A nurse is preparing a client for an elective vaginal hysterectomy when the
client states, "My doctor said there are more conservative ways to treat my
problem. I realize now that I don't want this surgery, but I already signed that
consent form." Which of the following responses should the nurse make?
"You have the right to refuse this and any other procedure, even after you
have signed the consent form."
(The client has the right to refuse treatment, even after signing the informed
consent document. The nurse should inform the client of that right, notify the
surgeon about the refusal to continue with the procedure, and document the
refusal in the client's medical record.)
A nurse is planning a community health program about substance use
disorders. Which of the following information should the nurse include when
discussing the guidelines for safe limits of alcohol consumption?
A healthy women of any age should consume no more than seven drinks in a
week.
(Recommendations for safe limits of alcohol consumption for a healthy
woman include consuming no more than seven drinks in a week.)
A nurse is assessing the spiritual well-being and development of a
preschooler. The nurse asks the preschooler, "Why is it wrong to kick your
baby sister?" Which of the following responses should the nurse expect?
"It's wrong because my dad said I can't kick her."
(The nurse should expect the preschooler to be motivated to choose right
from wrong because of rules taught to him by his parents. The nurse should
understand that, even though the preschooler might know the rules, he is
not yet able to understand the rationale for the rules.)
,A nurse is providing change-of-shift report about a group of clients to the
incoming nurse at the end of the shift. Which of the following statements
should the nurse include?
"The client has been very tearful since finding out he has diabetes mellitus."
(The nurse should include significant information such as a new diagnosis in
the change-of-shift report. The nurse should also identify changes in the
clients emotional status that might indicate a need for additional client
support and teaching.)
A nurse is caring for an older adult client who has osteoarthritis and plans to
go to an assisted living facility due to decrease mobility. Which of the
following actions should the nurse take when acting in the role of client
advocate?
Research facilities for the client that best meet her special needs.
(The nurse is acting in the role of a client advocate when identifying the
clients specific needs and then advocating for those needs by researching
assisted living facilities that best meet those needs. The nurses research
findings support the clients autonomy by providing her with information
needed to make an informed decision when selecting a facility.)
A charge nurse is educating unit staff about the cultural aspects of client
care following death. Which of the following statements by an assistive
personnel indicates an understanding of the teaching?
"The body of a client who practices Islam is washed and wrapped in a cloth
following death."
(The body of a client who practices Islam is washed, wrapped, prayed over,
and buried as soon as possible following death. The clients head should be
turned toward Mecca.)
,A nurse is admitting a client who has pulmonary tuberculosis. Which of the
following transmission-based precautions should the nurse initiate?
Airborne
(Pulmonary tuberculosis is an infection that is transmitted by airborne
droplets smaller than 5 microns in diameter. Therefore, this client requires
airborne precautions to prevent communicating this infection to others.)
A nurse is caring for a client who is 2 days postoperative following an above-
the-knee amputation. The client states he is experiencing a dull, burning pain
in the leg that was amputated. Which of the following actions should the
nurse take to treat the client's neuropathic pain?
Administer a beta-blocking medication to the client.
(The nurse should administer a beta-blocking medication to the client. This
classification of medication has been shown to relieve the phantom limb pain
manifestations of constant dull and burning type pain.)
A newly licensed nurse asks a charge nurse where to find information about
scope of practice for registered nurses. Which of the following responses
should the charge nurse make?
"The state board of nursing can provide this information"
(each state develops a nurse practice act, which defines scope of practice for
nurses in that state. This practice act is available on the board of nursing
website for each state.)
, A nurse is planning care to prevent a catheter-related bloodstream infection
for a client who is receiving IV fluid therapy. Which of the following
interventions should the nurse include in the plan?
Perform hand hygiene before touching the IV tubing.
(The nurse should perform thorough hand hygiene before touching any part
of the infusion system or the client to reduce the risk of catheter-related
blood stream infections.)
A nurse is creating a plan of care for a client who is non-ambulatory and has
bladder and bowel incontinence. Which of the following interventions should
the nurse include to prevent skin breakdown?
Offer the client a glass of water every two hour when repositioning.
(The nurse should offer the client a glass of water every two hours on the
clients repositioning schedule. This helps prevent dehydration, which
increases the risk of skin breakdown.)
A nurse is teaching a young adult female client about health screening for
breast cancer. Which of the following statements by the client indicates an
understanding of breast self-examination (BSE)?
"I should expect to feel a firm ridge along the bottom curve of each breast."
(The nurse should instruct the client at a firm ridge is expected along the
bottom curve of each breast. The client should be able to feel this area
during the BSE. Performing a BSE promotes breast self awareness so that the
client knows how her breast normally feel. The awareness increases the
clients ability to identify changes that require further evaluation.)
A nurse is caring for an adolescent who is in critical condition following a
motor vehicle crash which he was the passenger. The clients parent shout at
the nurse, asking why her son is dying instead of the driver. Which of the
client states, "My doctor said there are more conservative ways to treat my
problem. I realize now that I don't want this surgery, but I already signed that
consent form." Which of the following responses should the nurse make?
"You have the right to refuse this and any other procedure, even after you
have signed the consent form."
(The client has the right to refuse treatment, even after signing the informed
consent document. The nurse should inform the client of that right, notify the
surgeon about the refusal to continue with the procedure, and document the
refusal in the client's medical record.)
A nurse is planning a community health program about substance use
disorders. Which of the following information should the nurse include when
discussing the guidelines for safe limits of alcohol consumption?
A healthy women of any age should consume no more than seven drinks in a
week.
(Recommendations for safe limits of alcohol consumption for a healthy
woman include consuming no more than seven drinks in a week.)
A nurse is assessing the spiritual well-being and development of a
preschooler. The nurse asks the preschooler, "Why is it wrong to kick your
baby sister?" Which of the following responses should the nurse expect?
"It's wrong because my dad said I can't kick her."
(The nurse should expect the preschooler to be motivated to choose right
from wrong because of rules taught to him by his parents. The nurse should
understand that, even though the preschooler might know the rules, he is
not yet able to understand the rationale for the rules.)
,A nurse is providing change-of-shift report about a group of clients to the
incoming nurse at the end of the shift. Which of the following statements
should the nurse include?
"The client has been very tearful since finding out he has diabetes mellitus."
(The nurse should include significant information such as a new diagnosis in
the change-of-shift report. The nurse should also identify changes in the
clients emotional status that might indicate a need for additional client
support and teaching.)
A nurse is caring for an older adult client who has osteoarthritis and plans to
go to an assisted living facility due to decrease mobility. Which of the
following actions should the nurse take when acting in the role of client
advocate?
Research facilities for the client that best meet her special needs.
(The nurse is acting in the role of a client advocate when identifying the
clients specific needs and then advocating for those needs by researching
assisted living facilities that best meet those needs. The nurses research
findings support the clients autonomy by providing her with information
needed to make an informed decision when selecting a facility.)
A charge nurse is educating unit staff about the cultural aspects of client
care following death. Which of the following statements by an assistive
personnel indicates an understanding of the teaching?
"The body of a client who practices Islam is washed and wrapped in a cloth
following death."
(The body of a client who practices Islam is washed, wrapped, prayed over,
and buried as soon as possible following death. The clients head should be
turned toward Mecca.)
,A nurse is admitting a client who has pulmonary tuberculosis. Which of the
following transmission-based precautions should the nurse initiate?
Airborne
(Pulmonary tuberculosis is an infection that is transmitted by airborne
droplets smaller than 5 microns in diameter. Therefore, this client requires
airborne precautions to prevent communicating this infection to others.)
A nurse is caring for a client who is 2 days postoperative following an above-
the-knee amputation. The client states he is experiencing a dull, burning pain
in the leg that was amputated. Which of the following actions should the
nurse take to treat the client's neuropathic pain?
Administer a beta-blocking medication to the client.
(The nurse should administer a beta-blocking medication to the client. This
classification of medication has been shown to relieve the phantom limb pain
manifestations of constant dull and burning type pain.)
A newly licensed nurse asks a charge nurse where to find information about
scope of practice for registered nurses. Which of the following responses
should the charge nurse make?
"The state board of nursing can provide this information"
(each state develops a nurse practice act, which defines scope of practice for
nurses in that state. This practice act is available on the board of nursing
website for each state.)
, A nurse is planning care to prevent a catheter-related bloodstream infection
for a client who is receiving IV fluid therapy. Which of the following
interventions should the nurse include in the plan?
Perform hand hygiene before touching the IV tubing.
(The nurse should perform thorough hand hygiene before touching any part
of the infusion system or the client to reduce the risk of catheter-related
blood stream infections.)
A nurse is creating a plan of care for a client who is non-ambulatory and has
bladder and bowel incontinence. Which of the following interventions should
the nurse include to prevent skin breakdown?
Offer the client a glass of water every two hour when repositioning.
(The nurse should offer the client a glass of water every two hours on the
clients repositioning schedule. This helps prevent dehydration, which
increases the risk of skin breakdown.)
A nurse is teaching a young adult female client about health screening for
breast cancer. Which of the following statements by the client indicates an
understanding of breast self-examination (BSE)?
"I should expect to feel a firm ridge along the bottom curve of each breast."
(The nurse should instruct the client at a firm ridge is expected along the
bottom curve of each breast. The client should be able to feel this area
during the BSE. Performing a BSE promotes breast self awareness so that the
client knows how her breast normally feel. The awareness increases the
clients ability to identify changes that require further evaluation.)
A nurse is caring for an adolescent who is in critical condition following a
motor vehicle crash which he was the passenger. The clients parent shout at
the nurse, asking why her son is dying instead of the driver. Which of the
