential for the acceptance of the healthcare practices?
Income grouping. Ethic background.
Individual beliefs. Educational level.
Rationale
The client’s beliefs are key to accepting healthcare practices and interventions. Although income level, ethical background and educational level influence an individual's interpretation and acceptance of different healthcare practices, individual beliefs are most influential.
A male client who lives in an area endemic with Lyme disease asks the nurse what to do if he thinks he may have been exposed. Which response should the nurse provide?
Cover the ticks with oil to suffocate and kill them to prevent transmission.
Look for early signs of a lesion that increases in size with a red border, clear center. See a healthcare provider if nausea, vomiting, and joint pain occur after a tick bite. Obtain early treatment with antiviral agents to prevent cardiac manifestations.
Rationale
The client should look for the early signs of localized Lyme disease known as erythema migrans, a skin lesion that slowly expands to form a large round lesion with a bright red border and clear center at the site of the tick bite. A tick should be
removed with tweezers by pulling straight from its insertion away from the skin, and not compressing its body or covering it with oil. Lyme disease is caused by the spirochete, Borrelia burgdorferi, which is transmitted by the bite of an infected deer tick, and antiviral agents are ineffective. Symptoms, such as fever, chills, headache, stiff neck, fatigue, and swollen lymph nodes are more typical, not nausea and vomiting.
The nurse is caring for a client who is unable to void. The plan of care establishes an objective for the client to ingest at least 1000 ml of fluid between 7:00 am and 3:30 pm. Which client response should the nurse document that indicates a successful outcome?
Demonstrates adequate fluid intake and output. Voids at least 1000 ml between 7am and 3 pm. Verbalizes abdominal comfort without pressure.
Drinks 240 ml of fluid five times during the shift.
Rationale
The nurse should evaluate the client's outcome by observing the client’s performance of each expected behavior, so drinking 240 ml of fluid five or six times during the shift indicates a fluid intake of 1200 to 1440 ml, which meets the objective of at least 1000 ml during the designated period. The term "adequate," which is not quantified. Voiding 1000 ml between 0700 and 1500 is not the objective, which establishes an intake of at least 1000 ml. Abdominal comfort is not an evaluation of the specific fluid intake.
The nurse is caring for a client who is one day postoperative after a left total knee arthroplasty (TKA). Which intervention should the nurse include in the plan of care?
Progressive leg exercises to obtain 90-degree flexion.
Ambulation with full weight-bearing on first postop day. Bed rest for three days with the left knee extended.
Immobilization of the left knee to prevent dislocation.
Rationale
Isometric quadriceps setting begins the first day after TKA surgery and progresses to straight-leg raises, then gentle ROM to increase muscle strength until 90-degree knee flexion is obtained. Bed rest and immobilization is contraindicated to prevent scar tissue, which limits mobility. Active flexion exercises through the use of a continuous passive motion (CPM) machine postoperatively promotes joint mobility. Postoperative exercise progresses to full weight-bearing before discharge, but not the first postoperative day. Joint mobility is a priority outcome, and dislocation is not typical with TKA.
The nurse obtains the pulse rate of 89 beats/minute for an infant before administering digoxin (Lanoxin). Which action should the nurse take?
Assess respiratory rate for one minute next. Give the medication dosage as scheduled.
Wait 30 minutes and give half of the dosage of medication.
Withhold the medication and contact the healthcare provider.
Rationale
Bradycardia is an early sign of digoxin toxicity, so if the infant's pulse rate is less than 100 beats/minute, digoxin should be withheld and the healthcare provider should be notified. Assessing the respiratory rate is not indicated before administering Lanoxin. Administering the dose or only giving a partial dose places the infant at further risk for digoxin toxicity.
The nurse is teaching staff in a long-term facility home the principles of caring for clients with essential hypertension. Which comment should the nurse include in the inservice presentation about the care of clients with hypertension?
"Clients with an elevated blood pressure often exhibit a stiff neck and are diaphoretic."
"As long as clients receive daily antihypertensive medications, no further interventions are needed." "Caregivers should only conduct blood pressure checks under a registered nurse's direct
supervision."
"Frequent blood pressure checks, including readings taken by automated machines, are recommended."
Rationale
Frequent blood pressure checks are recommended for hypertensive clients to evaluate the effectiveness of treatment. Symptoms such as a stiff neck are not typical of essential hypertension, which is an asymptomatic disease. Treatment usually includes dietary modifications and exercise, which should not be discontinued when medications are added to the treatment plan. While the RN is ultimately responsible for the assessment of blood pressures, caregivers are not restricted from obtaining the blood pressure readings.
The school nurse is reviewing health risks associated with extracurricular activities of grade-school children. Regular participation in which activity places the child at highest risk for developing external otitis?
Batting practice at a batting cage. Soccer practice at an outdoor field.
Swimming lessons in an indoor pool.
Roller skating at an indoor rink.
Rationale
External otitis is commonly caused by exposure to bacteria while swimming. In addition, chlorine tends to alter the normal flora of the external ear canal, increasing the risk for infection. Participation in the other sports may increase the child's risk for trauma, and families should be instructed to use protective equipment to reduce this risk.
A male client is angry and is leaving the hospital against medical advice (AMA). The client demands to take his chart with him and states the chart is "his" and he doesn’t want any more contact with the hospital. How should the nurse respond?
"Because you are leaving against medical advice, you may not have your chart." "The information in your chart is confidential and cannot leave this facility legally." "This hospital does not need to keep it if you are leaving and not returning here."
"The chart is the property of the hospital but I will see that a copy is made for you."
Rationale
The chart is the property of the facility, but the client has a legal right to the information in it, even if he is leaving AMA, so a copy of the record should be provided. The client does not lose his legal rights to his medical record if he leaves AMA. The medical record is confidential, but the hospital protects the client's privacy by not allowing unauthorized access to the record, so the hospital may provide the client with a copy. The hospital must maintain records of the care provided and should not release the original record.
Which action should the nurse implement when administering a prescription drug that should be given on an empty stomach?
Administer after an eight-hour fast.
Give one hour before or two hours after a meal.
Provide the dose after the client has missed a meal.
Take with liquids, but no solid foods.
Rationale
When administering a drug on an empty stomach, the drug should be given either one hour before a meal or two hours after a meal, which is the average transit time from the stomach to the duodenum after eating. An eight-hour fast is more time than is needed for the stomach to empty and is not necessary. The last time any food or drink has been ingested is a better indicator of an empty stomach, rather than after the client has missed a meal. Some liquids, such as grapefruit juice, can alter the drug's dilution and absorption.
Clinical portfolios are being introduced into the performance appraisal process for staff nurses employed at a hospital. What should the nurse-manager request that each staff nurse include in the portfolio?
Evaluations by past nursing faculty and employers to document ongoing competence. Copies of any articles the nurse has read that relate to client care on the nursing unit. Letters of support from family members and friends who are healthcare professionals.
A self-evaluation that identifies how the nurse has met professional objectives and goals.
Rationale
A clinical portfolio should include pertinent information that assists in providing a comprehensive view of the employee's performance. A self-evaluation provides an important assessment of the nurse's strengths, weaknesses, and progress toward the achievement of professional goals. Past evaluations not pertinent nor useful evaluative data regarding current
performance. While documentation of continuing education and any certifications achieved are important to include in a clinical portfolio, copies of articles read is not necessary. Letters of support are not a significant component of a clinical portfolio.
A 63-year-old female client whose husband died one month ago is seen in the psychiatric clinic. Her daughter tells the nurse that her mother is eating poorly, sleeps very little at night, and continues to set the table for her deceased husband. What nursing problem best describes this problem?
Confusion related to recent death of loved one.
Delayed grief reaction related to death of husband.
Denial related to the loss of a loved one.
Unresolved anger related to death of husband.
Rationale
Based on the data provided, denial of the loss is the best nursing diagnosis. This client is exhibiting symptoms of anxiety and the pain is too great for her to acknowledge, so she is denying the situation. Although she may seem confused, she is actually trying to deal with the pain through the defense mechanism of denial. Delayed grief occurs after one year or longer following the loss. The client's husband died one month ago. Unsresolved anger and depression are often related, and depression is sometimes described as unexpressed anger. However, this client has not acknowledged her loss (denial) and the anger is not yet realized.
Two unlicensed assistive personnel (UAP) are arguing on the unit about who deserves to take a break first. What is the most important basic guideline that the nurse should follow in resolving the conflict?
Deal with issues and not personalities.
Require the UAPs to reach a compromise.
Weigh the consequences of each possible solution.
Encourage the two to view the humor of the conflict.
Rationale
Dealing with the issues which are concrete, not personalities which include emotional reactions, is one of seven important key behaviors in managing conflict. The other choices do not resolve the conflict when diverse opinions are expressed emotionally. [Show Less]