Basic Physical care (Part 2)

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Quizzes Created: 12 | Total Attempts: 16,422

Questions: 114 | Attempts: 625 | Updated: Mar 22, 2023

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Physical care is the type of care given to someone who is facing a health problem or issue in order to get him or her back to working condition. The quiz below is the second in the series of tests that to see how equipped you are to offer basic care to your loved ones. Give it a try!

Questions and Answers

1.

A nurse works on a general medical-surgical unit where nurses work on 12-client pods. Each pod is staffed by two registered nurses. When one of the nurses leaves the unit for any reason, the other nurse cares for all 12 clients. If she needs help, she can call the agency's in-house resource nurse. One evening, the remaining nurse, who was making rounds of the other nurse's clients, found medications left at bedsides and a client with a blood-draw tourniquet on his arm. In addressing the problems, the nurse should:
- A.
  
  Inform the nurse-supervisor right away.
- B.
  
  Correct the problems and submit a written report.
- C.
  
  Speak to the coworker when she returns to the unit.
- D.
  
  Ask for a meeting with the coworker and a manager.
Correct Answer
C. Speak to the coworker when she returns to the unit.

Explanation
RATIONALE: When a nurse discovers substandard practice by another nurse, it's always appropriate to address the situation before conveying the information to a manager or supervisor. Informing the nurse-supervisor first doesn't promote goodwill between nurses and can affect nursing care. It may be necessary to correct the problem before the nurse returns, but a written report may not be necessary if the issues can be remedied informally. If the problem persists, it may be necessary to meet jointly with a manager, but initially the problem should be addressed only by those directly involved.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Application

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 342.

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2.

A postoperative client receives a lunch tray with milk, custard, and vanilla ice cream. What is the client's current diet order?
- A.
  
  American Dietetic Association Exchange diet
- B.
  
  Full-liquid diet
- C.
  
  Clear liquid diet
- D.
  
  BRAT diet
Correct Answer
B. Full-liquid diet

Explanation
RATIONALE: A full-liquid diet consists of fluids and foods that are liquid at room temperature. Some examples are milk, custard, ice cream, puddings, vegetable and fruit juices, refined or strained cereals, and egg substitutes. Although milk, custard, and vanilla ice cream may be included in a dietetic exchange diet, they don't necessarily indicate that the client is following a dietetic exchange diet. A clear-liquid diet includes transparent liquids, such as apple juice, ginger ale, and chicken broth. The BRAT diet is commonly used to combat diarrhea and limits intake to bananas, rice, applesauce, toast, and dairy products.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Basic care and comfort
COGNITIVE LEVEL: Comprehension

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 989.

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3.

Which assessment is most supportive of the nursing diagnosis, Impaired skin integrity related to purulent wound drainage?
- A.
  
  A heart rate of 88 beats/minute
- B.
  
  Wound healing by primary intention
- C.
  
  Oral temperature of 101° F (38.3° C)
- D.
  
  Dry and intact wound dressing
Correct Answer
C. Oral temperature of 101° F (38.3° C)

Explanation
RATIONALE: The nursing diagnosis indicates that the client's wound, which has purulent drainage, is infected. In response to the infection, the client's temperature would be elevated. A heart rate of 88 beats/minute, healing by primary intention, and a dry, intact dressing demonstrate normal assessment findings.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Application

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1192.

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4.

A client is scheduled for an appendectomy. What is the nurse's highest priority when planning preoperative teaching for this client?
- A.
  
  The client should begin coughing and deep-breathing exercises as soon as he's able to follow instructions.
- B.
  
  Surgical wound infection is most likely to occur during the first postoperative day.
- C.
  
  The client should be encouraged to take food and fluids to prevent dehydration and malnutrition.
- D.
  
  The client's skin should be assessed hourly.
Correct Answer
A. The client should begin coughing and deep-breathing exercises as soon as he's able to follow instructions.

Explanation
RATIONALE: The nurse should encourage the client to cough and breathe deeply as soon as possible after surgery to help prevent atelectasis and pneumonia. She shouldn't encourage the client to take food or fluids until bowel sounds are present (usually 24 hours postoperatively). Wound infection is a concern, but usually not during the first postoperative day. The nurse should assess the client's skin every 2 hours when he is made to either change position or get out of bed.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Application

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 888.

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5.

A nurse is reviewing a client's laboratory test results. Which electrolyte is the major cation controlling a client's extracellular fluid (ECF) osmolality?
- A.
  
  Potassium
- B.
  
  Sodium
- C.
  
  Chloride
- D.
  
  Calcium
Correct Answer
B. Sodium

Explanation
RATIONALE: Sodium, the major ECF cation, maintains ECF osmolality. Potassium is the major cation in intracellular fluid. Chloride is the major anion in the ECF. Calcium, found primarily in the intravascular fluid compartment of ECF, is the major cation involved in the structure and function of the teeth and bones.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation
COGNITIVE LEVEL: Knowledge

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 920.

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6.

To evaluate a client for hypoxia, the physician is most likely to order which laboratory test?
- A.
  
  Red blood cell count
- B.
  
  Sputum culture
- C.
  
  Total hemoglobin
- D.
  
  Arterial blood gas (ABG) analysis
Correct Answer
D. Arterial blood gas (ABG) analysis

Explanation
RATIONALE: Red blood cell count, sputum culture, total hemoglobin, and ABG analysis all help evaluate a client with respiratory problems. However, ABG analysis is the only test that evaluates gas exchange in the lungs, providing information about the client's oxygenation status.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Comprehension

REFERENCE: Smeltzer, S.C., and Bare, B. Brunner & Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 334.

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7.

A client in a long-term care facility refuses to take his oral medications. The nurse threatens that she will apply restraints and inject the medication if he doesn't take it orally. The nurse's statement constitutes which legal tort?
- A.
  
  Assault
- B.
  
  Battery
- C.
  
  Negligence
- D.
  
  Right to refuse care
Correct Answer
A. Assault

Explanation
RATIONALE: Assault occurs when a person puts another person in fear of harmful or threatening contact. Battery is offensive contact with another's body. If the nurse actually carried out the threat, battery would also apply. Negligence involves actions that don't meet the standard of care. The client has the legal right to refuse care. In this situation, the nurse should try to calm the client, allow him time to talk, and then determine if he will take the medications. If the client still won't take the medications, the nurse should document his refusal, note the medications involved, and notify the physician and nursing supervisor. The nurse should follow the facility's policy related to clients refusing care.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Comprehension

REFERENCE:Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 101.

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8.

A client who's dehydrated has urinary incontinence and excoriation in the perineal area. Which action would be a priority?
- A.
  
  Keeping the perineal area clean and dry
- B.
  
  Offering the client the urinal every 3 hours
- C.
  
  Maintaining a fluid intake of 1 L/day
- D.
  
  Applying moist, warm compresses to the client's groin
Correct Answer
A. Keeping the perineal area clean and dry

Explanation
RATIONALE: Because the skin, the body's first line of defense, is broken and excoriated, keeping the area clean and dry is a priority and promotes healing. Offering the urinal every 3 hours would help set a voiding schedule; however, to avoid incontinence, the urinal should be offered more often. Fluid intake of 1 L/day is insufficient for a client who has been diagnosed as dehydrated, and the fluids wouldn't aid healing. Continued incontinence as well as moist compresses would contribute to additional skin excoriation and breakdown.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Application

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 1018.

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9.

An obese, malnourished client has undergone abdominal surgery. While ambulating on the fourth postoperative day, she complains to the nurse that her dressing is saturated with drainage. Before this activity, the dressing was dry and intact. Which is the best initial action for the nurse to take?
- A.
  
  Splint the abdomen with a pillow and call the surgeon.
- B.
  
  Apply an abdominal binder.
- C.
  
  Reinforce the existing dressing with another dressing.
- D.
  
  Lift the dressing to assess the wound.
Correct Answer
D. Lift the dressing to assess the wound.

Explanation
RATIONALE: The client probably has a wound evisceration or dehiscence. The first step is to assess the wound; then the nurse can implement appropriate measures. Splinting the abdomen, applying an abdominal binder, or reinforcing the existing dressing would delay treatment.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Application

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1193.

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10.

A nurse having difficulty setting up humidified oxygen at 40% per Venturi mask doesn't know how many liters of flow she should use. Which intervention should the nurse perform to ensure that the oxygen is properly administered?
- A.
  
  Consult with a respiratory therapist.
- B.
  
  Read the package directions.
- C.
  
  Ask a nursing assistant what to do.
- D.
  
  Use a conventional oxygen mask.
Correct Answer
A. Consult with a respiratory therapist.

Explanation
RATIONALE: When a problem falls outside of a nurse's experience or knowledge, she should consult with a specialist in that area. A respiratory therapist is an expert at setting up oxygen delivery systems. A nurse who incorrectly follows package directions could harm a client. A nursing assistant isn't considered an expert in oxygen delivery. A conventional oxygen mask wouldn't deliver the correct rate of flow to the client.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Analysis

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 161.

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11.

A nurse is preparing to help a client with weakness in his right leg move from his bed to a chair. Where should the nurse place the chair?
- A.
  
  Parallel to the bed on the right side
- B.
  
  Perpendicular to the bed on the right side
- C.
  
  Parallel to the bed on the left side
- D.
  
  Parallel to the bed on either side
Correct Answer
A. Parallel to the bed on the right side

Explanation
RATIONALE: The client can maintain his weight and pivot with his left foot if the chair is placed on his right side parallel to the bed. The nurse shouldn't place the chair on the client's left side or perpendicular to the bed because he won't be able to support his weight on his right leg.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Application

REFERENCE: Ellis, J.R., and Bentz, P.M. Modules for Basic Nursing Skills, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 355.

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12.

A client complains of abdominal discomfort and nausea while receiving tube feedings. Which intervention is most appropriate for this problem?
- A.
  
  Give the feedings at room temperature.
- B.
  
  Stop the feedings and check for residual volume.
- C.
  
  Place the client in semi-Fowler's position while feeding.
- D.
  
  Change the feeding container daily.
Correct Answer
B. Stop the feedings and check for residual volume.

Explanation
RATIONALE: Complaints of abdominal discomfort and nausea are common in clients receiving tube feedings. Stopping the feeding and checking for residual volume helps assess the reason for the client's nausea and discomfort. If residual volume is greater than 100 ml, hold the feeding and notify the physician. Feedings are normally given at room temperature to minimize abdominal cramping; however, this action doesn't help assess why nausea and discomfort are occurring. Elevating the head of the client's bed to at least 30 degrees prevents aspiration during feeding. Also, feeding containers are changed daily to prevent bacterial growth.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Basic care and comfort
COGNITIVE LEVEL: Application

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 992.

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13.

According to Elizabeth Kübler-Ross, which stages of grief do a client or family member experience?
- A.
  
  Acceptance, depression, anger, bargaining, and denial
- B.
  
  Denial, anger, decreased interaction, depression, and mourning
- C.
  
  Acceptance, anger, denial, and bargaining
- D.
  
  Denial, anger, bargaining, depression, and acceptance
Correct Answer
D. Denial, anger, bargaining, depression, and acceptance

Explanation
RATIONALE: Denial, the avoidance of death's inevitability, is the first step of the grieving process. Anger, the most intense grief reaction, arises when people realize that a family member will die or has died. Bargaining occurs when family members attempt to stall or manipulate the outcome or death. Depression is a response to loss expressed as profound sadness or deep suffering. Acceptance, the final stage of grief, is the ability to overcome the emotion and accept what has happened.

CLIENT NEEDS CATEGORY: Psychosocial integrity
CLIENT NEEDS SUBCATEGORY: None
COGNITIVE LEVEL: Knowledge

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 987.

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14.

A nurse-manager works for a nonprofit health care corporation whose revenues have significantly exceeded annual expenses. The nurse-manager has been told to anticipate which action?
- A.
  
  Receiving a portion of the revenue to improve client services on the unit
- B.
  
  Identifying revenue as profit
- C.
  
  Dividing revenue among stockholders as dividends
- D.
  
  Reducing operating expenses to help the organization pay taxes on the revenue
Correct Answer
A. Receiving a portion of the revenue to improve client services on the unit

Explanation
RATIONALE: In a nonprofit organization, revenue exceeding expenses is tax-exempt and is usually reinvested in the organization and used to improve services. A for-profit organization calls revenue in excess of expenses a profit and divides it as a dividend among stockholders or reinvests it in the organization.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Application

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 155.

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15.

A nurse is assessing a client for the risk of falls. The nurse should obtain:
- A.
  
  Gait and balance information.
- B.
  
  The facility's restraint policy.
- C.
  
  The family's psychosocial history.
- D.
  
  The client's dietary preferences.
Correct Answer
A. Gait and balance information.

Explanation
RATIONALE: Assessing the client's gait and balance helps determine his risk of falls. The facility's policy on restraints isn't relevant to a risk assessment for falls. Assessing the family's psychosocial history and the client's dietary preferences are important but not as important as gait and balance in relation to the risk of falls.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Analysis

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 678.

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16.

The managers of the physical and occupational therapy neurologic departments tell a nurse-manager of an adult neurologic rehabilitation unit that they're concerned that clients have been arriving late for therapy. In response, the nursing staff of the rehabilitation unit complains that therapy schedules don't allow sufficient time for performing nursing interventions. Which action by the nurse-manager is the best solution to this problem?
- A.
  
  Meet with the managers of physical and occupational therapy and determine how to reschedule clients; then inform the nursing staff.
- B.
  
  Tell the nursing staff that nurses need to determine how to transport clients to therapy according to the schedules developed by the therapists.
- C.
  
  Meet with physical and occupational therapy managers to identify scheduling solutions.
- D.
  
  Ask several staff nurses to work with the therapy staff to help solve the scheduling problem and offer herself as a resource.
Correct Answer
D. Ask several staff nurses to work with the therapy staff to help solve the scheduling problem and offer herself as a resource.

Explanation
RATIONALE: In this situation, functioning as a democratic leader is best. The nursing and therapy staffs who deal with the day-to-day problems of direct client care have the best grasp of the situation and should have autonomy to solve problems. The nurse-manager, however, should be available to help. Meeting with only the managers of physical and occupational therapy reflects an autocratic manager. Without staff input, the nurse-manager won't have the information she needs to identify the best solution. By simply telling the nursing staff to follow the therapists' schedules, the nurse-manager has abdicated responsibility for problem solving, yet the problem still exists. Determining problem-solving options without staff input is indicative of a participative manager. A participative manager asks staff members for opinions, but staff membres don't have input into actual problem solving. This lack of input may cause resentment and frustration.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Analysis

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 115.

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17.

A client has a blood pressure of 152/86 mm Hg. The nurse should document the client's pulse pressure as:
- A.
  
  66 mm Hg.
- B.
  
  238 mm Hg.
- C.
  
  86 mm Hg.
- D.
  
  152 mm Hg.
Correct Answer
A. 66 mm Hg.

Explanation
RATIONALE: Pulse pressure is the difference between the systolic and diastolic pressures — in this case, 66 mm Hg.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Basic care and comfort
COGNITIVE LEVEL: Comprehension

REFERENCE: Weber, J., and Kelley, J. Health Assessment in Nursing, 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 102.

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18.

A nurse is to collect a sputum specimen from a client. The best time to collect this specimen is:
- A.
  
  Early in the evening.
- B.
  
  Any time during the day.
- C.
  
  In the morning, as soon as the client awakens.
- D.
  
  Before bedtime.
Correct Answer
C. In the morning, as soon as the client awakens.

Explanation
RATIONALE: Because sputum accumulates in the lungs during sleep, the nurse should collect a sputum specimen in the morning, as soon as the client awakens. This specimen will be concentrated, increasing the likelihood of an accurate culture. Sputum specimens collected at other times during the day aren't concentrated and may not provide an accurate culture.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Knowledge

REFERENCE: Ellis, J.R., and Bentz, P.M. Modules for Basic Nursing Skills, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 288.

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19.

A nurse-manager in the office of a group of surgeons has received complaints from discharged clients about inadequate instructions for performing home care. Knowing the importance of good, timely client education, the nurse-manager should take which steps?
- A.
  
  Inform the nurses who work in the facility that client education should be implemented as soon as the client is admitted to either the hospital or the outpatient surgical center.
- B.
  
  Review and revise the way client education is conducted in the surgeons' office.
- C.
  
  Because none of the clients suffered any serious damage, the nurse-manager can safely ignore their complaints.
- D.
  
  Work with the surgeons' staff and the nursing staff in the hospital and outpatient surgical center to evaluate current client education practices and make revisions as needed.
Correct Answer
D. Work with the surgeons' staff and the nursing staff in the hospital and outpatient surgical center to evaluate current client education practices and make revisions as needed.

Explanation
RATIONALE: Every nurse who provides client care should provide client education. Nurses must work together to establish the best methods of educating clients. The most appropriate response is to contact the facility's nurse-manager, not the nursing staff. Evaluating client education in only the surgeon's office doesn't consider the entire client education process and all of the staff providing it. Client education is an important nursing responsibility and every complaint derserves attention.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Application

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 541.

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20.

Which scenario complies with Health Insurance Portability and Accountability Act of 1996 (HIPAA) regulations?
- A.
  
  Two nurses in the cafeteria are discussing a client's condition.
- B.
  
  The health care team is discussing a client's care during a formal care conference.
- C.
  
  A nurse checks the computer for the laboratory results of a neighbor who has been admitted to another floor.
- D.
  
  A nurse talks with her spouse about a client's condition.
Correct Answer
B. The health care team is discussing a client's care during a formal care conference.

Explanation
RATIONALE: To provide interdisciplinary continuity of care, nurses must share relevant information during client care conferences. Nurses discussing information in the cafeteria may be overheard; this indiscretion violates HIPAA regulations. Looking up laboratory results for a neighbor is a HIPAA violation, as is discussing a client's condition with one's spouse.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Application

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 256.

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21.

To follow standard precautions, the nurse should carry out which measure?
- A.
  
  Recapping needles after use
- B.
  
  Wearing a gown when bathing a client
- C.
  
  Wearing gloves when administering I.M. medication
- D.
  
  Wearing gloves for all client contact
Correct Answer
C. Wearing gloves when administering I.M. medication

Explanation
RATIONALE: To follow standard precautions, caregivers must place used, uncapped needles and syringes in a puncture-resistant container; wear gloves when anticipating contact with a client's blood, body fluid, mucous membranes, or nonintact skin (such as when administering an I.M. injection); and wear a gown during procedures that are likely to generate splashes of blood or body fluids. Standard precautions don't call for caregivers to wear a gown or gloves when bathing a client because this activity isn't likely to cause contact with blood or body fluids.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Knowledge

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 531.

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22.

A client with terminal breast cancer is being cared for by a long-time friend who's a physician. The client has identified her sister as the agent in her health care power of attorney. The client loses decision-making capacity, and the sister tells the nurse, "A different physician will be caring for my sister now. I've dismissed her friend." In response, the nurse should:
- A.
  
  Inform the sister that she doesn't have the authority to assign a different physician.
- B.
  
  Ask the dismissed physician if the client ever stated that she wanted a different physician.
- C.
  
  Abide by the wishes of the sister who holds the durable power of attorney.
- D.
  
  Politely ignore the sister's statement and continue to call the dismissed physician for orders.
Correct Answer
C. Abide by the wishes of the sister who holds the durable power of attorney.

Explanation
RATIONALE: A health care power of attorney transfers an individual's rights regarding health care decisions to the designated agent. It's within the power of the sister to change the physician caring for the terminally ill client. The dismissed physician has no power to interfere with the wishes of the health care power of attorney. It would be inappropriate and unprofessional of the nurse to ignore the wishes of the client's agent.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Application

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 92.

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23.

A charge nurse tells a new nurse, "You really need to get your skills up to speed." The statement hurts and embarrasses the new nurse. How can she best handle the situation?
- A.
  
  Tell the charge nurse she feels hurt by her statement.
- B.
  
  Tell the charge nurse she needs to be more specific about what she means.
- C.
  
  Discuss her feelings with a coworker in order to vent.
- D.
  
  Ask for a private meeting to explore the charge nurse's concerns in detail.
Correct Answer
D. Ask for a private meeting to explore the charge nurse's concerns in detail.

Explanation
RATIONALE: The charge nurse's statement is vague; the priority issue is to gather information about what she meant. Meeting privately with the charge nurse is one way to diffuse tension in a nonthreatening manner and gather information that might have professional value for the nurse. Stating that the nurse felt hurt immediately focuses on subjective issues rather than objective concerns. Professional respect dictates inquiring about what the charge nurse meant, rather than telling her to be more specific. Discussing the situation with a coworker may make the nurse feel better but doesn't address the issue at hand.

CLIENT NEEDS CATEGORY: Psychosocial integrity
CLIENT NEEDS SUBCATEGORY: None
COGNITIVE LEVEL: Analysis

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 541.

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24.

In planning a presentation that advocates decreasing the client-to-nurse ratio from 8:1 to 6:1, a nurse should emphasize the effect on:
- A.
  
  Institutional resources.
- B.
  
  Standards of practice.
- C.
  
  Client-care quality.
- D.
  
  Nursing recruitment.
Correct Answer
C. Client-care quality.

Explanation
RATIONALE: Client-care quality should always be the first consideration when proposing a change in care provision. Institutional resources, standards of practice, and nursing recruitment will all influence the decision but none should be as influential as client-care quality.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Knowledge

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 27.

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25.

A client has a nursing diagnosis of Ineffective airway clearance related to poor coughing. When planning this client's care, the nurse should include which intervention?
- A.
  
  Increasing fluids to 2,500 ml/day
- B.
  
  Teaching the client how to deep-breathe and cough
- C.
  
  Improving airway clearance
- D.
  
  Suctioning the client every 2 hours
Correct Answer
B. Teaching the client how to deep-breathe and cough

Explanation
RATIONALE: Interventions should address the etiology of the client's problem — poor coughing. Teaching deep breathing and coughing addresses this etiology. Increasing fluids may improve the client's condition, but this intervention doesn't address poor coughing. Improving airway clearance is too vague to be considered an appropriate intervention. Suctioning isn't indicated unless other measures fail to clear the airway.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Application

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 873.

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26.

A nurse should encourage a client with a wound to consume foods high in vitamin C because this vitamin:
- A.
  
  Restores the inflammatory response.
- B.
  
  Enhances oxygen transport to tissues.
- C.
  
  Reduces edema.
- D.
  
  Enhances protein synthesis.
Correct Answer
D. Enhances protein synthesis.

Explanation
RATIONALE: The client should be encouraged to consume foods high in vitamin C because vitamin C is essential for protein synthesis, an important part of wound healing. Hemostasis is responsible for the inflammatory response and reducing edema. Hemoglobin is responsible for oxygen transport.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Basic care and comfort
COGNITIVE LEVEL: Knowledge

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1189.

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27.

When planning cost-effective care, a nurse should choose interventions that:
- A.
  
  Encourage each discipline involved in care to practice independently.
- B.
  
  Don't involve frequent client follow-up and monitoring.
- C.
  
  Promote healthy lifestyles.
- D.
  
  Provide the greatest reimbursement to the facility.
Correct Answer
C. Promote healthy lifestyles.

Explanation
RATIONALE: Promoting a healthy lifestyle that may prevent many costly illnesses is an effective way to cut health care costs. Interdisciplinary care should involve frequent communication and feedback among team members to promote continuity of care and decrease length of stay. Following up frequently and monitoring outcomes are important ways of decreasing costs and preventing multiple readmissions for certain diagnoses. Nurses should choose interventions that provide cost-effective care rather than the greatest reimbursement to the facility.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Analysis

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 705.

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28.

A nurse is teaching a group of nursing assistants about infection-control measures. The nurse tells the group that the first line of intervention for preventing the spread of infection is:
- A.
  
  Wearing gloves.
- B.
  
  Administering antibiotics.
- C.
  
  Washing hands.
- D.
  
  Assigning clients to private rooms.
Correct Answer
C. Washing hands.

Explanation
RATIONALE: Hand washing is the first line of intervention for preventing the spread of infection. Wearing gloves and assigning private rooms for clients can also decrease the spread of infection and should be implemented according to standard precautions. Antibiotics should be initiated when a causative organism is identified.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Application

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 708.

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29.

A nurse who is preparing to boost a client up in bed instructs the client to use the overbed trapeze. Which risk factor for pressure ulcer development is the nurse reducing by instructing the client to move in this manner?
- A.
  
  Friction
- B.
  
  Impaired circulation
- C.
  
  Localized pressure
- D.
  
  Shearing forces
Correct Answer
D. Shearing forces

Explanation
RATIONALE: Friction, impaired circulation, localized pressure, and shearing forces are all risk factors of pressure ulcer development; trapeze use reduces shearing forces. Shearing forces (opposing forces that cause layers of skin to move over each other, stretching and tearing capillaries and, eventually, resulting in necrosis) can occur as clients slide down in bed or are pulled up in bed. Subcutaneous skin layers adhere to the sheets while deeper layers, muscle, and bone slide in the direction of movement. To reduce shearing forces, the nurse should instruct the client to use an overbed trapeze, place a draw sheet under the client to move him up in bed, and keep the head of the bed no higher than 30 degrees.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Basic care and comfort
COGNITIVE LEVEL: Application

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1196.

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30.

A physician has ordered a wet-to-damp dressing for an infected pressure ulcer. The nurse knows that the primary reason for this treatment is to:
- A.
  
  Prevent the spread of the infection.
- B.
  
  Debride the wound.
- C.
  
  Keep the wound moist.
- D.
  
  Reduce pain.
Correct Answer
C. Keep the wound moist.

Explanation
RATIONALE: Wet-to-damp dressings keep the wound bed moist, which helps promote the growth of granulation tissue. Because dead tissue adheres to a dry dressing, wet-to-dry dressings are used for debriding wounds. Wet-to-damp dressings don't prevent the spread of infection. Although these dressings provide a soothing, cool feeling, they don't relieve pain.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Basic care and comfort
COGNITIVE LEVEL: Knowledge

REFERENCE: Smeltzer, S.C., and Bare, B. Brunner & Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1947.

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31.

Which statement demonstrates a safe practice for taking telephone orders from a physician?
- A.
  
  The physician must rewrite the order within 3 days.
- B.
  
  The physician must cosign the order within 7 days.
- C.
  
  A nurse must verify the order by reading it back to the physician.
- D.
  
  Nurses aren't permitted to accept telephone orders.
Correct Answer
C. A nurse must verify the order by reading it back to the pHysician.

Explanation
RATIONALE: Nurses may accept telephone orders, but should do so only when absolutely necessary. To verify the information, the nurse must read back the order and clarify any questions about the order. The physician must cosign the order within 24 hours; there's no need for the physician to rewrite the order.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Application

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 255.

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32.

When assessing a client with cellulitis of the right leg, which finding should the nurse expect to observe?
- A.
  
  Painful skin that is swollen and pale in color
- B.
  
  Cold, red skin
- C.
  
  Small, localized blackened area of skin
- D.
  
  Red, swollen skin with inflammation spreading to surrounding tissues
Correct Answer
D. Red, swollen skin with inflammation spreading to surrounding tissues

Explanation
RATIONALE: Cellulitis, an inflammation of soft tissues, can extend to surrounding tissues. The skin becomes reddened, warm, swollen, and sometimes painful. The skin wouldn't be cold, pale, or necrotic.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Basic care and comfort
COGNITIVE LEVEL: Knowledge

REFERENCE: Smeltzer, S.C., and Bare, B. Brunner & Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1017.

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33.

Which statement is a guideline to help nurses protect themselves from liability?
- A.
  
  Follow all physician's orders.
- B.
  
  Do what the client desires even though the nurse may disagree.
- C.
  
  Practice within the scope of the state's nurse practice act.
- D.
  
  Obtain malpractice insurance.
Correct Answer
C. Practice within the scope of the state's nurse practice act.

Explanation
RATIONALE: The nurse practice act outlines acceptable standards for nursing for a particular state. Practicing within those guidelines will protect the nurse from liability. The nurse shouldn't follow all physician's orders because physicians may not be aware of guidelines for nurses and may delegate inappropriate treatment or practice for the nurse. The client doesn't know standards of care and isn't responsible for the nurse's actions. Insurance won't prevent a liability suit, it will only assist the nurse if a suit should be filed.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Knowledge

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 99.

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34.

The nurse-manager of a 20-bed coronary care unit is off duty when a staff nurse makes a serious medication error. The client, who received an overdose of medication, nearly dies. Which statement accurately reflects the nurse-manager's accountability?
- A.
  
  The nursing supervisor will notify the nurse-manager at home.
- B.
  
  The nurse-manager is off duty; therefore, she need not be notified.
- C.
  
  The nurse-manager should be informed when she returns to duty.
- D.
  
  The nursing supervisor decides to call the off-duty nurse-manager if time permits
Correct Answer
A. The nursing supervisor will notify the nurse-manager at home.

Explanation
RATIONALE: The nurse-manager is accountable for what happens on the unit 24 hours per day, 7 days per week. If a serious problem occurs, the nurse-manager should be notified as soon as possible.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Analysis

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 121.

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35.

A nurse is using the computer when a client calls for pain medication. Which action by the nurse helps maintain computer security?
- A.
  
  Staying logged on, leaving the terminal on, and administering the medication immediately
- B.
  
  Informing the client that he'll have to wait 15 minutes while she completes the entry
- C.
  
  Asking a coworker to log out for her and administering the medicine right away
- D.
  
  Logging out of the computer, then administering the pain medication
Correct Answer
D. Logging out of the computer, then administering the pain medication

Explanation
RATIONALE: A nurse should meet a client's request for pain medication as quickly as possible after she logs out of the computer. A nurse shouldn't ask a client to wait for as long as 15 minutes for requested pain medication. If the nurse leaves the terminal without logging out, others may view confidential information or use her password. Asking a coworker to log her out isn't safe computer practice.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Application

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36.

A nurse is monitoring a client who is receiving moderate sedation during a breast biopsy. Which symptom should the nurse assess first?
- A.
  
  Lower back pain
- B.
  
  Coarse crackles in both upper lobes
- C.
  
  Heart rate of 84 beats/minute
- D.
  
  Mild bleeding at the surgical site
Correct Answer
B. Coarse crackles in both upper lobes

Explanation
RATIONALE: Coarse crackles may indicate aspiration — a potentially life-threatening complication of conscious sedation. A heart rate of 84 beats/minute is within the normal range. Mild bleeding is expected at the surgical site. Poor positioning during surgery commonly causes lower back pain. Although the nurse should ultimately assess this pain, it isn't her first priority.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Analysis

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 828.

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37.

A client admitted with anorexia nervosa lost 30 lb (13.6 kg) during the previous 3 months. When planning this client's care, what should a nurse select as a priority intervention?
- A.
  
  Asking the physician for an order for physical therapy
- B.
  
  Requesting that a chaplain visit the client
- C.
  
  Consulting with a dietitian about the client's dietary needs
- D.
  
  Asking the nursing assistant to shampoo the client's hair
Correct Answer
C. Consulting with a dietitian about the client's dietary needs

Explanation
RATIONALE: The nurse must first assess and plan interventions for the client's nutrition and other immediate physical needs. The nurse should consult with a dietitian to determine the client's dietary requirements, set nutritional goals, and explore ways to meet those goals. Requesting an order for physical therapy, having a chaplain visit the client, and shampooing the client's hair are also important interventions. However, they don't meet basic physical needs and aren't priority interventions at this time.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Analysis

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 61.

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38.

A nurse implements a teaching plan for a client who's scheduled for discharge. Which client behavior best demonstrates effective teaching?
- A.
  
  Exhibiting a positive change in behavior
- B.
  
  Verbally repeating the instruction
- C.
  
  Making statements indicating understanding
- D.
  
  Exhibiting nonverbal signs such as nodding the head to indicate "yes"
Correct Answer
A. Exhibiting a positive change in behavior

Explanation
RATIONALE: Exhibiting a positive change in behavior best demonstrates that the client understands and is complying with discharge teaching. Merely repeating what has been said, telling the nurse that the client understands, or nodding the head to indicate "yes" wouldn't demonstrate that the client has learned anything.

CLIENT NEEDS CATEGORY: Psychosocial integrity
CLIENT NEEDS SUBCATEGORY: None
COGNITIVE LEVEL: Application

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 414.

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39.

When preparing a client with a draining vertical incision for ambulation, where should a nurse apply the thickest portion of a dressing?
- A.
  
  At the top of the wound
- B.
  
  In the middle of the wound
- C.
  
  At the base of the wound
- D.
  
  Over the total wound
Correct Answer
C. At the base of the wound

Explanation
RATIONALE: When a client is ambulating, gravity causes the drainage to flow downward. Covering the base of the wound with extra dressing will contain the drainage. Applying the thickest portion of the dressing at the top, in the middle, or over the total wound won't contain the drainage.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Application

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1192.

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40.

As a nurse-manager of a medical-surgical unit reviews the month's risk-management data, she notices that a number of incident reports were completed because 6 p.m. medications were administered late. Dinner is served between 5:30 p.m. and 6 p.m. Staff take their dinner breaks between 5 p.m. and 6:30 p.m. Based on this information, which is the most appropriate action for the nurse-manager to take?
- A.
  
  Terminate the nurses responsible for failing to administer medications on time.
- B.
  
  Decide that the staff must postpone dinner breaks until at least 7 p.m.
- C.
  
  Decide that the kitchen staff must change the time they deliver supper trays.
- D.
  
  Investigate when medications are given, staff and client dinner times, the number of medications that must be given at 6 p.m., and staff availability between 5 p.m. and 6 p.m.
Correct Answer
D. Investigate when medications are given, staff and client dinner times, the number of medications that must be given at 6 p.m., and staff availability between 5 p.m. and 6 p.m.

Explanation
RATIONALE: An effective nurse-manager knows that to accurately evaluate risk-management findings, she must look at the entire process and the circumstances surrounding each incident. Terminating staff without such evaluation doesn't resolve all the problem's contributing factors. She shouldn't change dinner breaks or kitchen delivery times unless she has evaluated how these factors influence medication administration.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Analysis

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 321.

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41.

Which situation demonstrates correct principles of confidentiality?
- A.
  
  An emergency department nurse reports suspected child abuse.
- B.
  
  Two nurses in an elevator are discussing a client's status.
- C.
  
  A nurse copies and e-mails client information to a friend.
- D.
  
  During change-of-shift report, a nurse talks about a client's personal problems.
Correct Answer
A. An emergency department nurse reports suspected child abuse.

Explanation
RATIONALE: Any health care provider must report suspected child abuse. Sharing this information doesn't violate the client's right to confidentiality. A discussion of confidential information in a public place may be overheard and is a breach of confidentiality. Any client information, whether written or electronic, is considered confidential; e-mailing it to a friend would be considered a breach of confidentiality. Nurses must discuss client's problems during change-of-shift report, but these discussions should be limited to information needed to provide safe care.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Application

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 256.

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42.

A nurse prepares to transfer a client from a bed to a chair. Which principle demonstrates safe body mechanics?
- A.
  
  The nurse stands an arm's length away from the client.
- B.
  
  The nurse uses a rocking motion while helping the client to stand.
- C.
  
  The nurse keeps her knees straight and stiff and bends at the waist.
- D.
  
  The nurse keeps her feet as close together as possible.
Correct Answer
B. The nurse uses a rocking motion while helping the client to stand.

Explanation
RATIONALE: Rocking provides extra force when pushing or pulling. The nurse should keep any weight as close to her body as possible when lifting — not at arm's length. The nurse should keep her knees slightly bent and her feet spread apart to provide a wide base of support. Keeping the knees straight and stiff and bending at the waist and keeping the feet close together aren't examples of safe body mechanics. These positions could result in injury to the nurse or to the client.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Application

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 775.

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43.

A client hospitalized with pneumonia has thick, tenacious secretions. Which intervention should the nurse include when planning this client's care?
- A.
  
  Turning the client every 2 hours
- B.
  
  Elevating the head of the bed 30 degrees
- C.
  
  Encouraging increased fluid intake
- D.
  
  Maintaining a cool room temperature
Correct Answer
C. Encouraging increased fluid intake

Explanation
RATIONALE: Increasing the client's intake of oral or I.V. fluids helps liquefy thick, tenacious secretions and ensures adequate hydration. Turning the client every 2 hours would help prevent pressure ulcers but wouldn't help with the secretions. Elevating the head of the bed would reduce pressure on the diaphragm and ease breathing but wouldn't help the client with secretions. Maintaining a cool room temperature wouldn't help the client with secretions.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., and Bare, B. Brunner & Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 640.

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44.

For healing by secondary intention, a client's wound has been packed with medicated dressings. The nurse evaluates the wound. Which finding indicates wound healing?
- A.
  
  The tissue surrounding the wound is red in color.
- B.
  
  The wound drainage is serous.
- C.
  
  The skin around the wound is edematous.
- D.
  
  The granulation tissue is at the wound edges.
Correct Answer
D. The granulation tissue is at the wound edges.

Explanation
RATIONALE: Connective tissue develops and fills in (or approximates) the wound edges from granulation tissue. Thus, evidence of granulation tissue indicates wound healing. Red or edematous surrounding tissue and serous drainage are insufficient evidence that the wound is healing.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Basic care and comfort
COGNITIVE LEVEL: Analysis

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 1013.

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45.

Policy and procedure require hand washing when caring for clients. Which statement about hand washing is true?
- A.
  
  Frequent hand washing reduces transmission of pathogens from one client to another.
- B.
  
  Wearing gloves is a substitute for hand washing.
- C.
  
  Bar soap, which is generally available, should be used for hand washing.
- D.
  
  Waterless products shouldn't be used in situations in which running water is unavailable.
Correct Answer
A. Frequent hand washing reduces transmission of pathogens from one client to another.

Explanation
RATIONALE: Even if the nurse wears gloves, she must wash her hands before and after client contact because thorough hand washing reduces the risk of cross-contamination. She shouldn't use bar soap because it's a potential carrier of bacteria. Soap dispensers are preferable, but they must be checked for bacteria. When water is unavailable, the nurse should use a liquid hand sanitizer to wash her hands.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Comprehension

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 708.

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46.

When preparing a client for a diagnostic study of the colon, the nurse teaches the client how to self-administer a prepackaged enema. Which statement by the client indicates effective teaching?
- A.
  
  I will administer the enema while sitting on the toilet.
- B.
  
  I will administer the enema while lying on my left side with my right knee flexed.
- C.
  
  I will administer the enema while lying on my right side with my left knee flexed.
- D.
  
  I will administer the enema while lying on my back with both knees flexed.
Correct Answer
B. I will administer the enema while lying on my left side with my right knee flexed.

Explanation
RATIONALE: Lying on the left side allows the enema solution to flow downward by gravity into the rectum and sigmoid colon. The other options don't accomplish this goal and, therefore, are less effective in evacuating the lower bowel.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Comprehension

REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1588.

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47.

A client is at risk for excess fluid volume. Which nursing intervention ensures the most accurate monitoring of the client's fluid status?
- A.
  
  Measuring and recording fluid intake and output
- B.
  
  Weighing the client daily at the same time each day
- C.
  
  Assessing the client's vital signs every 4 hours
- D.
  
  Checking the client's lungs for crackles during every shift
Correct Answer
B. Weighing the client daily at the same time each day

Explanation
RATIONALE: Increased fluid volume leads to rapid weight gain — 2.2 lb (1 kg) for each liter of fluid retained. Weighing the client daily at the same time and in similar clothing provides more objective data than measuring fluid intake and output, which may be inaccurate because of omitted measurements such as insensible losses. Changes in vital signs are less reliable than daily weight because these changes usually are subtle during early stages of fluid retention. Weight gain is an earlier sign of excess fluid volume than crackles, which represent pulmonary edema. The nurse should plan to detect fluid accumulation before pulmonary edema occurs.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Application

REFERENCE: Smeltzer, S.C., and Bare, B. Brunner & Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 957.

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48.

A nurse is teaching a client with left leg weakness to walk with a cane. The nurse should instruct the client to proceed in which manner?
- A.
  
  Hold the cane on the left side 4″ to 6″ from the base of the little toe.
- B.
  
  Hold the cane away from the body.
- C.
  
  Move the cane and the right leg simultaneously.
- D.
  
  Hold the cane in the right hand.
Correct Answer
D. Hold the cane in the right hand.

Explanation
RATIONALE: To ambulate safely, a client with a leg weakness should hold the cane in the hand opposite the weak leg 4″ to 6″ from the base of the little toe. Therefore, this client should hold the cane in his right hand. The client should hold the cane close to his body to prevent leaning and he should move the cane and the involved leg (left, in this case) simultaneously, then move the uninvolved leg.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Basic care and comfort
COGNITIVE LEVEL: Comprehension

REFERENCE: Ellis, J.R., and Bentz, P.M. Modules for Basic Nursing Skills, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 379.

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49.

A nurse gives a client the wrong medication. After assessing the client, the nurse completes an incident report. Which statement describes what will happen next?
- A.
  
  The facility will report the incident to the state board of nursing for disciplinary action.
- B.
  
  The incident will be documented in the nurse's personnel file.
- C.
  
  The nurse will be suspended and, possibly, terminated from employment at the facility.
- D.
  
  The incident report will provide a basis for promoting quality care and risk management.
Correct Answer
D. The incident report will provide a basis for promoting quality care and risk management.

Explanation
RATIONALE: Incident reports document unusual occurrences and deviations from care. Facilities use the internal documents to evaluate care, determine potential risks, or discover system problems that might have contributed to the error. This type of error won't result in a report to the state board of nursing or in the nurse's suspension. Some facilities do track the number of errors a nurse or a particular unit makes; the purpose of tracking errors is to provide appropriate education and to improve the nursing process.

CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care
COGNITIVE LEVEL: Analysis

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 566.

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A client who suffered a stroke has a nursing diagnosis of Ineffective airway clearance. The goal of care for this client is to mobilize pulmonary secretions. Which intervention helps meet this goal?
- A.
  
  Repositioning the client every 2 hours
- B.
  
  Restricting fluids to 1,000 ml/24 hours
- C.
  
  Administering oxygen by nasal cannula as ordered
- D.
  
  Keeping the head of the bed at a 30-degree angle
Correct Answer
A. Repositioning the client every 2 hours

Explanation
RATIONALE: Repositioning the client every 2 hours helps prevent secretions from pooling in dependent lung areas. Restricting fluids would make secretions thicker and more tenacious, thereby hindering their removal. Administering oxygen and keeping the head of the bed at a 30-degree angle might ease respirations and make them more effective but wouldn't help mobilize secretions.

CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Application

REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 873.

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