Question 1

The unit implemented a quality improvement program to address client pain relief. Which set of criteria is the best determinant that the goal has been met? A)Chart audits found clients' self-reported pain scores improved by 10% B)Number of narcotics used on the unit increased by 20% C)Positive comments on returned client satisfaction surveys increased by 30% D)Survey found that 90% of the nurses believed clients had better pain control

Accepted Answer

Measurements should be objective, rather than subjective. Evidence-based criteria should be used, if applicable. These survey results are objective, retrospective measurements of a positive change. (Option B) This increase in use could be attributed to many other factors, including difference in the number or type of clients on the unit and theft of the narcotics. In addition, clients may obtain pain relief by alternate means. (Option C) These are subjective criteria. It is possible to consider satisfaction as an outcome, but there is no indication in the option that the percentage of returned surveys is a satisfactory amount. There is no indication whether the positive comments are about pain relief or other aspects of care. There is no indication if these clients had pain relief as part of their nursing needs. (Option D) This is a subjective perception on the part of the nurses that may or may not be accurate. Educational objective: The outcomes of a quality improvement program should be objective and measureable.

Question 2

A client with renal failure recently started dialysis and is unable to work due to ongoing health problems. The client's spouse has started working for a cleaning service to replace the lost income. The dialysis nurse notices that the client has become withdrawn and increasingly frustrated by small inconveniences when coming to dialysis. Which is the most appropriate first response by the nurse? A)"How is your spouse's new job going?" B)"I notice that you seem frustrated." C)"It can take time to adjust to dialysis. We have a support group that can be helpful." D)"It's normal to be angry when you can't work any longer."

Accepted Answer

The client with chronic illness who is unable to work may experience depression, grief, loss, a feeling of inadequacy, or a loss of meaning and purpose in life. It can take time to adjust and accept the new roles, and this stress can increase a person's vulnerability to ongoing health problems. This client has gone from being the main source of income, or "breadwinner," to being someone who is unable to support the family. The client is now dependent on the spouse for financial stability and this is causing a strain. This type of role change can be particularly difficult for men who are used to providing for their families and for anyone who is well-established in a career. The nurse has noticed a change in the client's behavior but has not assessed the client to determine the factors contributing to this change. Assessment is needed before interventions can be planned. An open-ended reflective statement and nonverbal communication expressing acceptance and willingness to listen in the setting of a trusting relationship are appropriate to begin this assessment. (Option A) This response ignores the client's feelings and closes off an opportunity to assess the client's emotional state and the role change brought on by illness and the spouse's new job. (Option C) The source of the client's behavior change is not apparent at this point, so further assessment is needed. It is premature to intervene by recommending a support group. (Option D) The nurse is assuming that the client is angry about inability to work, but the client has not said this. Further assessment is needed to understand the client's emotions and their source. Educational objective: Chronic illness can result in role changes that influence the client's self-concept. The nurse can positively influence self-concept by empathizing, communicating acceptance, and assessing the client's feelings and perceptions on the issue.

Question 3

A client is admitted to the hospital for chemotherapy complications. Laboratory results show an absolute neutrophil count of 450 cells/mm³ (0.45 ×10⁹/L). What information contained in the admission history of this client will need to be addressed during discharge education? A)Eats steamed vegetables daily B)Enjoys eating grilled shrimp weekly C)Gardens as hobby D)Takes a bath daily and applies moisturizer

Accepted Answer

This client has a very low absolute neutrophil count (normal: 2200-7700 cells/mm³ [2.2-7.7 ×10⁹/L]); having <500 cells/mm³ (0.5 ×10⁹/L) indicates severe neutropenia and increases the risk of infection. All risks for infection should be minimized in a client with neutropenia. Soil contains many pathogens, including Aspergillus fungus, which could expose this client to infection. Gardening and contact with fresh flowers and plants should be avoided when a client is at increased risk for infection. In addition, the client's room should not have standing water. Strict hand-washing is recommended. The client should be placed in a private room while in the hospital and all visitors should wear a mask. (Option A) The client with neutropenia is allowed to consume cooked vegetables. However, raw or unwashed vegetables should be avoided due to possible contamination with pathogens as this can increase the risk of infection. A healthy diet containing vegetables is encouraged to increase consumption of necessary nutrients. (Option B) Protein is a necessary component in the diet of a client receiving chemotherapy. Protein aids in the healing process of the body. As long as the meat or seafood is fully cooked, it is safe for the client with neutropenia to consume. Raw or undercooked meat/seafood is to be avoided due to possible exposure to pathogens. (Option D) Clients with neutropenia are encouraged to bathe daily to remove pathogens that could cause infection. Moisturizer should be applied to prevent dry skin. If the skin becomes dry or cracked, pathogens could use these openings as portals of entry; this can lead to infection in the host. Educational objective: A low absolute neutrophil count increases a client's risk for infection. Gardening (soil) and contact with fresh flowers and plants should be avoided due to potential exposure to pathogens. The client's room should not have standing water.

Question 4

An unlicensed assistive personnel (UAP) is aiding a client recovering from a right-sided cerebrovascular accident with resulting mild oropharyngeal dysphagia. The client has been placed on a dysphagia diet. Which actions require intervention by the registered nurse? Select all that apply. A)The UAP adds milk to mashed potatoes to make them thinner B)The UAP encourages the client to occasionally turn the head to the left C)The UAP helps the client sit in an upright position D)The UAP places food on the strong side of the client's mouth E)The UAP puts a straw in a fruit smoothie to prevent spilling

Accepted Answer

Clients with dysphagia are at risk for aspiration and aspiration pneumonia. Dietary modifications and swallowing rehabilitation measures can reduce the risk of aspiration in clients who can tolerate oral feedings. Specific techniques include the following: Modification of food consistency (pureed, mechanically altered, soft)Thickened liquidsHaving the client sit upright at a 90-degree angle (Option C)Placing food on the stronger side of the mouth to aid in bolus formation (Option D)Tilting the neck slightly to assist with laryngeal elevation and closure of the epiglottis Modification of food consistency (pureed, mechanically altered, soft) Thickened liquids Having the client sit upright at a 90-degree angle (Option C) Placing food on the stronger side of the mouth to aid in bolus formation (Option D) Tilting the neck slightly to assist with laryngeal elevation and closure of the epiglottis Some clients who have suffered a cerebrovascular accident (CVA) are also left with visual impairment such as hemianopsia; in this condition, a person sees only a portion of the visual field from each eye. A client with a right-sided CVA may have left-sided hemianopsia. Having the client turn the head during a meal will help the client see everything on the plate (Option B). (Option A) Adding milk to mashed potatoes will alter the consistency; if the consistency is too thin, the client will be at increased risk of aspiration. (Option E) Using a straw for drinking liquids might cause increased swallowing difficulty and choking. Controlling liquid intake through a straw is more difficult than drinking straight from a cup or glass. Educational objective: Measures for reducing the risk of aspiration for clients with dysphagia include diet modification (pureed, mechanically altered, soft), thickened liquids, positioning the client in an upright position, placing food on the stronger side of the mouth, and flexing the chin slightly downward. A client with visual impairment should be reminded to turn the head from time to time while eating.

Question 5

Which client is at the greatest risk for development of hospital-acquired pressure injuries? A)25-year-old client with quadriplegia, urosepsis, temperature of 101 F (38.3 C), and white blood cell count of 18,000/mm³ (18.0 x 10⁹/L) B)50-year-old client with AIDS who is receiving norepinephrine infusion and has a weight loss of 20 lb (9.1 kg) in a month, prealbumin level <10 mg/dL (100 mg/L), and mean arterial pressure of 50 mm Hg C)80-year-old client 2 days post hip replacement with dementia, 2 Jackson-Pratt drains, and hemoglobin level of 14 g/dL (140 g/L) D)87-year-old client 2 days post open cholecystectomy

Accepted Answer

11ecbb05_cb0e_ad14_b433_dd9423f72714_MD0009_00 Pressure injuries are areas of localized skin injury and underlying tissue caused by external pressure with or without friction and/or shearing. These result from ischemia and hypoxia of tissue following periods of prolonged pressure. Clients at greatest risk include older adults with limited movement and long bone (femur) or hip fractures, those with quadriplegia, and the critically ill. Clients with deficits in mobility and activity, incontinence, inadequate nutrition, chronic illness, renal failure, anemia, problems with oxygenation, edema, or infection are also at increased risk. This client (Option B) has 5 risk factors: chronic illness and immune deficiency disease; significant weight loss; prealbumin <16 mg/dL (<160 mg/L), indicating inadequate nutrition and protein deficiency; hypotension (decreases perfusion pressure); and receiving norepinephrine (Levophed), a vasoconstrictor. These risks affect circulation, capillary perfusion pressure, and the ability to provide adequate nutrition to the cells. (Option A) This client has 4 risk factors: a deficit in independent mobility and activity, spinal cord injury with quadriplegia, decreased sensation, and fever and infection. (Option C) This client has 3 risk factors: advanced age, surgery, and dementia. Hemoglobin is within the normal range. (Option D) This client has 2 risk factors: advanced age and surgery. Surgery can be associated with deep-tissue injuries. Positioning and immobility during the surgical procedures (>2½ hours) and receiving anesthetic and vasoactive drugs (to treat hypotension) present a special risk for the development of deep-tissue injury in postoperative clients. Educational objective: Although pressure injuries can develop in any client with limited mobility and activity, those at most risk include older adults; those with quadriplegia; the critically ill; and those with fracture of a long bone or hip, incontinence, nutritional deficits, chronic illness, renal failure, anemia, oxygenation and circulation problems, infection, or fever.

Question 6

A client expresses concern about facial appearance after surgery for excision of a melanoma on the side of the nose. What is the best response by the nurse? A)"Have you shared your concerns with your health care provider (HCP)?" B)"If I were you, I would be more worried about whether the melanoma has spread." C)"Scar tissue formation is part of the natural healing process. We will teach you how to care for your wound to minimize any complications." D)"There is special make-up you can use to hide any facial scars left from the surgery."

Accepted Answer

Clients facing surgery often have concerns and anxiety over the procedure, postoperative course, outcome, and issues related to altered body image. The best response by the nurse uses 2 therapeutic approaches aimed at reducing the client's concerns and anxiety: The client is provided with factual information about facial surgery and the healing process. The client is provided with factual information about facial surgery and the healing process. The client is given assurance and support that something can be done to minimize the complications of wound healing. This will provide the client with a plan of action and a sense of control over the condition and post-surgical course. It is impossible to predict the lasting effect of the surgery on the client's facial appearance; however, teaching on managing wound care will help lessen the client's anxiety. The client is given assurance and support that something can be done to minimize the complications of wound healing. This will provide the client with a plan of action and a sense of control over the condition and post-surgical course. It is impossible to predict the lasting effect of the surgery on the client's facial appearance; however, teaching on managing wound care will help lessen the client's anxiety. (Option A) This is not the best or priority response. Although the HCP will be able to give the client more information and details about the surgery and potential outcomes, the response suggests that the nurse has little or no role in providing information or teaching the client about the upcoming procedure. The response is also a "yes" or "no" question; closed-ended questions tend to minimize nurse-client interactions. (Option B) This is a non-therapeutic response; it gives advice to the client, suggests that the nurse "knows better," and minimizes the client's concerns. It also introduces a more serious issue about the diagnosis. (Option D) This is a non-therapeutic response. Although it is true that there are methods to conceal scars and other skin discolorations, the response is dismissive and does not address the client's concerns. Educational objective: Clients facing surgery often have concerns and anxiety over the procedure, postoperative course, outcome, and altered body image. Providing information about the surgical procedure, healing process, and self-care activities, and giving support will lessen anxiety and give the client a sense of control.

Question 7

The nurse is teaching a client with insomnia about techniques to improve sleep habits.  Which statement by the client requires further teaching?
A)"I will avoid naps later in the day."
B)"I will keep the bedroom temperature cool."
C)"I will read in bed before trying to go to sleep."
D)"I will try to go to bed and wake up at the same time each day."

Accepted Answer

Sleep hygiene refers to a group of practices that promote regular, restful sleep. The nurse should encourage clients who have trouble sleeping (insomnia) to maintain good sleep habits. A primary objective is reducing stimuli in the bedroom. Clients should be taught to avoid non-sleep-related activities (eg, reading, television, working) other than sex in bed. Relaxed reading before bed is helpful for stimulating sleep but should occur in a different setting, not in bed (Option C). The nurse should encourage the following healthy sleep habits: Avoid caffeine, nicotine, and alcohol within 4-6 hours of sleep Exercise daily but avoid exercise or strenuous activity within 4-6 hours of sleep Avoid going to bed hungry or eating a heavy meal just before bed Practice relaxation techniques (eg, deep breathing) if stress is causing insomnia (Option A) It is best to avoid naps during the day, especially later in the day. Any naps taken should be short (20-30 min). (Option B) The client should keep the bedroom slightly cool, quiet, and dark for comfort. (Option D) As much as possible, the client should develop a consistent sleep-wake pattern (ie, same bedtime and wake time each day) to obtain 7-8 hours of sleep nightly. Educational objective: The nurse should teach clients with insomnia good sleep hygiene such as using the bed for sleep only (no reading or television), avoiding stimulants (eg, caffeine) before bedtime, keeping the bedroom cool and dark, and developing a consistent sleep-wake pattern (ie, same bedtime and wake time each day).

Question 8

A 55-year-old client on a medical-surgical unit has just received a diagnosis of pancreatic cancer. The client says to the nurse, "Is this disease going to kill me?" What is the best response by the nurse? A)"Hearing this diagnosis must have been difficult for you. What are your thoughts?" B)"We will do everything possible to prevent that from happening." C)"Well, we're all going to die sometime." D)"You should concentrate on getting better rather than thinking about death."

Accepted Answer

The stress of receiving a life-threatening diagnosis often causes clients to feel very vulnerable. There is a tendency to keep feelings and concerns closed off; clients may not be able to express how distressed they feel or find the right words to express feelings and concerns. In asking, "Is this disease going to kill me?," the client is most likely not looking for a direct "yes" or "no" answer. This would immediately close off the conversation and create a missed opportunity for a meaningful engagement and communication with the nurse. It is more likely that this question is being asked to provide an opening for further discussion about the meaning of this devastating diagnosis as well as the client's thoughts and feelings. The nurse can facilitate a sense of trust, connection, and collaboration by the following: Providing empathy - acknowledging the distressing nature of the diagnosis Providing situations (eg, broad opening for discussion) in which the client can share thoughts and feelings in a safe environment Active listening - being very attentive to what the client is saying and trying to understand what the client is thinking and feeling Focusing - going beyond words and explanations to attain new awareness of a client's concerns Communicating effectively will assist the client in coping with difficult situations, reducing stress, and developing approaches for making necessary life changes (Option B) This response attempts to give reassurance but does not address the client's thoughts and concerns. (Option C) This is a very trite response and will close down any opportunity for further discussion. (Option D) This response gives advice to the client and is non-therapeutic; it does not acknowledge the client's current concerns. Educational objective: Clients with devastating conditions or situations may have difficulty expressing their concerns, thoughts, and feelings. A nurse who is skilled in using effective communication techniques such as active listening, providing broad openings for discussion, and focusing can help clients cope with and reduce the stress of difficult situations.

Question 9

The nurse teaches safety precautions of home oxygen use to a client with emphysema being discharged with a nasal cannula and portable oxygen tank. Which client statement indicates the need for further teaching? Select all that apply. A)"I can apply Vaseline to my nose when my nostrils feel dry from the oxygen." B)"I can cook on my gas stove as long as I have a fire extinguisher in the kitchen." C)"I can increase the liter flow from 2 to 6 liters a minute whenever I feel short of breath." D)"I should not polish my nails when using my oxygen." E)"I should not use a wool blanket on my bed."

Accepted Answer

Oxygenis a colorless, odorless gas that supports combustion and makes up about 21% of the atmosphere. Oxygen is not combustible itself, but it can feed a fire if one occurs. When using home oxygen, safety precautions are imperative. Vaselineis an oil-based, flammableproduct and should be avoided. A water-soluble lubricant may be used instead. Vaselineis an oil-based, flammableproduct and should be avoided. A water-soluble lubricant may be used instead. Oxygen canisters should be kept at least5-10 feet away from gas stoves, lighted fireplaces, wood stoves, candles, or other sources of open flames. Clients should use precautions as cooking oils and grease are highly flammable. Oxygen canisters should be kept at least5-10 feet away from gas stoves, lighted fireplaces, wood stoves, candles, or other sources of open flames. Clients should use precautions as cooking oils and grease are highly flammable. The prescribed concentration of oxygen, usually 24%-28% for clients with COPD, should be maintained. Oxygen is prescribed to raise the PaO₂ to 60-70 mm Hg and the saturations from 90%-93%. A flow rate of 2 L/min provides approximately 28% oxygen concentration, and 6 L/min provides approximately 44%. Higher ratesusually do not help and can even be dangerousin clients with COPD as they can decrease the drive to breathe. The client should notify the care provider about excessive shortness of breath as additional treatment may be indicated. The prescribed concentration of oxygen, usually 24%-28% for clients with COPD, should be maintained. Oxygen is prescribed to raise the PaO₂ to 60-70 mm Hg and the saturations from 90%-93%. A flow rate of 2 L/min provides approximately 28% oxygen concentration, and 6 L/min provides approximately 44%. Higher ratesusually do not help and can even be dangerousin clients with COPD as they can decrease the drive to breathe. The client should notify the care provider about excessive shortness of breath as additional treatment may be indicated. (Option D) The client understands that nail polish remover and nail polish contain acetone, which is highly combustible. (Option E) Clients should avoid synthetic and wool fabrics because they can cause static electricity, which may ignite a fire in the presence of oxygen. Clients should use cotton blankets and wear cotton fabrics. Educational objective: Safety precautions for home oxygen use include the following: no smoking; electrical devices in good condition and plugs grounded; avoiding volatile, flammable products and materials that generate static electricity; staying at least 5-10 feet away from open sources of flame; keeping fire extinguishers readily available; and regularly testing smoke detectors.

Question 10

The nurse is caring for an 83-year-old bedridden client experiencing fecal incontinence. Which nursing intervention is the highest priority for this client? A)Consult with the wound care nurse specialist B)Insert a rectal tube to contain the feces C)Provide perianal skin care with barrier cream D)Use incontinence briefs to protect the skin

Accepted Answer

Disruptions of motor function (anal sphincter and rectal floor muscle dysfunction) and/or sensory function (lack of urge to defecate or inability to sense stool) can result in fecal incontinence. The presence of stool can lead to skin breakdown, urinary tract infections, spread of infection (eg, Clostridium difficile), and contamination of wounds. Therefore, maintenance of perineal and perianal skin integrity is the highest priority. Stool should be removed promptly from the skin by gently cleansing the perineum and perianal area with mild soap. Dry the soiled area and apply a thick moisture barrier product to the skin (Option C). Clean, dry linens and clothing should be provided. (Option A) Wound care and incontinence specialists are useful resources in developing a bowel and/or incontinence management plan; however, the highest priority is promotion of skin integrity. (Option B) Rectal tubes and other indwelling containment devices can cause skin/mucosal breakdown, decreased response of the anal sphincter, and infection. Skin integrity may be maintained without the risks associated with these devices; however, if other measures fail, these devices may be used. (Option D) Absorptive incontinence products (eg, pads, undergarments) can be used after interventions to prevent incontinence and maintain perineal hygiene have failed. Incontinence products such as adult briefs may cause chemical irritation of the skin, further exacerbating skin breakdown. These products should wick moisture away from the client's skin. Educational objective: Interventions to prevent and handle fecal incontinence should be implemented from least to most invasive. Maintenance of skin integrity through perineal and perianal hygiene is the highest priority. Implementation of containment products (eg, absorbent pads, adult briefs, rectal tubes) can be considered after hygiene practices fail.

Question 11

An adult client has developed diarrhea 24 hours after the initiation of total enteral nutrition via nasogastric tube. The client is receiving a hypertonic formula. What is the bestnursing action? A)Dilute the formula with water B)Discontinue the tube feeding C)Send a stool sample to the lab for culture and sensitivity D)Slow the rate of administration of the feeding

Accepted Answer

Most clients tolerate hypertonic and isotonic enteral formulas without complications. However, because of their higher osmolality, hypertonic formulas sometimes cause nausea, vomiting, or diarrhea, especially during the initiation of total enteral nutrition. The gastrointestinal tract will pull fluid from the surrounding intra- and extravascular compartments to dilute the formula, making it similar to body fluid osmolality. This process is similar to dumping syndrome and may cause temporary diarrhea with cramps, nausea, and vomiting. Slowing down the rate of administration of total enteral nutrition will usually alleviate these problems. The feeding can gradually progress to the established goal rate. (Option A) Diluting enteral formulas is not necessary. This practice may increase the risk of intolerance secondary to microbial contamination. A diluted formula supports microbial growth better than a full-strength formula. Diluting total enteral nutrition may also be detrimental because the client may receive inadequate nutrition; it will take a larger volume of fluid to provide the same number of calories and protein. (Option B) It is not necessary to discontinue the feeding; the client needs nutrition support. (Option C) Sending a stool sample for culture and sensitivity would be appropriate if bacterial contamination or a bacterial infection is suspected as the cause of the diarrhea. It is not the best nursing action in this situation. Educational objective: Complications of total enteral nutrition at the start of treatment are nausea, vomiting, and diarrhea. These signs and symptoms can usually be alleviated by slowing down the rate of administration and then gradually increasing the rate to the established goal.

Question 12

The nurse initiates prescribed intravenous (IV) therapy on an 86-year-old hospitalized client. Which life span concept(s) should be considered when initiating IV therapy and caring for an older adult receiving IV therapy? Select all that apply. A)Avoid infusion devices in confused clients as alarms can be disruptive B)Cardiac and renal changes may put the client at risk for hypervolemia C)Older adults may have more fragile veins, increasing the risk of infiltration D)Skin protectants and nonporous tape are helpful in reducing skin tears on fragile skin E)Use a 30-45-degree angle on insertion because older adults have deeper veins that roll

Accepted Answer

The nurse must consider several life span changes that occur with aging when initiating IV therapy and caring for IV infusions in the older adult. Important considerations include the following: The age-related cardiovascular and renal function changes that can occur in the elderly, such as a mild increase in the size and thickness of the heart, prolonged filling time, and declined glomerular filtration rate, may put the client at risk for rapid development of hypervolemia. Use of an infusion pump is recommended, even in clients with dementia, as they are at increased risk for fluid imbalance (Option A). Older adults with fragile veins are at increased risk for IV infiltration; therefore, the site should be monitored carefully by the nurse every 1-2 hours. Fragile skin may tear easily; use nonporous tape, skin protectant solutions, andminimal tourniquet pressure. Because hearing and visual impairments may pose a problem for client education, the nurse should speak clearly and face the client when speaking. Use the smallest gauge catheter (24-26 gauge) indicated for the client's therapy as veins are more fragile. Consider vein sites to promote client independence (non-dominant arm, avoiding back of the hand). Use a 5-15-degree angle on insertion as veins of the elderly are usually more superficial (Option E). Educational objective: Important age-related considerations for the older adult receiving IV therapy include consideration of renal and cardiac function to prevent hypervolemia, use of an infusion pump for control, close monitoring of the site for infiltration and infection, measures to prevent skin tears, and use of small-bore (24-26 gauge) IV catheters and correct technique (5-15-degree angle) for insertion of an IV into fragile veins.

Question 13

The nurse provides an in-service for hospital staff on how to prevent pressure injuries in clients with limited mobility. Which instructions are appropriate for the nurse to include? Select all that apply. A)Apply moisture barrier cream to dry skin B)Clean perineal area after incontinent episodes C)Massage bony prominences frequently D)Place foam-padded seat cushions on chairs E)Reposition clients in bed every 6 hours

Accepted Answer

11ecbb05_cb10_cff5_b433_a98d0cea446a_MD0009_00 Pressure injuries develop from external pressure compressing capillaries and underlying soft tissue, or from friction and shearing forces. The nurse should assess every client's risk for pressure injuries (using the Braden scale) upon admission and at least once daily during hospitalization. To prevent pressure injuries: Use emollients and barrier creams to hydrate, protect, and strengthen the skin (Option A).Use foam padding on chairs, commode seats, and other surfaces to help reduce pressure on bony prominences (Option D).Provide prompt incontinence care and use additional barrier cream to keep skin clean and dry; this will further help reduce irritation and associated breakdown of the skin (Option B).Reposition clients with a turn sheet every 2 hours using devices (eg, pillows, foam wedges) to maintain position; avoid pulling/dragging the client up in bed, as shearing can occur. Use emollients and barrier creams to hydrate, protect, and strengthen the skin (Option A). Use foam padding on chairs, commode seats, and other surfaces to help reduce pressure on bony prominences (Option D). Provide prompt incontinence care and use additional barrier cream to keep skin clean and dry; this will further help reduce irritation and associated breakdown of the skin (Option B). Reposition clients with a turn sheet every 2 hours using devices (eg, pillows, foam wedges) to maintain position; avoid pulling/dragging the client up in bed, as shearing can occur. (Option C) Massage is not an acceptable intervention for pressure injury prevention as it can lead to deep tissue damage. It is contraindicated in the presence of inflammation, damaged blood vessels, or fragile skin. (Option E) Clients must be repositioned and turned every 2 hours. Turning clients every 6 hours is too infrequent and will not confer the same protection against pressure and associated tissue ischemia. Educational objective: Skin assessment, proper skin care, repositioning every 2 hours, adequate nutrition, and proper support surfaces are effective in helping prevent pressure injuries. Massage over the bony prominences is not recommended for pressure injury prevention.

Question 14

The nurse is caring for a group of clients. Which finding requires immediate action by the nurse? A)Client scheduled for discharge who has had a peripheral IV in place for 84 hours B)Client with a do-not-resuscitate prescription who has swelling at the IV site C)Client with a saline lock who had a scheduled IV saline flush due 15 minutes ago D)Client with an IV infusing at 20 mL/hr who has 100 mL fluid remaining in the bag

Accepted Answer

11ecbb05_cb11_ba56_b433_0fc71d18625f_MD0009_00 During IV therapy, the nurse should monitor the site to assess for patency and signs of infection (eg, redness, drainage, edema, discomfort, warmth, coolness, hardness). Infiltration is a complication that occurs when solution infuses into the surrounding tissues of the infusion site. Interventions include: Discontinuing the IV line immediately and starting a new IV, preferably on the opposite extremity Continuing to monitor the infiltration site for swelling or other abnormalities (eg, redness, warmth, coolness) Elevating the affected extremity to decrease swelling Notifying the health care provider if severe complications (eg, cellulitis, tissue necrosis, nerve damage) develop Applying a cold or warm, moist compress based on the solution infiltrated. Heat is avoided when extravasation of a vesicant (ie, drug capable of causing tissue necrosis) occurs. (Option A) Peripheral IV sites should be changed no more frequently than every 72-96 hours unless complications develop. This client's IV line will likely be discontinued at discharge and is not the highest priority. (Option C) It is important to flush saline locks every 8-12 hours as prescribed. However, this client is not the highest priority. (Option D) An IV infusing at 20 mL/hr will take 5 hours to complete when 100 mL remain in the bag. Educational objective: The IV site should be monitored for redness, edema, discomfort, drainage, hardness, warmth, or coolness. If infiltration occurs, discontinue the IV line immediately and restart it in another site.

Question 15

The nurse admits an 81-year-old client with gastroenteritis.  Admission vital signs are temperature 101 F (38.3 C), blood pressure 90/42 mm Hg, pulse 118/min, and respirations 32/min.  Pulse oximetry shows 88%.  The nurse suspects which of the following factors may be affecting accuracy of the pulse oximetry reading?
A)Dehydration
B)Elevated temperature
C)Hypotension
D)Tachypnea

Accepted Answer

11ecbb05_cb14_5267_b433_c9ed6fc50202_MD0009_00 A pulse oximeter is a noninvasive device that estimates the arterial blood saturation (SaO₂) by using a sensor attached to the adult client's finger, toe, earlobe, nose, or forehead. The sensor (reusable clip or disposable adhesive) contains both light-emitting and light-sensing components and measures the amount of light absorbed by hemoglobin in the arterial blood. Because the sensor estimates the value at a peripheral site, the oximeter reports the value as SpO₂. The sensor relies on adequate tissue perfusion, so low blood flow or decreased perfusion can decrease SpO₂ readings. Conditions associated with low blood flow or decreased perfusion states include cardiac dysrhythmias, heart failure, peripheral vascular disease, edema, hypotension, hypovolemic shock, and vasoconstriction (eg, hypothermia, smoking, drugs). Other factors affecting accuracy of the reading include improper positioning or fit of the sensor, excessive movement, smoke inhalation, and carbon monoxide poisoning. (Option A) Although dehydration can be associated with conditions that could cause decreased pulse oximetry readings, it is not an independent factor. (Option B) Elevated temperature is not a factor that could cause an inaccurately low pulse oximeter reading. (Option D) Although tachypnea can be associated with conditions that could cause decreased pulse oximetry readings, it is not an independent factor. Educational objective: Because the pulse oximeter sensor relies on adequate tissue perfusion, any condition associated with low blood flow or low perfusion states can decrease the reading. Pulse oximetry is also inaccurate in clients with carbon monoxide poisoning.

Question 16

A client has just returned to the room after having a mammogram. The client is teary and in a shaky voice says to the nurse, "The radiology technician told me that it looks really bad - the tumor in my breast is very large." Which is the best response by the nurse? A)"I can see that you are very upset. Let's talk about what happened." B)"I'll report the technician to the head of the radiology department." C)"The technician never should have said that to you." D)"Your health care provider will discuss treatment options with you."

Accepted Answer

Acknowledging that the client is upset conveys concern and understanding on the part of the nurse and helps establish a therapeutic dialogue. The client can vent feelings and discuss fears because the nurse provides the opportunity to talk about what happened (focusing and listening). This action also establishes interpersonal sensitivity and helps the nurse relate therapeutically to the client. Clients who feel threatened or injured by their medical condition(s) need to feel safe and supported. The nurse is in a unique position to provide the nurturing and caring that clients need as they cope with medical diagnoses and difficult situations. (Option B) This is not an appropriate response; the proper chain of command would have the nurse report the event to a supervisor. (Option C) This statement may be true, but it does not facilitate a dialogue about the client's feelings and fears. (Option D) This response does not address the client's feelings or what happened during the mammogram. Educational objective: Therapeutic communication techniques such as acknowledgement of feelings, focusing, and listening can help establish a dialogue and relationship with a client that is protective, supportive, nurturing, and caring.

Question 17

The nurse is caring for a client with advanced Alzheimer disease. Which techniques are appropriate when speaking with this client? Select all that apply. A)Ask open-ended questions B)Face the client while speaking C)Speak in a loud voice D)Turn off the television and close the door E)Use simple statements and questions

Accepted Answer

Alzheimer disease (AD) is a progressive neurodegenerative disease that causes reduced cognitive function (dementia) in older individuals (most commonly age >60). Conversation becomes progressively more difficult, and the client experiences word-finding difficulty. The best way for the nurse to obtain information and communicate is to use simple statements and questions (Option E). Facing the client allows the client to visualize the speaker's face and helps reduce distraction (Option B). Providing a quiet environment (eg, turning off the television, closing the door) removes competing or distracting stimuli (Option D). (Option A) Asking open-ended questions is a valuable communication technique for collecting information from most clients, but it may confuse the client with AD. The nurse should instead ask simple, direct questions. (Option C) AD results in a reduction in cognitive function. Speaking loudly does not improve comprehension and may increase anxiety and confusion. Educational objective: When speaking with a client with Alzheimer disease, the nurse should face the client and use clear, simple statements and questions. Facing the client allows the client to visualize the speaker's face and helps reduce distraction. The nurse should also maintain a quiet environment to reduce competing or distracting stimuli.

Question 18

Which interventions does the nurse perform to promote normal rest and sleep patterns for a critically ill client? Select all that apply. A)Dimming the lights at night B)Increasing the level of continuous IV sedation during nighttime hours C)Leaving the television on for diversion at night D)Opening the window blinds/shades in the morning E)Scheduling interventions and activities during the day when possible F)Turning off equipment alarms in the client's room at night

Accepted Answer

It is important to maintain the client's normal circadian rhythms in the intensive care unit (ICU). Interventions that help to maintain the normal sleep-wake cycle include dimming the lights at night, providing quiet and uninterrupted periods of sleep when possible, scheduling interventions and activities during the day, frequently reorienting the client as necessary, and opening the shades in the morning. Excessive stimuli and lack of sleep can predispose the client to delirium. (Option B) Continuous IV sedation, if indicated, should be given at the lowest dose adequate for pain management. (Option C) Unless the client is awake and chooses to have the television turned on, this extra stimulus is disruptive to sleep. (Option F) Turning the alarms off in the client's room would pose a risk to safety, as the nurse may not be alerted to a change in condition or equipment failure. If possible, alarm parameters should be adjusted according to the client's routine to prevent unnecessary awakening. Educational objective: To prevent disorientation and delirium in the ICU, it is important to develop a plan of care that includes maintaining the client's normal circadian rhythm.

Question 19

The nurse is conducting a home visit to assess an elderly client with advanced heart failure who lives alone. When the nurse asks about sodium intake, the client becomes angry and says, "I'm so tired of people telling me what to do! I'm going to eat what I want, so leave me alone!" Which of the following is the most appropriate response by the nurse? A)"I can tell that you want me to go, so I will call in a few days to see how you are doing." B)"I know you are frustrated with losing control of your life." C)"It sounds like you are angry. Tell me what's bothering you." D)"Okay. I'll just check your blood pressure and then go."

Accepted Answer

The client exhibits anger, which is likely a sign of grief due to loss of control from illness. However, the source of the client's anger is not clear. Therefore, further assessment is now indicated to understand more about the client's feelings and perceptions. Verbalizing feelings may also help the client to move past anger toward acceptance of the loss. The nurse's statement, "It sounds like you are angry" reflects the nurse's perception of the client's emotion and will allow the client to clarify feelings. The open-ended probing statement, "Tell me what's bothering you," facilitates assessment of the client's concerns without making any assumptions about them. This approach will promote accurate assessment of the client's needs and concerns. It will also prevent premature closure, incorrect assumptions, and escalation of the client's anger. (Option A) This client's angry response likely indicates an unmet need. Further assessment is indicated if the client is willing to talk. This response shuts the door on further assessment. (Option B) The nurse is making an assumption that the source of the client's frustration is loss of control. This assumption may cause the nurse to draw inaccurate conclusions about the client's concerns, contributing to further escalation of anger. (Option D) This response will probably diffuse the situation, but further assessment of the client's concern is more important. If the client remains angry and the nurse attempts to take blood pressure after being told to leave, the client may become angrier, putting the nurse's safety at risk. Educational objective: The client with serious illness who exhibits anger may be experiencing anxiety, grief, or fear. The nurse should remain at a safe distance while attempting to diffuse the situation; assess the client's concerns using a calm, non-threatening approach; reflect the client's statements; and try to understand the client's feelings, perceptions, and beliefs to address the priority problem.

Question 20

A client of the Orthodox Jewish faith with a history of type 2 diabetes mellitus is hospitalized, recovering from a total right hip arthroplasty. At noon, the client consumed a lean roast beef sandwich with lettuce and mustard, carrot and celery sticks, and fresh fruit. What would be the most appropriate 2:00 PM snack for this client? A)Angel food cake and fresh strawberries B)Crackers and low-fat cheese C)Hard-boiled egg and blueberries D)Nonfat plain yogurt

Accepted Answer

Individuals who practice Orthodox Judaism follow Kosher dietary laws. These regulations are strict regarding the consumption of certain animal products (eg, no pork, shellfish, fish without scales) and the separation of meat/poultry from dairy. When meat or poultry is consumed, at least 3-6 hours must pass before a dairy product is consumed. Certain foods, including fresh fruits and vegetables, grains, tea, and coffee, are considered neutral and can be consumed at any time. Hard-boiled eggs and blueberries are nondairy foods and would be an appropriate snack (Option C). This choice also provides a combination of carbohydrates and protein, which would help in regulating blood glucose. (Option A) This choice might be allowable under Kosher rules; however, it is not the best choice for a client with diabetes due to the high carbohydrate content. (Option B) Low-fat cheese is a dairy product and cannot be consumed within 3-6 hours of a meat/poultry meal. (Option D) Yogurt is a dairy product and may not be consumed within 3-6 hours of meat or poultry. Educational objective: Clients of the Orthodox Jewish faith follow Kosher dietary rules. These include no pork, shellfish, or fish without scales. When meat or poultry is consumed, at least 3-6 hours must pass before a dairy product may be consumed.

Exam 4: Fundamentals

The unit implemented a quality improvement program to address client pain relief. Which set of criteria is the best determinant that the goal has been met?

A client is admitted to the hospital for chemotherapy complications. Laboratory results show an absolute neutrophil count of 450 cells/mm³ (0.45 ×10⁹/L) . What information contained in the admission history of this client will need to be addressed during discharge education?

An unlicensed assistive personnel (UAP) is aiding a client recovering from a right-sided cerebrovascular accident with resulting mild oropharyngeal dysphagia. The client has been placed on a dysphagia diet. Which actions require intervention by the registered nurse? Select all that apply.

Which client is at the greatest risk for development of hospital-acquired pressure injuries?

A client expresses concern about facial appearance after surgery for excision of a melanoma on the side of the nose. What is the best response by the nurse?

The nurse is teaching a client with insomnia about techniques to improve sleep habits. Which statement by the client requires further teaching?

A 55-year-old client on a medical-surgical unit has just received a diagnosis of pancreatic cancer. The client says to the nurse, "Is this disease going to kill me?" What is the best response by the nurse?

The nurse teaches safety precautions of home oxygen use to a client with emphysema being discharged with a nasal cannula and portable oxygen tank. Which client statement indicates the need for further teaching? Select all that apply.

The nurse is caring for an 83-year-old bedridden client experiencing fecal incontinence. Which nursing intervention is the highest priority for this client?

An adult client has developed diarrhea 24 hours after the initiation of total enteral nutrition via nasogastric tube. The client is receiving a hypertonic formula. What is the bestnursing action?

The nurse initiates prescribed intravenous (IV) therapy on an 86-year-old hospitalized client. Which life span concept(s) should be considered when initiating IV therapy and caring for an older adult receiving IV therapy? Select all that apply.

The nurse provides an in-service for hospital staff on how to prevent pressure injuries in clients with limited mobility. Which instructions are appropriate for the nurse to include? Select all that apply.

The nurse is caring for a group of clients. Which finding requires immediate action by the nurse?

A client has just returned to the room after having a mammogram. The client is teary and in a shaky voice says to the nurse, "The radiology technician told me that it looks really bad - the tumor in my breast is very large." Which is the best response by the nurse?

The nurse is caring for a client with advanced Alzheimer disease. Which techniques are appropriate when speaking with this client? Select all that apply.

Which interventions does the nurse perform to promote normal rest and sleep patterns for a critically ill client? Select all that apply.