CORRECT ANSWERS
A new nurse is working with a preceptor on an inpatient medical-surgical unit. The preceptor advises the
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student that which is the priority when working as a professional nurse?
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a. Attending to holistic client needs
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b. Ensuring client safety
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c. Not making medication errors
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d. Providing client-focused care - correct answer ANS: B
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All actions are appropriate for the professional nurse. However, ensuring client safety is the priority. Up to
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98,000 deaths result each year from errors in hospital care, according to the 2000 Institute of Medicine report.
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Many more clients have suffered injuries and less serious outcomes. Every nurse has the responsibility to
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guard the client's safety. e e e
A nurse is caring for a postoperative client on the surgical unit. The client's blood pressure was 142/76 mm Hg
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30 minutes ago, and now is 88/50 mm Hg. What action by the nurse is best?
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a. Call the Rapid Response Team.
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b. Document and continue to monitor.
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c. Notify the primary care provider.
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d. Repeat blood pressure measurement in 15 minutes. - correct answer ANS: A
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The purpose of the Rapid Response Team (RRT) is to intervene when clients are deteriorating before they
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suffer either respiratory or cardiac arrest. Since the client has manifested a significant change, the nurse
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should call the RRT. Changes in blood pressure, mental status, heart rate, and pain are particularly significant.
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,Documentation is vital, but the nurse must do more than document. The primary care provider should be e e e e e e e e e e e e e e e e e
notified, but this is not the priority over calling the RRT. The client's blood pressure should be reassessed
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frequently, but the priority is getting the rapid care to the client. e e e e e e e e e e e
A nurse wishes to provide client-centered care in all interactions. Which action by the nurse best
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demonstrates this concept? e e
a. Assesses for cultural influences affecting health care
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b. Ensures that all the clients' basic needs are met
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c. Tells the client and family about all upcoming tests
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d. Thoroughly orients the client and family to the room - correct answer ANS: A
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Competency in client-focused care is demonstrated when the nurse focuses on communication, culture, e e e e e e e e e e e e e
respect, compassion, client education, and empowerment. By assessing the effect of the client's culture on
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health care, this nurse is practicing client-focused care. Providing for basic needs does not demonstrate this
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competence. Simply telling the client about all upcoming tests is not providing empowering education. e e e e e e e e e e e e e e
Orienting the client and family to the room is an important safety measure, but not directly related to
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demonstrating client-centered care. e e
A nursing faculty member working with students explains that the fastest growing subset of the older
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population is which group? e e e
a. Elite old
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b. Middle olde e
c. Old old
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d. Young old - correct answer ANS: C
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The old old is the fastest growing subset of the older population. This is the group comprising those 85 to 99
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years of age. The young old are between 65 and 74 years of age; the middle old are between 75 and 84 years of
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age; and the elite old are over 100 years of age.
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A nurse working with older adults in the community plans programming to improve morale and emotional
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health in this population. What activity would best meet this goal?
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a. Exercise program to improve physical function
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b. Financial planning seminar series for older adults
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c. Social events such as dances and group dinners
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d. Workshop on prevention from becoming an abuse victim - correct answer ANS: A
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, All activities would be beneficial for the older population in the community. However, failure in performing
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one's own activities of daily living and participating in society has direct effects on morale and life satisfaction.
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Those who lose the ability to function independently often feel worthless and empty. An exercise program
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designed to maintain and/or improve physical functioning would best address this need.
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A nurse caring for an older client on a medical-surgical unit notices the client reports frequent constipation
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and only wants to eat softer foods such as rice, bread, and puddings. What assessment should the nurse
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perform first? e
a. Auscultate bowel sounds.
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b. Check skin turgor.
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c. Perform an oral assessment.
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d. Weigh the client. - correct answer ANS: C
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Poorly fitting dentures and other dental problems are often manifested by a preference for soft foods and
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constipation from the lack of fiber. The nurse should perform an oral assessment to determine if these e e e e e e e e e e e e e e e e e
problems exist. The other assessments are important, but will not yield information specific to the client's
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food preferences as they relate to constipation.
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A nurse caring for an older adult has provided education on high-fiber foods. Which menu selection by the
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client demonstrates a need for further review?
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a. Barley soup
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b. Black beans
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c. White rice
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d. Whole wheat bread - correct answer ANS: C
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Older adults need 25 to 50 grams of fiber a day. White rice is low in fiber. Foods high in fiber include barley,
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beans, and whole wheat products. e e e e
A nurse is working with an older client admitted with mild dehydration. What teaching does the nurse provide
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to best address this issue?
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a. "Cut some sodium out of your diet."
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b. "Dehydration can cause incontinence."
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c. "Have something to drink every 1 to 2 hours."
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d. "Take your diuretic in the morning." - correct answer ANS: C
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