lOMoARcPSD|67691079
1. A nurse is becoming increasingly frustrated by the family members'
efforts to participate in the care of a hospitalized client. Which action
should the nurse implement to cope with these feelings of frustration?
Examine one's own culturally based values, beliefs, attitudes, and
practices.
Rationale
Acknowledging a client's beliefs and customs related to sickness and health
care are valuable components in the plan of care that prevents conflict
between the goals of nursing and the client's cultural practices. Cultural
sensitivity begins with examining one's own cultural values to compare,
recognize, and acknowledge cultural bias.
2. A male client arrives at the outpatient surgery center for a scheduled
needle aspiration of the knee. He tells the nurse that he has already
given verbal consent for the procedure to the healthcare provider.
Which action should the nurse pursue next?
Verify the client's consent with the healthcare provider.
Rationale
Written informed consent is required prior to any invasive procedure. The
healthcare provider must explain the procedure to the client, but the nurse
can witness the client's signature on a consent form. If the nurse was not
present when the HCP explained the procedure/surgery, then the first action
before witnessing the client's signature on the consent should be to verify
that the HCP indeed, received verbal consent from the client.
3. On the third postoperative day following thoracic surgery, a client
reports feeling constipated. Which intervention should the nurse
implement to promote bowel elimination?
Provide warm prune juice before the client goes to bed at night.
Rationale
Prune juice is a natural laxative that stimulates peristalsis, and warming the
prune juice facilitates peristalsis.
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, lOMoARcPSD|67691079
4. Which action should the nurse implement when adding sterile liquids
to a sterile field?
Consider the sterile field contaminated if it becomes wet during the
procedure.
Rationale
Wet or damp areas on a sterile field allow organisms to wick from the table
surface and permeate into the sterile area, so the field is considered
contaminated if it becomes wet. Outdated liquids may be contaminated and
should be discarded. The container's cap should be removed, placed facing
up, and off the sterile field. To prevent contamination of the sterile field,
liquids should be held close (6 inches) to the receptacle when pouring to
prevent splashing, and the receptacle should be placed near the front edge
to avoid reaching over or across the sterile field.
5. A client is admitted with a stage four pressure injury that has a black,
hardened surface (eschar) that is stable. Which dressing is best for the
nurse to use first?
No dressing.
Rationale
If eschar is dry and intact and debridement is not part of the plan of care, no
dressing is used, allowing eschar to act as physiological cover.
6. A male client with an infected wound tells the nurse that he follows a
macrobiotic diet. Which type of foods should the nurse recommend
that the client select from the hospital menu?
Combination of plant proteins to provide essential amino acids.
Rationale
A macrobiotic diet is high in whole-grain cereals, vegetables, sea vegetables,
beans, and vegetarian soups, and the client needs essential amino acids to
provide complete proteins to heal the infected wound. Although a
macrobiotic diet contains no source of animal protein, essential amino acids
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, lOMoARcPSD|67691079
should be obtained by combining plant (incomplete) proteins to provide
complete (all essential amino acids) proteins for anabolic processes.
7. How should the nurse handle linens that are soiled with incontinent
feces?
Place the soiled linens in the designated fluid-resistant dirty linen
bag and deposit them in the dirty linen hamper.
Rationale
The nurse should be careful to keep the soiled linens from contaminating the
fresh linens and should handle the soiled linens like any other dirty linens as
outlined in the facility guidelines/protocols.
8. In providing care for a terminally ill resident of a long-term care facility,
the nurse determines that the resident is exhibiting signs of impending
death and has a do not resuscitate or DNR status. Which intervention
should the nurse implement first?
Notify family members of the client's condition.
Rationale
The nurse's first priority is to notify the family of the resident's impending
death.
9. A signed consent form indicated a client should have an
electromyogram, but a myelogram was performed instead. Though the
myelogram revealed the cause of the client’s back pain, which was
subsequently treated, the client filed a lawsuit against the nurse and
healthcare provider for performing the incorrect procedure. The court is
likely to rule in favor of the plaintiff because these events represent
which infraction?
Assault and battery with deliberate intent to deviate from the
consent form.
Rationale
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The client was not properly informed of the procedure, and failure to obtain
informed consent constitutes assault and battery.
10. When teaching a female client to perform intermittent self-
catheterization, the nurse should ensure the client's ability to perform
which action?
Locate the perineum.
Rationale
Adequate visualization or palpation of the perineum is essential to ensure the
correct placement of the catheter. During a self-catheterization, the client
typically allows the urine to drain into an open collection device, rather than
a drainage bag and uses a straight catheter without a balloon.
11. The nurse is preparing to give a dehydrated client IV fluid
delivered at a continuous rate of 175 mL/hour. Which infusion device
should the nurse use?
Electronic infusion device/smart pump.
Rationale
An electronic infusion device/smart pump should be used to accurately
deliver large volumes of fluid over longer periods of time with extreme
precision, such as mL/hour. A syringe pump is accurate for low-dose
continuous infusion of low-dose medication at a basal rate, but not large fluid
volume replacement. Volumetric and nonvolumetric controllers count
drops/minute to administer fluid volume and are inherently inaccurate
because of variations in drop size.
12. Which statement is an example of a correctly written nursing
problem statement?
Ineffective coping related to an inadequate level of perception of
control.
Rationale
messages.downloaded_by
1. A nurse is becoming increasingly frustrated by the family members'
efforts to participate in the care of a hospitalized client. Which action
should the nurse implement to cope with these feelings of frustration?
Examine one's own culturally based values, beliefs, attitudes, and
practices.
Rationale
Acknowledging a client's beliefs and customs related to sickness and health
care are valuable components in the plan of care that prevents conflict
between the goals of nursing and the client's cultural practices. Cultural
sensitivity begins with examining one's own cultural values to compare,
recognize, and acknowledge cultural bias.
2. A male client arrives at the outpatient surgery center for a scheduled
needle aspiration of the knee. He tells the nurse that he has already
given verbal consent for the procedure to the healthcare provider.
Which action should the nurse pursue next?
Verify the client's consent with the healthcare provider.
Rationale
Written informed consent is required prior to any invasive procedure. The
healthcare provider must explain the procedure to the client, but the nurse
can witness the client's signature on a consent form. If the nurse was not
present when the HCP explained the procedure/surgery, then the first action
before witnessing the client's signature on the consent should be to verify
that the HCP indeed, received verbal consent from the client.
3. On the third postoperative day following thoracic surgery, a client
reports feeling constipated. Which intervention should the nurse
implement to promote bowel elimination?
Provide warm prune juice before the client goes to bed at night.
Rationale
Prune juice is a natural laxative that stimulates peristalsis, and warming the
prune juice facilitates peristalsis.
messages.downloaded_by
, lOMoARcPSD|67691079
4. Which action should the nurse implement when adding sterile liquids
to a sterile field?
Consider the sterile field contaminated if it becomes wet during the
procedure.
Rationale
Wet or damp areas on a sterile field allow organisms to wick from the table
surface and permeate into the sterile area, so the field is considered
contaminated if it becomes wet. Outdated liquids may be contaminated and
should be discarded. The container's cap should be removed, placed facing
up, and off the sterile field. To prevent contamination of the sterile field,
liquids should be held close (6 inches) to the receptacle when pouring to
prevent splashing, and the receptacle should be placed near the front edge
to avoid reaching over or across the sterile field.
5. A client is admitted with a stage four pressure injury that has a black,
hardened surface (eschar) that is stable. Which dressing is best for the
nurse to use first?
No dressing.
Rationale
If eschar is dry and intact and debridement is not part of the plan of care, no
dressing is used, allowing eschar to act as physiological cover.
6. A male client with an infected wound tells the nurse that he follows a
macrobiotic diet. Which type of foods should the nurse recommend
that the client select from the hospital menu?
Combination of plant proteins to provide essential amino acids.
Rationale
A macrobiotic diet is high in whole-grain cereals, vegetables, sea vegetables,
beans, and vegetarian soups, and the client needs essential amino acids to
provide complete proteins to heal the infected wound. Although a
macrobiotic diet contains no source of animal protein, essential amino acids
messages.downloaded_by
, lOMoARcPSD|67691079
should be obtained by combining plant (incomplete) proteins to provide
complete (all essential amino acids) proteins for anabolic processes.
7. How should the nurse handle linens that are soiled with incontinent
feces?
Place the soiled linens in the designated fluid-resistant dirty linen
bag and deposit them in the dirty linen hamper.
Rationale
The nurse should be careful to keep the soiled linens from contaminating the
fresh linens and should handle the soiled linens like any other dirty linens as
outlined in the facility guidelines/protocols.
8. In providing care for a terminally ill resident of a long-term care facility,
the nurse determines that the resident is exhibiting signs of impending
death and has a do not resuscitate or DNR status. Which intervention
should the nurse implement first?
Notify family members of the client's condition.
Rationale
The nurse's first priority is to notify the family of the resident's impending
death.
9. A signed consent form indicated a client should have an
electromyogram, but a myelogram was performed instead. Though the
myelogram revealed the cause of the client’s back pain, which was
subsequently treated, the client filed a lawsuit against the nurse and
healthcare provider for performing the incorrect procedure. The court is
likely to rule in favor of the plaintiff because these events represent
which infraction?
Assault and battery with deliberate intent to deviate from the
consent form.
Rationale
messages.downloaded_by
, lOMoARcPSD|67691079
The client was not properly informed of the procedure, and failure to obtain
informed consent constitutes assault and battery.
10. When teaching a female client to perform intermittent self-
catheterization, the nurse should ensure the client's ability to perform
which action?
Locate the perineum.
Rationale
Adequate visualization or palpation of the perineum is essential to ensure the
correct placement of the catheter. During a self-catheterization, the client
typically allows the urine to drain into an open collection device, rather than
a drainage bag and uses a straight catheter without a balloon.
11. The nurse is preparing to give a dehydrated client IV fluid
delivered at a continuous rate of 175 mL/hour. Which infusion device
should the nurse use?
Electronic infusion device/smart pump.
Rationale
An electronic infusion device/smart pump should be used to accurately
deliver large volumes of fluid over longer periods of time with extreme
precision, such as mL/hour. A syringe pump is accurate for low-dose
continuous infusion of low-dose medication at a basal rate, but not large fluid
volume replacement. Volumetric and nonvolumetric controllers count
drops/minute to administer fluid volume and are inherently inaccurate
because of variations in drop size.
12. Which statement is an example of a correctly written nursing
problem statement?
Ineffective coping related to an inadequate level of perception of
control.
Rationale
messages.downloaded_by
