Summary NURS 624 N624 Fundamental Success Qs Exam 1 Practice latest updates included

NURS 624 N624 Fundamental Success Qs Exam 1 Practice NURS 624 N624 Fundamental Success Qs Exam 1 Practice TOPICS Clinical Decision making Nursing Process Medical Asepsis & Surgical Asepsis Evidence Based Practice Critical Thinking in Nursing Evidence Vital Signs Med Administration Nursing Process Wound Healing Hygiene and Comfort Mobility PG 128 - 136 Communication PG 184 -194 The Nursing Process PG 219 - 233 Infection Control PG 234 - 248 Safety PG 249 - 271 Med Admin PG 297 - 312 Hygiene PG 313 - 332 Mobility PG 415 - 423 Pain, Comfort, Rest, and Sleep CHAPTER 3 COMMUNICATION 128 1. A nurse is collecting data from a client for an admission nursing history. Which question by the nurse is best to open the discussion? 1. “What brought you to the hospital?” Open-ended statement 2. “Would it help to discuss your feelings?” Yes or no 3. “Do you want to talk about your concerns?” Yes or no 4. “Would you like to talk about why you are here?” Yes or no 2. A nurse must conduct a focused interview to complete an admission history. Which interviewing technique should the nurse use?1. Probing 2. Clarification 3. Direct questions 4. Paraphrasing statements 3. Which statement about communication should the nurse consider to be accurate? 1. Verbal communication is essential for human relationships. 2. Hands are the most expressive part of the body. 3. Behavior clearly reflects feelings. 4. Communication is inevitable. All behavior has meaning 4. A client is extremely upset and mentions something about a workrelated issue that the nurse cannot understand. Which is the nurse’s best response? 1. “It’s natural to worry about your job.” 2. “Your job must be very important to you.” 3. “Calm down so that I can understand what you are saying.” 4. “I’m not quite sure I heard what you were saying about your work.” 5. Which is the purpose of the use of humor by a nurse when interacting with a client? 1. Diminish feelings of anger 2. Refocus the client’s attention 3. Maintain a balanced perspective 4. Delay dealing with the inevitable 6. A nurse is caring for a client who is blind in the left eye and visually impaired in the right eye. Which actions should the nurse employ to promote communication with this client? 1. Touch the client’s left arm before initiating a conversation. 2. Ensure that the door to the client’s room is on the client’s left side. 3. Close the window curtains and dim the lights before speaking with the client.4. Knock on the door and request permission to enter before approaching the client. 7. A client is admitted to the hospital with cirrhosis of the liver caused by long-term alcohol misuse. Which is the best response by the nurse when the client says, “I really don’t believe that my drinking a couple of beers a day has anything to do with my liver problem”? 1. “You find it hard to believe that beer can hurt the liver.” 2. “How long is it that you have been drinking several beers a day?” 3. “Each beer is equivalent to one shot of liquor, so it’s just as damaging to the liver as hard liquor.” 4. “Do you believe that beer is not harmful even though research shows that it is just as bad for you as hard liquor?” 8. Which is being communicated when the nurse leans forward during a client interview? 1. Aggression 2. Anxiety 3. Interest 4. Privacy 9. Which statement describes the following proverb? What you do speaks so loudly I cannot hear what you say. 1. Hearing ability is an important factor in communicating. 2. Nonverbal messages are often more meaningful than words. 3. Listening to what people say requires attention to what is being said. 4. When people talk too loudly, it is hard to understand what is being said. 10. A mother whose young daughter has died of leukemia is crying and is unable to talk about her feelings. Which is the best response by the nurse? 1. “Everyone will remember her because she was so cute. She was one of our favorites.”2. “As hard as this is, it is probably for the best because she was in a lot of pain.” 3. “She put up the good fight, but now she is out of pain and in heaven.” 4. “It must be hard to deal with such a precious loss.” 11. A young adult who had a leg amputated because of trauma says, “No one will ever choose to love a person with one leg.” Which is the best response by the nurse? 1. “You are a good-looking person, and you will have no trouble meeting someone who cares.” 2. “You may feel that way now, but you will feel differently as time passes.” 3. “Do you feel that no one will marry you because you have one leg?” Paraphrasing promotes communication 4. “How do you see your situation at this point?” 12. A nurse is changing a client’s dressing over an abdominal wound. Which level of space around the client is entered during the dressing change? 1. Public 2. Social 3. Intimate 4. Personal 1 ½ to 4 feet 13. Which stage of an interview establishes the relationship between the nurse and the client? 1. Preinteraction stage 2. Orientation stage 3. Examining stage 4. Working stage14. A client is exhibiting anxious behavior and states, “I just found out that I have cancer everywhere, and I don’t have very long to live. My life is over.” Which is the best response by the nurse? 1. “It might be good if your family were here right now. Shall I call them?” 2. “What might be the best way to approach this terrible news?” Client is in shock and disbelief mode of coping and will not be able to explore approaches to coping. Also, using the words “terrible news” may increase anxiety and hopelessness. 3. “That is so sad. You must feel like crying.” 4. “It sounds like you feel hopeless.” An example of reflective technique because the nurse incorporated the client’s feelings into the response. 15. Which interviewing skill is used when the nurse says, “You mentioned before that you are having a problem with your colostomy”? 1. Focusing Nurse selects one topic for further discussion from among several topics presented by the client. 2. Clarifying Not an example of clarifying which lets the client know that a message was unclear and seeks specific information to make the message clearer. 3. Paraphrasing 4. Acknowledging 16. A client says, “I am really nervous about having a spinal tap tomorrow.” Which is the best response by the nurse? 1. “I’ll ask the doctor for a little medication to help you relax.” This statement avoids the client’s feelings and fails to respond to the client’s need to talk about concerns. 2. “Clients who have had a spinal tap say it is not that uncomfortable.” This is a generalization and minimizes the client’s concern. 3. “It’s all right to be nervous, and I don’t remember anyone who wasn’t.” Recognizes the client’s feelings, gives the client permission to feel nervous and reassures client that one’s behavior is not unusual4. “Your physician is excellent and is very careful when spinal taps are done.” 17. A client with chest pain is being admitted to the emergency department. When asked about next of kin, the client states, “Don’t bother calling my daughter; she is always too busy.” Which is the best response by the nurse? 1. “Your daughter might be upset if you don’t call.” False assumption 2. “What does your daughter do that makes her so busy?” 3. “Is there someone else besides your daughter that I can call?” This lets the client know that the message has been heard and moves forward to meet the need to notify a different significant other of the client’s situation. 4. “I think that your daughter would want to know that you are sick.” False reassurance 18. Which is the nurse doing when using the interviewing technique of attentive listening? 1. Identifying the client’s concerns and exploring them with “why” questions Client may become defensive 2. Determining the content and feeling of the client’s message Attentive listening is the active use of all the senses to comprehend and appreciate the client’s verbal and nonverbal thoughts and feelings 3. Employing silence to encourage the client to talk 4. Using verbal skills to obtain information This is talking not listening 19. A client who has had postoperative complications appears upset and agitated yet withdrawn. Which is the most appropriate statement by the nurse? 1. “You seem distressed. Tell me why you are upset.” First part of statement is therapeutic, but the second part with “why” can be taken as accusation 2. “You’ve been having a pretty rough time recovering since surgery.” Therapeutic example of interviewing skill of an openended statement. It demonstrates that the nurse recognizeswhat the client is going through and the statement encourages the client’s expression of feelings. 3. “It’s not uncommon to have complications after the kind of surgery that you had.” 4. “I’m not sure that I know everything that has been happening. Tell me what has happened to you since surgery.” Nurse should already know what is happening 20. A nurse is admitting a client to the unit who was transferred from the emergency department. Which should the nurse do to facilitate communication? 1. Ensure that the client has an effective way to communicate with health-care team members. 2. Use interviewing techniques to control the direction of the client’s communication. 3. Minimize energy spent by the client on negative feelings and concerns. All feelings should be addressed 4. Refocus to the positive aspects of the client’s situation and prognosis. 21. A nurse is caring for a very confused client with a diagnosis of dementia of the Alzheimer’s type. Which should the nurse say when assisting the client to eat? 1. “Please eat your meat.” Simple words and sentences for confused clients 2. “It’s important that you eat.” Client may be confused about what “important” means 3. “What would you like to eat?” 4. “If you don’t eat, you can’t have dessert.” 22. A client states, “Do you think I could have cancer?” The nurse responds, “What did the doctor tell you?” Which interviewing approach did the nurse use? 1. Paraphrasing 2. Confrontation3. Reflective technique Reflective technique refers back to basic feelings underlying the client’s statement 4. Open-ended question 23. A nurse is developing a therapeutic relationship with a client with emotional needs. Which nursing intervention is essential during the working stage of the relationship? 1. Establish a formal or informal contract that addresses the client’s problems. Introductory (orientation) stage 2. Implement nursing actions that are designed to achieve expected client outcomes. 3. Develop rapport and trust so the client feels protected and an initial plan can be identified. Introductory (orientation) stage 4. Clearly identify the role of the nurse and establish the parameters of the professional relationship. Introductory (orientation) stage 24. A nurse uses reflective technique when communicating with an anxious client. On which does the nurse focus when using reflective technique in this situation? 1. Feelings Reflective technique requires active listening to identify the underlying emotional concerns or feelings contained in clients’ messages. These feelings are then referred back to clients to promote a clearer understanding of what they have said. 2. Content themes 3. Clarification of information 4. Summarization of the topics discussed 25. A client states, “My wife is going to be very upset that my prostate surgery probably is going to leave me impotent.” Which is the best response by the nurse? 1. “I’m sure your wife will be willing to make this sacrifice in exchange for your well-being.” 2. “The surgeons are getting great results with nerve-sparing surgery today.”3. “Your wife may not put as much emphasis on sex as you think.” 4. “Let’s talk about how you feel about this surgery.” 26. A client states, “I think that I am dying.” The nurse responds, “You believe that you are dying?” Which interviewing approach did the nurse use? 1. Focusing 2. Reflecting 3. Validating 4. Paraphrasing 27. A nurse plans to foster a therapeutic relationship with a client. Which is important for the nurse to do? 1. Sympathize with the client when the client communicates sad feelings. Empathize, not sympathize 2. Demonstrate respect when discussing emotionally charged subjects. 3. Use humor to defuse emotionally charged topics of discussion. 4. Work on establishing a friendship with the client. 28. A client appears tearful and is quiet and withdrawn. The nurse says, “You seem very sad today.” Which interviewing approach did the nurse use? 1. Examining Not an interviewing technique 2. Reflecting Reflective technique refers to feelings implied in context or verbal/nonverbal communication. 3. Clarifying 4. Orienting 29. A client is admitted to the hospital with a tentative medical diagnosis, and multiple diagnostic tests are performed. Where in the client’s medical record can the nurse find documentation about the current medical diagnosis after the diagnostic test results are reviewed by the primary health-care provider? 1. Progress Notes 2. Admission Sheet 3. History and Physical4. Social Service Record 30. Which nursing action should the nurse implement when speaking with an older adult whose hearing is impaired? Select all that apply. 1. __X__ Limit background noise. 2. __X__ Enunciate words without exaggeration. 3. __X__ Use gestures to augment communication. 4. __X__ Stand directly in front of the client when speaking. 5. __X__ Talk in a normal rate and volume when speaking with the client. 31. A client with a newly created colostomy wants to learn how to irrigate the colostomy. The nurse provides this teaching by developing a therapeutic nurse-client relationship and implementing teaching strategies. Identify the statement that is included in the working stage of this therapeutic relationship. Select all that apply. 1. “How do you feel about doing this procedure?” Orientation stage 2. “Would you like to try to insert the cone yourself today?” Working stage involves completing interventions that address expected outcomes, such as learning how to perform a colostomy irrigation. 3. “You did a great job managing the instillation of fluid today.” Working stage includes providing feedback and encouragement 4. “I am here to help you learn how to irrigate your colostomy.” Orientation stage where nurse and client make a verbal agreement to work together to assist client to achieve a goal 5. “I’ll arrange for a home-care nurse to visit you in your home when you are discharged.” Termination stage 32. A risk manager is conducting a retrospective audit of a client’s clinical record to identify the use of unacceptable abbreviations. Which abbreviation did the risk manager identify that is on The Joint Commission’s official Do Not Use List? Select all that apply.1. __X__ U 2. _____ ml 3. _____ mg 4. __X__ MS 5. __X__ QOD 6. _____ 0800 hour CLIENT’S CLINICAL RECORD 33. A nurse is attempting to develop a helping relationship with a client who was recently diagnosed with cancer. Which factor is unique to this helping relationship? Select all that apply. 1. _____ The client should always assume the dominant role. 2. _____ The nurse and the client equally share information. Focus on client not nurse 3. __X__ The interaction is specific to the client. 4. __X__ The interaction is guided by a purpose. 5. _____ The needs of both participants are met. Focus on client not nurse 35. An agitated 80-year-old client states, “I’m having trouble with my bowels.” Which response by the nurse incorporates the interviewing skill of paraphrasing? Select all that apply. 1. _____ “Tell me what you mean by having trouble.” Clarification 2. __X__ “It sounds like your bowels are causing you problems.” 3. _____ “You sound upset that your bowels are causing difficulties.” Reflection 4. _____ “It’s common to have problems with the bowels at your age.” Negates client’s concern and cuts off communication 5. _____ “When did you first notice having trouble with your bowels?” Direct question (focused assessment) 36. A client states, “I am surprised that I couldn’t even eat half my breakfast.” Which statement by the nurse uses the interviewing skill of reflection? Select all that apply. 1. _____ “Let’s talk about your inability to eat.” 2. _____ “What part of your breakfast were you able to eat?”3. __X__ “You appear startled that you did not finish your tray of food.” 4. _____ “How long have you been unable to eat most of your breakfast?” 5. __X__ “You seem surprised that you were unable to eat all your breakfast.” 37. A nurse in a subacute unit in a skilled nursing facility is caring for a client who recently had the surgical creation of a colostomy. Place the following nursing actions in the order that reflects the nurse-client therapeutic relationship, beginning with the first stage and progressing to the last stage. 1. Review all the information on the client’s clinical record. Preinteraction stage 2. Introduce self to the client. Orientation stage 3. Explore the reasons for the nurse-client interaction. Orientation stage 4. Assist the client to learn how to perform colostomy self-care. Working stage 5. Provide positive feedback to the client for successful performance of a colostomy irrigation. Working stage 6. Summarize the goals and objectives achieved. Termination stage 38. Which ability of the nurse is important to achieve effective therapeutic communication? Select all that apply. 1. __X__ Using interviewing skills 2. __X__ Remaining nonjudgmental 3. _____ Sending only verbal messages 4. _____ Being assertive when collecting data 5. _____ Displaying sympathy when communicating Empathy, not sympathy 39. A client is to have arthroscopic surgery of the knee to repair a torn tendon. The client says, “I don’t know if I’ll make it through this surgery.” Which response by the nurse may block further communication by the client? Select all that apply. 1. __X__ “The type of surgery you are having is minor.”2. _____ “Surgery often can be frightening.” Reflective 3. __X__ “Everything will be all right.” 4. __X__ “You are not going to die.” 5. _____ “You sound scared.” Reflective 40. Which should a nurse never do when documenting information on a client’s electronic medical record? Select all that apply. 1. Leave the client’s medical record open on the computer screen when entering the client’s room to administer a medication. 2. Share information verbally about a client with another nurse who is also caring for the client. 3. Document nursing care administered to a client immediately after it is completed. 4. Give a personal access code to another member of the health-care team. 5. Document exact quotes of a client’s subjective information. CHAPTER 4 THE NURSING PROCESS 185 1. A nurse makes a home-care visit for a client who had total hip replacement surgery 1 week ago. During which of the five steps in the nursing process does the nurse determine whether outcomes of care are achieved? 1. Implementation Outcomes are not determined; planned nursing care is delivered 2. Evaluation Evaluation occurs when actual outcomes are compared with expected outcomes that reflect goal achievement. If the goal is achieved the client’s needs are met3. Planning Expected outcomes are determined but their achievement is not measured yet 4. Analysis Outcomes are not determined, the nurse identifies human responses to actual or potential health problems 2. When considering the nursing process, the word “observe” is to “assess” as the word “explore” is to which of the following words? 1. Plan Observe = view something scientifically, assess = collect information 2. Analyze Explore = examine, Analyze = investigate 3. Evaluate Evaluate = come to a conclusion about a client’s response to a nursing intervention 4. Implement Implement = carry out an action 3. Which statement is related to the concept that is central to the nursing process? 1. It is dynamic rather than static. “Nursing process is a complex, interactive, five-step problem-solving process designed to meet a client’s needs.” 2. It focuses on the role of the nurse. Focuses on needs of client, not role of nurse 3. It moves from the simple to the complex. 4. It is based on the client’s medical problem. 4. Which word best describes the role of the nurse when using the nursing process to meet the needs of the client holistically? 1. Teacher 2. Advocate 3. Surrogate 4. Counselor 5. Which word is most closely associated with scientific principles? Scientific principles = established rules of action1. Data 2. Problem 3. Rationale Justification based on reasoning 4. Evaluation 6. A pebble dropped into a pond causes ripples on the surface of the water. Which part of the nursing diagnosis is directly related to this concept? 1. Defining characteristics 2. Outcome criteria 3. Etiology Also known as contributing factors includes conditions, situations or circumstances that cause the development of the human response identified in the problem statement of the nursing diagnosis 4. Goal 7. A nurse teaches a client to use visualization to cope with chronic pain. Which step of the nursing process is associated with this nursing intervention? 1. Planning In the Planning Step, identification of nursing interventions that are most likely to be effective 2. Analysis 3. Evaluation Evaluation occurs when actual outcomes are compared with expected outcomes that reflect goal achievement 4. Implementation In the Implementation step, planned nursing care is delivered 8. A nurse is caring for several clients. Which nursing action reflects the assessment step of the nursing process? 1. Taking a client’s apical pulse rate every 2 hours after the client is admitted for an episode of chest pain Implementation  Nurse puts into action the plan to monitor the client’s V/S after a cardiac event is suspected 2. Scheduling a client’s fluid intake over 12 hours when the client has a fluid restriction Planning3. Examining a client for injury after a fall in the bathroom Assessment involves collecting data via observation, physical examination, and interviewing 4. Obtaining a client’s respiratory rate after a nebulizer treatment Evaluation  Nurse assess the client’s RR and effort after a nebulizer treatment to determine if the treatment was effective in reducing airway resistance, thereby improving the client’s RR and reducing respiratory effort 9. A nurse is caring for a client with a fever. Which is a well-designed goal for this client? 1. “The client will have a lower temperature.” “Lower” is not specific, measurable, or objective 2. “The client will be taught how to take an accurate temperature.” Not a goal, an action the nurse plans to implement to help a client achieve a goal 3. “The client will maintain fluid intake adequate to prevent dehydration.” Goals must be client centered, specific, measurable, realistic and have a time frame in which the expected outcome is to be achieved. The words “adequate” and “dehydration” are based on generally accepted criteria against which to measure the client’s actual outcome. The word “maintain” connotes continuously, which is a time frame. 4. “The client will be given aspirin every eight hours whenever necessary.” Not a goal, an action the nurse plans to implement to help a client achieve a goal 10. Which should the nurse do during the evaluation step of the nursing process? 1. Set the time frames for goals. Part of Planning 2. Revise a plan of care. Revising a plan of care takes place in the evaluation step of the nursing process. If, during evaluation, it is determined that the goal was not met, the reasons for failure have to be identified and plan to be modified. 3. Determine priorities. Part of Planning 4. Establish outcomes. Part of Planning11. A client is admitted to a postoperative surgical unit after abdominal surgery. During which step of the nursing process does the nurse determine which actions are required to meet the needs of this client? 1. Implementation Implementation = putting plan of care into action 2. Assessment Assessment = use various skills, such as observation, interviewing, and physical examination, to collect data from various sources 3. Planning 4. Analysis Analysis = nurse identifies the client’s human responses to actual or potential health problems 12. Which information supports the appropriateness of a nursing diagnosis? 1. Defining characteristics Defining characteristics are the major and minor cues that form a cluster that supports or validates the presence of a nursing diagnosis. At least one major defining characteristic must be present for a nursing diagnosis to be considered appropriate for the client. 2. Planned interventions 3. Diagnostic statement A nursing diagnosis is made up of two parts, the diagnostic statement (aka problem statement) and the “related to” factors (aka factors that contribute to the problem or etiology) 4. Related risk factors 13. Which is the primary goal of the assessment phase of the nursing process? 1. Build trust 2. Collect data 3. Establish goals 4. Validate the medical diagnosis 14. Which most directly influences the planning step of the nursing process?1. Related factors 2. Diagnostic label 3. Secondary factors 4. Medical diagnosis 15. A nurse collects information about a client. Which should the nurse do next? 1. Plan nursing interventions. Nursing care is planned after nursing diagnoses and goals are identified, not immediately after data are collected 2. Write client-centered goals. Goals are designed after nursing diagnosis is identified, not after data collection 3. Formulate nursing diagnoses. Need to find significance before formulating any nursing diagnoses 4. Determine significance of the data. 16. When two nursing diagnoses appear closely related, which should the nurse do first to determine which diagnosis most accurately reflects the needs of the client? 1. Reassess the client. 2. Examine the related to factors. These factors are identified after the problem statement is identified 3. Analyze the secondary to factors. Secondary to factors are identified after the related to factors of the problem are identified 4. Review the defining characteristics. The first thing to do should be to differentiate b/w two closely associated nursing diagnoses is to compare the data collected to the major and minor defining characteristics. 17. Which is the primary reason why a nurse performs a physical assessment of a newly admitted client? 1. Identify if the client is at risk for falls. 2. Ensure that the client’s skin is totally intact.3. Identify important information about the client. 4. Establish a therapeutic relationship with the client. 18. A nurse evaluates a client’s response to a nebulizer treatment. To which aspect of the nursing process is this evaluation most directly related? 1. Goal To evaluate effectiveness of a nursing action, nurse must compare the actual client outcome with the expected client outcome. The expected outcomes are measurable data that reflect goal achievement and the actual outcomes are what really happened. 2. Problem 3. Etiology 4. Implementation 19. A nurse concludes that a client’s elevated temperature, pulse, and respirations are significant. Which step of the nursing process is being used when the nurse comes to this conclusion? 1. Implementation 2. Assessment 3. Evaluation 4. Analysis 20. When the nurse considers the nursing process, the word “identify” is to “recognize” as the word “do” is to which of the following words? 1. Implement 2. Evaluate 3. Analyze 4. Plan 21. A nurse is collecting subjective data associated with a client’s anxiety. Which assessment method should be used to collect this information? 1. Observing 2. Inspection3. Auscultation 4. Interviewing 22. A nurse assesses that a client has slurred speech and a retained bolus of food in the mouth. Which additional condition assessed by the nurse should be clustered with these clinical indicators? Select all that apply. 1. __X__ Hoarseness 2. _____ Dyspepsia 3. __X__ Coughing 4. __X__ Drooling 5. __X__ Gurgling 6. _____ Plaque 23. Nurses use the nursing process to provide nursing care. These statements reflect nursing care being provided to several clients. Place the statements in order as the nurse progresses through the steps of the nursing process, starting with assessment and ending with evaluation. 1. “Did you sleep last night after I gave you the sleeping medication?” 2. “The client’s clinical manifestations indicate dehydration.” 3. “The client will have a bowel movement in the morning.” 4. “What brought you to the hospital today?” 5. “I am going to give you an enema.” 4. “What brought you to the hospital today?” Assessment 2. “The client’s clinical manifestations indicate dehydration.” Analysis 3. “The client will have a bowel movement in the morning.” Planning 5. “I am going to give you an enema.” Implementation1. “Did you sleep last night after I gave you the sleeping medication?” Evaluation 24. A nurse is caring for a client with a urinary elimination problem. Which is an accurately stated goal? Select all that apply. 1. “The client will be taught how to use a bedpan while on bedrest.” Action to implement 2. “The client will experience fewer incontinence episodes at night.” “Fewer” is not specific, measurable, or objective 3. “The client will transfer from a chair to the toilet independently and safely.” Does not include time frame for expected goal 4. “The client will be assisted to the commode every 2 hours and whenever necessary.” Action to implement 5. “The client will experience one or no events of urinary incontinence daily within 6 weeks.” 25. Which human response identified by the nurse is an example of objective data? Select all that apply. 1. __X__ Irregular radial pulse of 50 beats per minute 2. __X__ Wheezing on expiration 3. __X__ Temperature of 99°F 4. __X__ Bradypnea 5. __X__ Vomiting 26. Place the following statements that reflect the analysis step of the nursing process in the order in which they should be implemented. 1. Cluster data. 2. Identify conclusions. 3. Interpret clustered data. 4. Communicate conclusion to other health team members.5. Identify when additional data are needed to further validate clustered data. 1. Cluster data 5. Identify when additional data are needed to further validate clustered data. 3. Interpret clustered data. 2. Identify conclusions. 4. Communicate conclusion to other health team members. 27. Which client statement provides subjective data? Select all that apply. 1. __X__ “I’m not sure that I am going to be able to manage at home by myself.” 2. _____ “I can call a home-care agency if I feel I need help at home.” 3. _____ “What should I do if I have uncontrollable pain at home?” 4. _____ “Will a home health aide help me with my care at home?” 5. __X__ “I’m afraid because I live alone and I’m on my own.” 28. Which nursing action reflects an activity associated with the analysis step of the nursing process? Select all that apply. 1. _____ Formulating a plan of care Planning 2. __X__ Identifying the client’s potential risks 3. __X__ Grouping data into meaningful relationships 4. _____ Designing ways to minimize a client’s stressors Planning 5. _____ Making decisions about the effectiveness of client care Evaluation 29. A nurse is interviewing a client. Which client statement is an example of objective data? Select all that apply. 1. _____ “I am hungry.” 2. _____ “I feel very warm.”3. __X__ “I ate half my lunch.” 4. __X__ “I have a rash on my arm.” 5. _____ “I have the urge to urinate.” 6. __X__ “I vomit every time I eat something.” 30. Which statement indicates that the nurse is using inductive reasoning? Select all that apply. 1. A client is admitted with a diagnosis of dehydration, and the nurse assesses the client’s skin for tenting. Deductive reasoning moves from general (client is dehydrated) to specific deduction (client will probably have tenting of skin, a sign of dehydration. 2. A nurse observes a client fall out of bed on the right hip and immediately assesses the client for right hip pain. 3. A client has an elevated white blood cell count and a fever. The nurse concludes that the client may have an infection. Inductive reasoning moves from specific to the general. 4. A client who is scheduled for surgery is crying, trembling, and has a rapid pulse. The nurse makes the inference that the client is anxious. 5. A nurse receives a call from the admission department that a client with hypoglycemia is being admitted to the unit. The nurse plans to assess the client for pale, cool, clammy skin and a low blood glucose level. 31. The following statements reflect steps in the nursing process. Place the statements in order as the nurse advances through the steps of the nursing process, beginning with assessment and ending with evaluation. 1. “The client is encouraged to attempt to defecate after meals.” 2. “The client reports not having had a bowel movement for 8 days.”3. “The client has constipation related to immobility and inadequate fluid intake.” 4. “The client will have a bowel movement within 2 days that is of soft consistency.” 5. “The client’s stool is still hard and dry 2 days after initiating an increase in fluids and activity.” 2. “The client reports not having had a bowel movement for 8 days.” Data collection that occurs in Assessment 3. “The client has constipation related to immobility and inadequate fluid intake.” Etiological factors contributing to the nursing diagnosis problem statement, which is “constipation” 4. “The client will have a bowel movement within 2 days that is of soft consistency.” Measurable goal 1. “The client is encouraged to attempt to defecate after meals.” Implementation of a planned action 5. “The client’s stool is still hard and dry 2 days after initiating an increase in fluids and activity.” Client’s response to compare with client’s actual outcome with expected outcome 32. A nurse is interviewing a client at the change of shift. Which client statement reflects subjective data? Select all that apply. 1. __X__ “When I lift my head up off the bed, I feel like vomiting.” 2. _____ “I just used the urinal, and it needs to be emptied.” 3. __X__ “My pain feels like a 5 on a scale of 0 to 5.” 4. _____ “The physician said I can go home today.” 5. _____ “I gained 10 pounds in the last month.” 34. A client is transferred from the emergency department to a medicalsurgical unit at 6:30 p.m. The nurse arriving on duty at 8 p.m. reviews theclient’s clinical record. Which information documented in the clinical record reflects the evaluation step of the nursing process? 1. Productive cough Info collected during Assessment 2. No dizziness reported by the client Client’s response to ambulation 3. Seek prescription for chest physiotherapy Planning 4. Acetaminophen 650 mg administered at 5 p.m. Implementation CLIENT’S CLINICAL RECORD 35. The nurse assesses a client and collects a variety of data. Identify the human response that is subjective data. Select all that apply. 1. __X__ Nausea 2. _____ Jaundice 3. _____ Ecchymosis 4. _____ Diaphoresis 5. _____ Hypotension CHAPTER 4 INFECTION CONTROL 219 1. Which is the primary reason why the nurse should avoid glued-on artificial nails? 1. They interfere with dexterity of the fingers. 2. They could fall off in a client’s bed. 3. They harbor microorganisms. 4. They can scratch a client. 2. A nurse working in a clinic is assessing clients of a variety of ages. Which age group should the nurse particularly assess for subtle clinical manifestations of subclinical infections? 1. Children of school age 2. Older adults 3. Adolescents4. Infants 3. Which condition places a client at the highest risk for developing an infection? 1. Implantation of a prosthetic device 2. Burns over more than 20% of the body 3. Presence of an indwelling urinary catheter 4. More than 2 puncture sites from laparoscopic surgery 4. Which does the nurse determine is a specific line of defense against infection? 1. Mucous membrane of the respiratory tract Nonspecific defense 2. Urinary tract environment Nonspecific defense 3. Integumentary system Nonspecific defense 4. Immune response 5. A nurse is concerned about a client’s ability to withstand exposure to pathogens. Which blood component should the nurse monitor? 1. Platelets Essential for blood clotting 2. Hemoglobin RBCs 3. Neutrophils WBCs are the primary defense against infection 4. Erythrocytes RBCs 6. When brushing a client’s hair, the nurse identifies white oval particles attached to the hair behind the ears. Which condition with additional clinical manifestations that support it should lead the nurse to assess the client further? 1. Pediculosis 2. Hirsutism Hirsutism is the excessive growth of hair in unusual places 3. Dandruff Dandruff is excessive shedding of dry white scales as a result of the expected exfoliation of the epidermis of the scalp4. Scabies Scabies is a communicable skin disease caused by an itch mite and is character by skin lesion with intense itching 7. A nurse educator is evaluating whether a new staff nurse understands the relationship between a fever and an infection. Which statement by the new staff nurse indicates an understanding of this relationship? 1. “Phagocytic cells release pyrogens that stimulate the hypothalamus.” 2. “Leukocyte migration precipitates the inflammatory response.” 3. “Erythema increases the flow of blood throughout the body.” Erythema does not increase flow of blood throughout the body. Increased blood flow to a localized area causes diffuse redness (erythema). 4. “Pain activates the sympathetic nervous system.” 8. A nurse is caring for a group of clients with infections. Which infection is classified as a health-care–associated infection? 1. Respiratory infection contracted from a visitor 2. Vaginal infection in a postmenopausal woman 3. Urinary tract infection in a client who is sedentary 4. Wound infection caused by unwashed hands of a caregiver Iatrogenic infection 9. A nurse is caring for a client with a high fever secondary to septicemia. The primary health-care provider prescribes a cooling blanket (hypothermia blanket). Through which mechanism does the hypothermia blanket achieve heat loss? 1. Radiation 2. Convection 3. Conduction 4. Evaporation10. Which client condition identified by a nurse is unrelated to infection? 1. Catabolism Catoblism, the destructive phase of metabolism with is resultant release of energy, is related to infection. 2. Hyperglycemia Serum glucose is increased (hyperglycemia) in the presence of an infection because of the release of glucocorticoids 3. Ketones in the urine 4. Decreased metabolic activity Metabolic activity increases, not decreases with an infection as the body mounts a defense to fight invading pathogenic microorganisms. 11. A nurse is caring for a group of hospitalized clients. Which should the nurse do first to prevent client infections? 1. Provide small bedside bags to dispose of used tissues. 2. Encourage staff to avoid coughing near clients. 3. Administer antibiotics as prescribed. 4. Identify clients at risk. 12. A client has a wound that is healing by secondary intention. Which solution to cleanse the wound and dressing should the nurse expect will be prescribed to support wound healing? 1. Normal saline and a gauze dressing Removal of dry dressing will pull recently granulated tissue off of wound bed, impeding wound healing. 2. Normal saline and a wet-to-damp dressing Wet-to-damp dressing allows epidermal cells to migrate more rapidly across wound 3. Povidone-iodine and a dry sterile dressing 4. Half peroxide and half normal saline and a wet-to-dry dressing 13. A nurse is caring for a group of clients experiencing various medical conditions. Which condition places the client at the highest risk for a wound infection? 1. Surgical creation of a colostomy Surgery is conducted using sterile technique 2. First-degree burn on the back3. Puncture of the foot by a nail 4. Paper cut on the finger 14. A school nurse is teaching a class of adolescents about the function of the integumentary system. Which fact about how the skin protects the body against infection is important to include in this discussion? 1. Cells of the skin are constantly being replaced, thereby eliminating external pathogens. 2. Epithelial cells are loosely compacted on skin, providing a barrier against pathogens. Epithelial cells on skin are closely, not loosely compacted. 3. Moisture on the skin surface prevents colonization of pathogens. Moisture on skin surface facilitates, not prevents. 4. Alkalinity of the skin limits the growth of pathogens. Acidity, not alkalinity limits growth of pathogens. 15. A client’s stool specimen is positive for Clostridium difficile. Which isolation precautions should the nurse institute for this client? 1. Droplet 2. Contact 3. Reverse 4. Airborne 16. Which should the nurse do to interrupt the transmission link in the chain of infection? 1. Wash the hands before providing care to a client. 2. Position a commode next to a client’s bed. 3. Provide education about a balanced diet. 4. Change a dressing when it is soiled. 17. Which client statement indicates that further teaching by the nurse is necessary regarding how to ensure protection from food contamination? Select all that apply.1. _____ “I should stuff a turkey immediately before putting it in the oven.” 2. __X__ “I love juicy, rare hamburgers with onion and tomato.” 3. _____ “I prefer chicken salad sandwiches with mayonnaise.” 4. _____ “I know to spit out food that does not taste good.” 5. _____ “I should defrost frozen food in the refrigerator.” 18. A client is admitted to the ambulatory surgery unit for an elective procedure. When performing a physical assessment, the nurse identifies that the client has Pediculus capitis (head lice). Place the nurse’s interventions in the order in which they should be implemented. 1. Establish contact isolation. 2. Comb the hair with a fine-toothed comb. 3. Notify the provider of the client’s condition. 4. Obtain a prescription for a pediculicidal shampoo. 5. Wash the client’s hair with a pediculicidal shampoo. 1. Establish contact isolation. 3. Notify the provider of the client’s condition. 4. Obtain a prescription for a pediculicidal shampoo. 5. Wash the client’s hair with a pediculicidal shampoo. 2. Comb the hair with a fine-toothed comb. 19. Which primary defense protects the body from infection? Select all that apply. 1. __X__ Tears in the eyes 2. __X__ Healthy, intact skin 3. __X__ Cilia of respiratory passages 4. __X__ Acidity of gastric secretions 5. __X__ Dry environment of the epidermis20. A nurse is caring for clients with a variety of wounds. Which wound will likely heal by primary intention? Select all that apply. 1. __X__ Cut in the skin from a kitchen knife Primary healing intention  Wound edges are lightly pulled together (approximated) 2. _____ Excoriated perianal area 3. _____ Abrasion of the skin 4. __X__ Surgical incision 5. _____ Pressure ulcer Heals by secondary intention  when wound edges are not approximated because of full-thickness tissue loss 22. A client has a wound infection. Which local human response should the nurse expect to identify? Select all that apply. 1. _____ Leukocytosis Systemic, not local 2. _____ Malaise Systemic, not local 3. __X__ Edema 4. _____ Fever Fever is a systemic, not local response 5. __X__ Pain 23. Which nursing action protects clients as susceptible hosts in the chain of infection? Select all that apply. 1. _____ Wearing personal protective equipment 2. __X__ Administering childhood immunizations 3. _____ Recapping a used needle before discarding 4. __X__ Instituting prescribed immunoglobulin therapy 5. _____ Disposing of soiled gloves in a waste container 24. From which type of isolation precaution is the N95 mask designed to protect the nurse? 1. Contact 2. Airborne 3. Standard 4. Protective25. A client tells the nurse, “I think I have an ear infection.” For which objective human response to an ear infection should the nurse assess this client? Select all that apply. 1. _____ Throbbing pain 2. __X__ Purulent drainage 3. _____ Feeling of pressure 4. _____ Dizziness when moving 5. _____ Hearing a buzzing sound 26. Which is an example of a primary defense that protects the body from infection? Select all that apply. 1. _____ Antibiotic therapy 2. __X__ Lysozymes in saliva 3. __X__ The low pH of the skin 4. __X__ The acidic environment of the vagina 5. __X__ Production of mucus by cells in the genitourinary tract 27. A nurse is caring for a client who has a prescription for shortening a Penrose drain 1 inch daily. The nurse washes the hands, removes the soiled dressing, sets a sterile field, dons sterile gloves, and cleans around the drain with sterile saline solution as prescribed. Place the following steps in the order in which they should be implemented by the nurse. 1. Complete dressing the wound. 2. Pull the drain out 1 inch, gently and steadily. 3. Grip the Penrose drain with a pair of sterile forceps. 4. Remove the pin and reattach it to the drain closer to the surface of the wound. 5. Cut off the excess drain using sterile scissors, ensuring that 2 inches remain outside the wound. 3. Grip the Penrose drain with a pair of sterile forceps. 2. Pull the drain out 1 inch, gently and steadily. 4. Remove the pin and reattach it to the drain closer to the surface of the wound.5. Cut off the excess drain using sterile scissors, ensuring that 2 inches remain outside the wound. 1. Complete dressing the wound. 28. Which nursing action protects clients from infection at the portal of entry portion of the chain of infection? Select all that apply. 1. Positioning an indwelling urine collection bag below the level of the client’s pelvis 2. Using sterile technique when administering an intramuscular injection 3. Enclosing a urine specimen in a biohazardous transport bag Controlling mode of transmission 4. Wearing clean gloves when handling a client’s excretions Controlling mode of transmission 5. Washing the hands after removal of soiled gloves Controlling mode of transmission 6. Maintaining a dressing over a surgical incision 29. The nurse is reviewing the clinical record of a newly admitted older adult male client. Which piece of information should cause the most concern? 1. Temperature 103°F 2. Abdominal cramping 3. WBC 30,000 cells/mcL 4. Blood pressure 110/86 mm Hg 30. A nurse identifies that a client has an inflammatory response. Which localized client response supports this conclusion? Select all that apply. 1. _____ Fever 2. __X__ Swelling3. __X__ Erythema 4. _____ Bradypnea 5. _____ Tachycardia 31. A nurse must collect the following specimens. Which specimen does not require the use of surgical aseptic technique? Select all that apply. 1. __X__ Stool for occult blood 2. __X__ Stool for ova and parasites 3. _____ Oropharyngeal mucus for a culture 4. _____ Urine from a retention catheter for a urinalysis 5. _____ Exudate from a wound for culture and sensitivity 32. A nurse plans to remove a client’s wound dressing. The nurse identifies the client, explains what is going to be done and why, washes the hands, collects equipment, provides for the client’s privacy, and places the client in an appropriate and comfortable position. Place the following steps in the order in which they should be implemented when removing the soiled dressing. 1. Don clean gloves. 2. Pull the tape away from the skin gently. 3. Assess the volume, color, and odor of exudate. 4. Place the soiled dressing and gloves in a biohazardous waste receptacle. 5. Remove the dressing by lifting the edge of the dressing upward and toward the center of the wound. 6. Loosen the edges of the tape around the dressing, starting from the outside and moving toward the center of the dressing. 1. Don clean gloves. 6. Loosen the edges of the tape around the dressing, starting from the outside and moving toward the center of the dressing. 2. Pull the tape away from the skin gently.5. Remove the dressing by lifting the edge of the dressing upward and toward the center of the wound. 3. Assess the volume, color, and odor of exudate. 4. Place the soiled dressing and gloves in a biohazardous waste receptacle. 33. Which client information collected by the nurse reflects a systemic response to a wound infection? Select all that apply. 1. __X__ Increased body temperature 2. __X__ Increased heart rate 3. __X__ Leukocytosis 4. __X__ Fatigue 5. __X__ Chills 34. A nurse is caring for a client who has a prescription for a vacuum-assisted closure device using black foam to facilitate wound healing. The nurse verifies the prescription, explains to the client what is to be done and why, gathers equipment, washes the hands, sets a sterile field, and dons sterile gloves. Place the following steps in the order in which they should be implemented. 1. Trim the black foam to the size of the wound cavity. 4. Place the foam in the wound cavity without overlapping onto the surrounding skin. 6. Place the suction device pad over the hole in the film and apply gentle pressure to the suction device pad. 2. Pinch and cut a 2-cm round hole in the center of the transparent film. 5. Apply the transparent film 1 to 2 inches beyond wound edges without stretching or wrinkling the transparent film.3. Connect the suction device tubing to the collection canister tubing and pump. 35. A primary health-care provider prescribes azithromycin for a client with a diagnosis of chronic bronchitis. Which should the nurse teach the client that is important to know about taking azithromycin? Select all that apply. 1. “Take this medication with food.” Azithromycin (Zithromax) should be taken 1h before or 2h after meals 2. “You can discontinue the medication as soon as you feel better.” Should finish entire regimen 3. “Take 500 mg on the first day and then 250 mg for 4 more days, for a total of 1.5 g.” 4. “The first dose should be taken after we notify you of the results of the culture and sensitivity.” Don’t wait to take 5. “Avoid taking an antacid containing aluminum or magnesium within 2 hours of taking this medication.” CHAPTER 4 SAFETY 234 1. A client brings several electronic devices to a nursing home. One of the devices has a two-pronged plug. Which rationale should the nurse provide when explaining why an electrical device must have a three-pronged plug? 1. Controls stray electrical currents 2. Promotes efficient use of electricity 3. Shuts off the appliance if there is an electrical surge 4. Divides the electricity among the appliances in the room 2. A nurse is caring for a client with Parkinson’s disease who is experiencing difficulty swallowing. For which major potential problemassociated with dysphagia should the nurse assess the client? 1. Anorexia 2. Aspiration 3. Self-care deficit 4. Inadequate intake 3. A nurse is caring for a confused client. Which should the nurse do to prevent this client from falling? 1. Encourage the client to use the corridor handrails. 2. Place the client in a room near the nurses’ station. 3. Reinforce how to use the call bell. 4. Maintain close supervision. 4. A school nurse is teaching children about fire safety procedures. Which is the first thing they should be taught to do if their clothes catch on fire? 1. Yell for help. 2. Roll on the ground. 3. Take their clothes off. 4. Pour water on their clothes. 5. A primary health-care provider prescribes a vest restraint for a client. Which should the nurse do first when applying this restraint? 1. Perform an inspection of the client’s skin where the restraint is to be placed. 2. Ensure that the back of the vest is positioned on the client’s back. 3. Permit four fingers to slide between the client and the restraint. Two fingers not four 4. Secure the restraint to the bed frame using a slipknot. Not first nursing intervention 6. An unconscious client begins vomiting. In which position should the nurse place the client?1. Supine 2. Side-lying 3. Orthopneic 4. Low-Fowler 7. A toaster is on fire in the pantry of a hospital unit. Which should the nurse do first? 1. Activate the fire alarm. Because no client is in jeopardy, the nurse’s initial action should be to activate the fire alarm. 2. Unplug the toaster from the wall. 3. Put out the fire with an extinguisher. 4. Evacuate the clients from the room next to the kitchen. 8. The risk management coordinator is preparing a program on the factors that contribute to falls in a hospital setting. Which factor that most often contributes to falls should be included in this program? 1. Wet floors 2. Frequent seizures 3. Advanced age of clients 4. Misuse of equipment by nurses 9. A nurse is assessing a client who is being admitted to the hospital. Which is the most important information that indicates whether the client is at risk for physical injury? 1. Weakness experienced during a prior admission 2. Medication that increases intestinal motility 3. Two recent falls that occurred at home 4. The need for corrective eyeglasses 10. Which should the nurse do to best prevent a client from falling? 1. Provide a cane.2. Keep walkways clear of obstacles. 3. Assist the client with ambulation. 4. Encourage the client to use hallway handrails. 11. Which is the last step in making an occupied bed that the nurse should teach a nursing assistant? 1. Elevating the head of the bed to a semi-Fowler position 2. Ensuring that the client is in a comfortable position 3. Lowering the height of the bed toward the floor 4. Raising both the upper side rails on the bed 12. A nurse is caring for a client with a nasogastric tube for gastric decompression. Which nursing action takes priority? 1. Discontinuing the wall suction when providing nursing care 2. Positioning the client in the semi-Fowler position The semi-Fowler position keeps gastric secretions in stomach via gravity (preventing reflux and aspiration) and allows the gastric contents to be suctioned out by the NG tube. 3. Instilling the tube with 30 mL of air every 2 hours Not done every 2h, but may be done to help reestablish patency of tube when clogged 4. Caring for the nares at least every 8 hours Should be done more frequently than every 8h 13. A family member brings an electric radio to a client in a longterm care facility. The client tells the nurse that an electric shock was felt while turning on the radio. Which should the nurse do first? 1. Arrange for the maintenance department to examine the radio. 2. Disconnect the radio from the source of energy. 3. Check the client’s skin for electrical burns. 4. Take the client’s apical pulse. 14. A nurse educator is teaching a group of newly hired nursing assistants. Which hospitalized client should they be taught is at the highest risk for injury?1. School-age child 2. Comatose teenager 3. Postmenopausal woman 4. Confused middle-age man 15. A nurse in the nursing education department of a community hospital is planning an in-service education class about injury prevention. Which factor that most commonly causes physical injuries in hospitalized clients should be included in the teaching plan? 1. Malfunctioning equipment 2. Failure to use restraints 3. Visitors 4. Falls 16. Which is the priority nursing intervention to prevent client problems associated with latex allergies? 1. Use nonlatex gloves. 2. Identify persons at risk. 3. Keep a latex-safe supply cart available. 4. Administer an antihistamine prophylactically. 17. Which nursing intervention enhances an older adult’s sensory perception and thereby helps prevent injury when walking from the bed to the bathroom? 1. Providing adequate lighting 2. Raising the pitch of the voice 3. Holding onto the client’s arm Doesn’t enhance sensory perception 4. Removing environmental hazards 18. A nurse is preparing a client for a physical examination. Which is most important for the nurse to do in this situation? 1. Identify the positions contraindicated for the client during the examination. 2. Explore the client’s attitude toward health-care providers.3. Inquire about other professionals caring for the client. 4. Ask when the client last had a physical examination. 19. A client has dysphagia. Which nursing action takes priority when feeding this client? 1. Ensuring that dentures are in place 2. Medicating for pain before providing meals 3. Providing verbal cueing to swallow each bite 4. Checking the mouth for emptying between every bite 20. A 3-year-old child is admitted to the pediatric unit. Which should the nurse do to maintain the safety of this preschool-age child? 1. Teach the child how to use the call bell. 2. Put the child in a crib with high side rails. 3. Ensure the child is under continuous supervision. 4. Have the child stay in the playroom most of the day. 21. A nurse is caring for a client with dementia. Which time of day is of most concern for the nurse when trying to protect this client from injury? 1. Afternoon 2. Morning 3. Evening 4. Night 22. A nurse is orienting a newly admitted client to the hospital. Which is most important for the nurse to teach the client how to do? 1. Notify the nurse when help is needed. 2. Get out of the bed to use the bathroom. 3. Raise and lower the head and foot of the bed. 4. Use the telephone system to call family members.23. Profuse smoke is coming out of the heating unit in a client’s room. Which should the nurse do first? 1. Open the window. Opening a window is contraindicated because environmental air will feed the fire. 2. Activate the fire alarm. 3. Move the client out of the room. 4. Close the door to the client’s room. 24. A nurse must apply a hospital gown that does not have snaps on the shoulders to a client receiving an IV infusion in the forearm. Which should the nurse do? 1. Put the gown on the client’s arm without the IV, drape the gown over the other shoulder, and adjust the closure behind the neck. 2. Close the clamp on the IV tubing for no more than 15 seconds while putting the gown on the client. 3. Disconnect the client’s IV at the insertion site, apply the gown, and then reconnect the IV. 4. Insert the client’s IV bag and tubing through the sleeve from inside of the gown first. 25. A nurse is planning care for a client with a wrist restraint. How often should a restraint be removed, the area massaged, and the joints moved through their full range? 1. Once a shift 2. Once an hour 3. Every 2 hours 4. Every 4 hours 26. A home-care nurse is assigned to care for an older adult living at home. Which is the first action the home-care nurse should employ to prevent falls by this older adult? 1. Conduct a comprehensive risk assessment. Assessment is first 2. Encourage the client to remove throw rugs in the home. 3. Suggest installation of adequate lighting throughout the home. 4. Discuss with the client the expected changes of aging that place one at risk.27. A nurse is preparing a bed to receive a newly admitted client to the hospital. Which action is most important? 1. Placing the client’s name on the end of the bed Name on bed violates the client’s right to privacy. An identification wristband must be worn for client identification. 2. Ensuring that the bed wheels are locked 3. Positioning the call bell in reach Should be done after positioning client in bed 4. Raising one side rail Should be done after positioning client in bed 28. Which is an appropriately worded goal for a client who is at risk for falling? Select all that apply. 1. “The client will be able to walk from a bed to a chair safely while hospitalized.” Realistic, specific, measurable, and has a time frame (“while hospitalized” reflects time frame of “continuously”). 2. “The client will be taught how to call for help to ambulate.” Planned intervention, not goal 3. “The client will be kept on bedrest when dizzy.” Maintaining a client on bedrest is a planned intervention 4. “The client will be restrained when agitated.” Planned intervention, not goal 5. “The client will be free from trauma.” Time frame of “free from” reflect “continuously” 30. Which intervention should a nurse implement when assisting a client to use a bedpan? Select all that apply. 1. Ensure that the bed rails are raised after the client is on the bedpan. 2. Position the rounded rim of the bedpan under the client’s buttocks. 3. Encourage the client to help as much as possible when using the bedpan.4. Raise the head of the bed to the semi-Fowler position once the client is placed on the bedpan. 5. Dust talcum powder on the rim of the bedpan before placing the bedpan under the client. 31. A nurse identifies the presence of smoke exiting the door to the dirty utility room. Place the nurse’s actions in order of priority using the RACE model. 1. Pull the fire alarm. 2. Close unit doors and windows. 3. Shut the door to the utility room. 4. Provide emotional support to agitated clients. 1. Pull the fire alarm. 3. Shut the door to the utility room. 2. Close unit doors and windows. 4. Provide emotional support to agitated clients. 32. Which clinical manifestation indicates that a further nursing assessment is necessary to determine if the client is having difficulty swallowing? Select all that apply. 1. __X__ Debris in the buccal cavity 2. __X__ Coughing episodes 3. __X__ Noisy breathing 4. __X__ Slurred speech 5. __X__ Drooling 33. A male client is admitted to ambulatory care for a bilateral herniorrhaphy. A nurse on the unit interviews the client, obtains the client’s vital signs, and reviews the primary health-care provider’s prescriptions. Which should the nurse do first?1. Contact the operating suite and inform them of the client’s latex allergy. Should be performed immediately after the priority intervention 2. Ensure the client’s allergy band includes the client’s identified allergies. 3. Notify the primary health-care provider of the client’s elevated vital signs. Should be documented and reported but not priority at this time 4. Share the information about the client’s anxiety with health team members. 34. A nurse is planning care for a client who requires bilateral arm restraints because the client is delirious and attempting to pull out a urinary retention catheter. Which information is important to consider when planning care for this client? Select all that apply. 1. _____ Use of restraints adequately prevents injuries. Statement is not true. Injuries and falls can occur if restraints are not applied appropriately. 2. __X__ Reasons for use of restraints must be clearly documented. 3. _____ Most clients recognize that restraints contribute to their safety. Statement is not true. Clients resist the use of restraints and are usually mentally or emotionally incompetent to understand their necessity or benefits. 4. _____ Restraints need a health-care provider’s prescription before application. 5. __X__ Laws permit the use of restraints when specific guidelines are followed. 36. An adult client consistently tries to pull out a nasogastric tube. As a last resort to maintain integrity of the tube and client safety, the nurse obtains a prescription for a restraint. Which type of restraint is appropriate in this situation? Select all that apply. 1. _____ Mummy restraint Usually for an infant or very young child during a procedure2. __X__ Elbow restraint 3. _____ Jacket restraint Usually to keep