HESI Extra Credit Module 5 Exam - NURSING 2231/ DETAILED SOLUTIONS

1. Questions 1. 1.ID: 9477027534 A client with leukemia is being considered for a bone marrow transplant. The healthcare team is discussing the risks and benefits of this treatment and other possible treatments with th ...

1. Questions 1. 1.ID: 9477027534 A client with leukemia is being considered for a bone marrow transplant. The healthcare team is discussing the risks and benefits of this treatment and other possible treatments with the goal of inflicting the least possible harm on the client. Which principle of healthcare ethics is the team practicing? A. Justice B. Fidelity C. Autonomy D. Nonmaleficence Correct Awarded 1.0 points out of 1.0 possible points. 2. 2.ID: 9477024200 Which action by the nurse represents the ethical principle of beneficence? A. The nurse upholds a client’s decision to refuse chemotherapy for lung cancer. B. The nurse follows a plan of care designed to relieve pain in a client with cancer. C. The nurse administers an immunization to a child even though it may cause discomfort. Correct D. The nurse provides equal amounts of care to all assigned clients on the basis of illness acuity. Awarded 1.0 points out of 1.0 possible points. 3. 3.ID: 9477029451 The nursing instructor asks a student to name an example of false imprisonment. Which situation reflects a violation of this client right? A. Performing a procedure without consent B. Telling the client that he or she may not leave the hospital Correct C. Threatening to give a client a medication against his or her will D. Observing the provision of care to the client without the client’s permission Awarded 1.0 points out of 1.0 possible points. 4. 4.ID: 9477017756 The nurse and an unlicensed assistive personnel (UAP)enter a client’s room to provide care and find the client lying on the floor. Which action should the nurse take first? A. Ask the nursing assistant to complete an incident report B. Check the client’s level of consciousness and vital signs Correct C. Ask the nursing assistant to assist in getting the client back to bed D. Contact the unit secretary on the intercom and ask that the client’s health care provider be called Awarded 1.0 points out of 1.0 possible points. 5. 5.ID: 9477020809 Which action exemplifies the use of evidence-based practice in the delivery of client care? A. Donning sterile gloves to change an abdominal wound dressing Correct B. Encouraging a client to take an herbal substance to treat his insomnia C. Advising a client to agree to the treatment recommended by her health care provider D. Taking a rectal temperature from a client for whom bleeding precautions have been instituted Awarded 1.0 points out of 1.0 possible points. 6. 6.ID: 9477020817 The registered nurse has accepted a new position as case manager in a hospital. Which responsibilities are part of the nurse’s new role? Select all that apply. A. Evaluating and updating the plan of care as needed Correct B. Prescribing treatments specific to the client’s needs C. Assessing the client’s needs for home supplies and equipment Correct D. Coordinating consultations and referrals to facilitate discharge Correct E. Establishing a safe and cost-effective plan of care with the client Correct Rationale: A case manager is a nurse who assumes responsibility for coordinating the client's care from the point of admission through, and after, discharge. Specific responsibilities of the case manager include establishing a safe and cost-effective plan of care with the client, coordinating consultations and referrals, and facilitating discharge; initiating a plan of nursing care, care map, or clinical pathway as appropriate to guide care and evaluating and updating the plan of care as needed; ensuring that the plan of care is tailored to the client’s needs, taking into account the client’s diagnosis, self-care ability, and prescribed treatments; assessing the client’s need for equipment such as oxygen or wound care supplies and exploring available resources to provide the client with these supplies; providing resources that will assist the client in maintaining independence as much as possible; and providing the client with information on discharge procedures and the plan of care. The nurse does not prescribe treatments. Test-Taking Strategy: Focus on the subject, the responsibilities of the case manager. Note the word “prescribing” in the incorrect option. It is not within the role of the nurse to prescribe. Review: the responsibilities of the case manager if you have difficulty with this question. Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., p. 21). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Leadership/Management Giddens Concepts: Care Coordination, Leadership HESI Concepts: Collaboration/Managing Care—Care Coordination, Collaboration/Managing Care–Leadership Awarded 4.0 points out of 4.0 possible points. 7. 7.ID: 9477028765 The nurse manager of a quality improvement program asks a nurse in the neurological unit to conduct a retrospective audit. Which action should the auditing nurse plan to perform in this type of audit? A. Checking the documentation written by a new nursing graduate on her assigned clients at the end of the shift B. Checking the crash cart to ensure that all needed supplies are readily available should an emergency arise C. Reviewing neurological assessment checklists for all clients on the unit to ensure that these assessments are being conducted as prescribed D. Obtaining the assigned medical record from the hospital’s medical record room to review documentation made during a client’s hospital stay Correct Rationale: Quality improvement, also known as performance improvement, is focused on processes or systems that significantly contribute to client safety and effective client care outcomes. Criteria are used to assess outcomes of care and determine the need for changes improve the quality of care. In a retrospective, or “looking back,” audit, the medical record is inspected after the client’s discharge for documentation of compliance with standards. In a concurrent, or “at the same time,” audit, the nursing staff’s compliance with predetermined standards and criteria is assessed as the nurses are providing care during the client’s stay. In this type of audit, a peer review approach in which members of the nursing staff are involved in data collection may be implemented. Obtaining the a client’s medical record from the medical record room for the purpose of reviewing documentation made during the client’s hospital stay is an example of a retrospective audit. The incorrect options are examples of concurrent audits. Test-Taking Strategy: Focus on the subject, a retrospective audit. Note the relationship of the word “retrospective” in the question and the description in the correct option. Review: the procedures for quality improvement and retrospective and concurrent audits if you have difficulty with this question. Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp. 64, 65). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Leadership/Management Giddens Concepts: Health Care Quality, Leadership HESI Concepts: Collaboration/Managing Care—Leadership, Quality Improvement/Health Care Quality Awarded 1.0 points out of 1.0 possible points. 8. 8.ID: 9477022320 The nurse preparing a client for a bronchoscopy notes that the client is wearing a gold necklace. What should the nurse do to safeguard the client’s necklace? A. Ask the client whether the necklace is gold B. Ask the client for permission to lock the necklace in the hospital safe Correct C. Ask the client to remove the necklace and place it in the top drawer of the bedside table D. Ask the client to sign a release to free the hospital of responsibility if the necklace is damaged or lost during the procedure Awarded 1.0 points out of 1.0 possible points. 9. 9.ID: 9477017796 The nurse providing preoperative care to a client who is scheduled for a left mastectomy and axillary lymph node dissection notes that the client is wearing a wedding band on her left ring finger. Which action should the nurse take? A. Tape the wedding band in place B. Explain to the client why the wedding band must be removed Correct C. Ask the client whether she would like to remove the wedding band or wear it to surgery D. Ask the client to sign a release to free the hospital of responsibility if the wedding band is lost during surgery Awarded 1.0 points out of 1.0 possible points. 10. 10.ID: 9477014230 The nurse preparing a client to go to the radiology department for a chest x-ray notes that the client is wearing a religious medal on a chain around the neck. The client, a Catholic, expresses a concern about removing the medal. What is the most appropriate action for the nurse to take? A. Asking the client to remove the medal until the x-ray has been completed B. Assisting the client in pinning the medal and chain to the waistband of the client’s pajama bottoms Correct C. Asking the client to place the medal in the top drawer of the bedside stand just before leaving for the radiology department D. Telling the client that the medal and chain will be kept at the nurses’ station for safekeeping while the client is undergoing the x- ray Awarded 1.0 points out of 1.0 possible points. 11. 11.ID: 9477030405 A health care provider writes a medication prescription in a client’s record. While transcribing the prescription, the nurse notes that the prescribed dose is three times higher than the recommended dose. The nurse calls the health care provider, who states that this is the dose that the client takes at home and that it is acceptable for this client’s condition. What is the appropriate action for the nurse to take? A. Contacting the nursing supervisor Correct B. Continuing to transcribe the prescription C. Asking the nurse assigned to care for the client to administer the medication D. Verifying the prescribed dose with the client before administering the medication Awarded 1.0 points out of 1.0 possible points. 12. 12.ID: 9477016885 The nurse monitoring a client with a chest tube notes that there is no tidaling of fluid in the water seal chamber. After further assessment, the nurse suspects that the client’s lung has reexpanded and notifies the health care provider. The health care provider verifies with the use of a chest x-ray that the lung has reexpanded, then calls the nurse to asks that the chest tube be removed. Which action should the nurse take first? A. Call the nursing supervisor B. Explain the procedure to the client, then remove the chest tube C. Inform the health care provider that removal of a chest tube is not a nursing procedure Correct D. Obtain petrolatum-impregnated gauze and ask another nurse to assist in removing the chest tube Awarded 1.0 points out of 1.0 possible points. 13. 13.ID: 9477025841 The nurse calls a health care provider to report that a client with congestive heart failure (CHF) is exhibiting dyspnea and worsening of wheezing. The health care provider, who is in a hurry because of a situation in the emergency department, gives the nurse a telephone prescription for furosemide (Lasix) but does not specify the route of administration. What is the appropriate action on the part of the nurse? A. Calling the health care provider who gave the telephone prescription to clarify the prescription Correct B. Calling the nursing supervisor for assistance in determining the route of administration C. Administering the medication intravenously, because this route is generally used for clients with CHF D. Administering the medication orally and clarifying the prescription once the health care provider has finished caring for the client in the emergency department Awarded 1.0 points out of 1.0 possible points. 14. 14.ID: 9477026697 A nurse is assisting a health care provider in assessing a hospitalized client. During the assessment, the health care provider is paged to report to the recovery room. The health care provider leaves the client’s bedside after giving the nurse a verbal prescription to change the solution and rate of the intravenous (IV) fluid being administered. What is the appropriate nursing action in this situation? A. Calling the nursing supervisor to obtain permission to accept the verbal prescription B. Changing the solution and rate of the IV fluid per the physician’s verbal prescription C. Asking the health care provider to write the prescription in the client’s record before leaving the nursing unit Correct D. Telling the health care provider that the prescription will not be implemented until it is documented in the client’s record Awarded 1.0 points out of 1.0 possible points. 15. 15.ID: 9477014249 A client scheduled for surgery tells the nurse that he signed an informed consent for the surgical procedure but was never told about the risks of the surgery. The nurse serves as the client’s advocate by taking which action? A. Reassuring the client that the risks are minimal B. Calling the surgeon and asking that the risks be explained to the client Correct C. Noting in the client’s record that the client was not told about the risks of the surgery D. Writing a note on the front of the client’s record so that the surgeon will see it when the client arrives in the operating room Awarded 1.0 points out of 1.0 possible points. 16. 16.ID: 9477030471 The nurse is planning to administer an oral antibiotic to a client with a communicable disease. The client refuses the medication and tells the nurse that the medication causes abdominal cramping. The nurse responds, “The medication is needed to prevent the spread of infection, and if you don’t take it orally I will have to give it to you in an intramuscular injection.” Which statement accurately describes the nurse’s response to the client? A. The nurse could be charged with battery. B. The nurse could be charged with assault. Correct C. The nurse is justified in administering the medication by way of the intramuscular route, because the client has a communicable disease. D. The nurse will be justified in administering the medication by the intramuscular route once a prescription has been obtained from the physician. Awarded 1.0 points out of 1.0 possible points. 17. 17.ID: 9477030487 The nurse discovers that another nurse has administered an enema to a client even though the client told the nurse that he did not want one. Which action is the most appropriate for the nurse to take? A. Contact the client’s health care provider B. Report the incident to the nursing supervisor Correct C. Tell the client that the nurse did the right thing in giving the enema D. Confront the nurse who gave the enema and tell the nurse that she is going to be charged with battery Awarded 1.0 points out of 1.0 possible points. 18. 18.ID: 9477027505 The nurse calls a health care provider to question a prescription written for a higher-than-normal dosage of morphine sulfate. The health care provider changes the prescription to a dosage within the normal range, and the nurse documents the new telephone prescription in accordance with the agency’s guidelines in the client’s record. Which other statement does the nurse document in the nursing notes? A. The health care provider was called to clarify the prescription for morphine sulfate. Correct B. The health care provider made an error in the written prescription for morphine sulfate. C. The health care provider was called to correct an error in the dosage of morphine sulfate. D. An incorrect dosage of morphine sulfate was prescribed and the health care provider was notified. Awarded 1.0 points out of 1.0 possible points. 19. 19.ID: 9477031437 The charge nurse on the 11 pm–to–7 am shift is gathering the nursing staff together to listen to the 3-to-11 pm intershift report. The charge nurse notes that a staff member has an odor of alcohol on her breath, slurred speech, and an unsteady gait and suspects alcohol intoxication. Which is the most appropriate action for the charge nurse to take? A. Send the staff member home Correct B. Ask the staff member how much alcohol she has consumed C. Tell the staff member that she is not allowed to administer medications D. Ask the staff member to rest in the nurses’ lounge until the effects of the alcohol wear off Awarded 1.0 points out of 1.0 possible points. 20. 20.ID: 9477016359 A client asks the nurse about the procedure for becoming an organ donor. What should the nurse tell the client? A. That anatomical gifts should be made in writing and signed by the client Correct B. To speak with the chaplain about the psychosocial aspects of becoming a donor C. That this decision must be made by the next of kin at the time of the client’s death D. To let the health care provider know about the request so that it may be documented in the client’s record Awarded 1.0 points out of 1.0 possible points. 21. 21.ID: 9477026638 The nurse enters a client’s room to administer a medication that has been prescribed by the health care provider. The client asks the nurse about the medication. Which response by the nurse is appropriate? A. “It’s to help get rid of the swelling in your feet.” B. “You need to discuss this medication with your physician.” C. “I know that it’s for fluid buildup, and I think you’ve taken it before.” D. “It’s called furosemide (Lasix), and it will promote urination and rid your body of the excess fluid. It can cause an alteration in electrolyte levels, so we’ll need to increase the potassium in your diet.” Correct Awarded 1.0 points out of 1.0 possible points. 22. 22.ID: 9477025856 A nursing student is assigned to care for a client who requires a total bed bath. When the student explains to the client that she is going to gather supplies to administer the bath, the client states, “I don’t want a bath. I’ve been up all night, and I’m clean enough.” The student reports the client’s refusal to the nurse in charge. Which action by the nurse in charge is appropriate? A. Telling the nursing student to allow the client to rest Correct B. Telling the nursing student to give the client the bath anyway C. Telling the client that the health care provider will be informed of the refusal of care D. Telling the nursing student to persuade the client to have a bath so that the evening shift staff will not have to do it Awarded 1.0 points out of 1.0 possible points. 23. 23.ID: 9477031472 A client with cancer is transported to the radiology department for a bone scan to determine whether the cancer has metastasized to bone. While the client is in the radiology department, the client’s wife arrives for a visit and asks what test is being performed on the client. What should the nurse tell the wife? A. A bone scan is being performed. B. She will have to discuss the prescribed test with the client. Correct C. The radiology department is not clear as to which test has been prescribed. D. She can read the client’s medical record to determine what the health care provider prescribed. Awarded 1.0 points out of 1.0 possible points. 24. 24.ID: 9477018519 A married couple is attending a hospital program about in vitro fertilization. During the program, a crew from a local television station arrives to film the proceedings because the station is publicizing a series on hospital services. The nurse conducting the program should: A. Allow the television crew to videotape the program B. Explain to the television crew that videotaping is not allowed Correct C. Ask the television crew to interview the individuals attending the program individually D. Allow the television crew to videotape the program as long as they do not publicize that the program is about in vitro fertilization Awarded 1.0 points out of 1.0 possible points. 25. 25.ID: 9477018553 A nurse is taking a morning break with the unit secretary in the nurses’ lounge. The unit secretary says to the nurse, “I read in Mr. Gage’s medical record that he has gonorrhea.” How should the nurse respond to the secretary? A. “Oh, really? I didn’t see that!” B. “We can’t discuss a client’s medical condition.” Correct C. “Yes, that’s why we’ve imposed contact precautions.” D. “Yes, he does, but be sure not to discuss this with anyone else.” Awarded 1.0 points out of 1.0 possible points. 26. 26.ID: 9477018544 A nurse on the night shift is making client rounds. When the nurse checks a client who is 97 years old and has successfully been treated for heart failure, he notes that the client is not breathing. If the client does not have a do-not- resuscitate (DNR) order, the nurse should: A. Call the client’s health care provider B. Contact the nursing supervisor for directions C. Administer cardiopulmonary resuscitation (CPR) Correct D. Administer oxygen to the client and call the health care provider Awarded 1.0 points out of 1.0 possible points. 27. 27.ID: 9477026670 A health care provider informs a nurse that the husband of an unconscious client with terminal cancer will not grant permission for a do-not-resuscitate (DNR) order. The health care provider tells the nurse to perform a “slow code” and let the client “rest in peace” if she stops breathing. How should the nurse respond? A. Telling the health care provider that “slow codes” are not acceptable Correct B. Telling the health care provider that the client would probably want to die in peace C. Telling the health care provider that all of the nurses on the unit agree with this plan D. Telling the health care provider that if the client stops breathing, the health care provider will be called before any other actions are taken Awarded 1.0 points out of 1.0 possible points. 28. 28.ID: 9477022383 A 51-year-old client with amyotrophic lateral sclerosis (Lou Gehrig’s disease) is admitted to the hospital because his condition is deteriorating. The client tells the nurse that he wants a do-not-resuscitate (DNR) order. The nurse should tell the client that: A. Consent must be obtained from the family B. The health care provider makes the final decision about a DNR request C. The DNR request should be discussed with the physician, who will write the order Correct D. Oral consent is sufficient and that his request will be honored by all healthcare providers Awarded 1.0 points out of 1.0 possible points. 29. 29.ID: 9477020827 A man who is visiting his wife in a long-term care facility for people with Alzheimer’s disease collapses and is transported to a hospital. The client remains unconscious, and testing reveals that he has cancer that has metastasized to bone, brain, and liver. The nursing staff at the wife’s care facility report to the hospital health care provider that the client has no other family members and that his wife is mentally incompetent. What information regarding do-not-resuscitate (DNR) orders does the nurse remember? A. That a DNR order may be written by a client’s health care provider Correct B. That everything possible must be done if the client stops breathing C. That medications only may be given to the client if the client stops breathing D. That life support measures will have to be implemented if the client stops breathing Awarded 1.0 points out of 1.0 possible points. 30. 30.ID: 9477020875 A client admitted to the hospital has a do-not-resuscitate (DNR) order in his medical record. The nurse understands that: A. The DNR order may not be changed once it is in effect B. The DNR order requires frequent review as specified by state or agency policy Correct C. The only people who may change the DNR order are members of the client’s immediate family D. The DNR order, as written on admission, must remain in effect for the duration of the client’s hospitalization Awarded 1.0 points out of 1.0 possible points. 31. 31.ID: 9477024288 A registered nurse (RN) is planning client assignments for the day. Which of the following clients should the RN assign to the nursing assistant? A. A client who requires periodic suctioning B. A client who needs a colostomy irrigation C. A client who needs frequent ambulation with a walker Correct D. A client who has undergone an arteriogram and requires close monitoring Awarded 1.0 points out of 1.0 possible points. 32. 32.ID: 9477027517 A registered nurse (RN) who has a licensed practical nurse (LPN) and a nursing assistant on the nursing team is planning client assignments for the day. Which of the following clients should the RN assign to the LPN? A. A client on bedrest who needs assistance with feeding B. A client who must be turned and repositioned every 2 hours C. A client receiving oxygen who requires frequent pulse oximetry monitoring and respiratory treatments Correct D. A client with retinal detachment who is wearing eye patches and requires assistance with hygiene measures Awarded 1.0 points out of 1.0 possible points. 33. 33.ID: 9477020845 A registered nurse (RN) in charge of a long-term care facility who is working with a nursing assistant on the night shift prepares to take her break. To ensure client safety during her break, which of the following actions should the nurse take? Select all that apply. A. Conducting client rounds before taking the break Correct B. Taking the break in the staff lounge located on the nursing unit Correct C. Asking the nursing assistant to administer a medication placed at the client’s bedside if the client awakens D. Asking the nursing assistant to monitor a client’s tube feeding and to contact the nurse when the feeding bag is empty E. Asking the nursing assistant to contact the health care provider during the nurse’s break if a client’s pain medication is not effective F. Informing the nursing assistant that she is leaving the nursing unit to get a cup of coffee from a vending machine in the lobby Awarded 2.0 points out of 2.0 possible points. 34. 34.ID: 9477016864 A nurse is providing a change-of-shift report on his assigned clients, using an audiotape. Which of the following pieces of information should the nurse include in the report about each assigned client? Select all that apply. A. Family history B. Client needs and priorities of care Correct C. Current diagnosis and any secondary diagnoses Correct D. Results of laboratory studies conducted that day Correct E. Client response to treatments implemented that day Correct F. The steps used to perform the procedure for changing the client’s sterile dressing at the gastrostomy tube site Awarded 4.0 points out of 4.0 possible points. 35. 35.ID: 9477014241 A nurse working the 7 am–to–3 pm shift is reviewing the records of her assigned clients. Which client should the nurse assess first? A. A client scheduled for hemodialysis at 10 am Correct B. A client scheduled for a nuclear scanning procedure at 10 am C. A client scheduled for contrast computed tomography (CT) at noon D. A client scheduled for hydrotherapy for treatment of a burn injury at 10:30 am Rationale: A client scheduled for hemodialysis has needs that must be met before the procedure. The nurse must ensure that the client is physically and emotionally ready for the treatment, which may take as long as 5 hours. Before the treatment, the nurse must assess the client, including looking for fluid overload by checking the client’s weight and lung sounds. The nurse must also assess the client’s predialysis vital signs and the results of laboratory tests for comparison in the postdialysis period. Although the clients described in the other options have needs, they are not immediate. A client scheduled for a nuclear scanning procedure at 10 am may require reinforcement of information about the procedure and will need to increase fluid intake before the procedure. A client scheduled for hydrotherapy for treatment of a burn injury at 10:30 am may require pain medication, but the medication should be administered approximately 30 minutes before the hydrotherapy. A client scheduled for contrast CT at noon may require reinforcement of information about the procedure and may need to drink a special contrast preparation just before the procedure. Test-Taking Strategy: Use Maslow’s Hierarchy of Needs theory and think about the needs of each client and what pretesting or preprocedure preparation involves. Although all of the clients have physiological needs, the client scheduled for hemodialysis has the priority need, that being the risk of fluid overload. Review: the principles of prioritizing . References: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp. 374, 375). St. Louis: Mosby. Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Delegating/Prioritizing Awarded 1.0 points out of 1.0 possible points. 36. 36.ID: 9477027583 A nurse has delegated several nursing tasks to staff members. The nurse’s primary responsibility after delegation of the tasks is: A. Documenting completion of each task B. Assigning any tasks that were not completed to the next nursing shift C. Allowing each staff member to make judgments when performing the tasks D. Following up with each staff member regarding the performance of the task and the outcomes related to implementation of the task. Correct Awarded 1.0 points out of 1.0 possible points. 37. 37.ID: 9477024260 A case manager is reviewing progress notes in a client’s medical record. Which notation indicates the need for follow-up? S. No Client Condition Notation 1. Client 1 Status post–mastectomy:18 hours Five milliliters of bloody drainage was emptied from the Jackson-Pratt drain. 2. Client 2 Heart Failure Crackles were heard in the lower lung lobes bilaterally on auscultation. 3. Client 3 Status post–appendectomy: 24 hours The surgical dressing is clean and dry. 4. Client 4 Diabetes mellitus Blood glucose level is is124 mg/dL (6.9 mmol/L). A. 1 B. 2 Correct C. 3 D. 4 Awarded 1.0 points out of 1.0 possible points. 38. 38.ID: 9477026689 The nurse reviewing a client’s record sees that the following medications are prescribed. Which medication should the nurse plan to administer first? Client Medications 1. Atorvastatin (Lipitor) 10 mg orally 2. Zolpidem (Ambien) 5 mg orally daily 3. Ferrous sulfate (Feosol) 1 tablet orally 4. Levothyroxine (Synthroid) 137 mg orally A. 1 B. 2 C. 3 D. 4 Correct Awarded 1.0 points out of 1.0 possible points. 39. 39.ID: 9477016348 A nurse manager has announced a change to computerized documentation of nursing care. A licensed practical nurse (LPN) on the team, resistant to the change, is not taking an active part in facilitating implementation of the new procedure. Which of the following strategies would be the best approach to dealing with the conflict? A. Ignoring the resistance B. Telling the LPN that his noncompliance will be documented in his personnel record C. Confronting the LPN and encouraging him to express his feelings regarding the change Correct D. Telling the LPN that a registered nurse will perform all of the computer documentation if he will document all intake and output and vital signs Awarded 1.0 points out of 1.0 possible points. 40. 40.ID: 9477014294 A registered nurse (RN) is planning client assignments for the day. Which clients should the nurse assign to a nursing assistant (unlicensed assistive personnel)? Select all that apply. A. A client with a permanent tracheostomy B. A client requiring a gastrostomy tube dressing change C. A client who requires transport to the radiology department in a wheelchair Correct D. A client with a Foley catheter for whom a 24-hour urine collection is in progress Correct E. A client who underwent surgery an hour earlier and has a nasogastric tube and a Foley catheter Awarded 2.0 points out of 2.0 possible points. 41. 41.ID: 9477028743 A registered nurse (RN) is planning assignments for five clients on the nursing unit. The team includes a licensed practical nurse (LPN) and a nursing assistant. Which clients should the nurse assign to the LPN? Select all that apply. A. A client who is confused and requires assistance with a shower B. A client requiring a bed bath and frequent ambulation with a cane C. A client who must be accompanied to physical therapy twice during the shift D. A client with a colostomy who requires reinforcement regarding the procedure for irrigation Correct E. A client with diabetes mellitus who requires the administration of regular insulin in accordance with a sliding dosage scale every 4 hours Correct Awarded 2.0 points out of 2.0 possible points. 42. 42.ID: 9477031401 A registered nurse (RN) has received the assignment for the day shift. Once the RN has made initial rounds and checked all of the assigned clients, which client will she plan to care for first? A. A client who is scheduled for surgery at 1 pm Correct B. A client scheduled for physical therapy at 11 am C. A client in skeletal traction who has just received pain medication D. A client who is able to perform activities of daily living independently Awarded 1.0 points out of 1.0 possible points. 43. 43.ID: 10465750996 A nurse working the 7 am–to–3 pm shift is assigned to care for four clients. List the clients in order of priority for the nurse. Incorrect A. A client with diabetes mellitus who requires the administration of NPH insulin before breakfast B. A client with pneumonia who is receiving oxygen C. A client preparing for discharge after surgery D. A client with a wound requiring dressing changes at 10 am and 2 pm The correct order is: E. A client with pneumonia who is receiving oxygen F. A client with diabetes mellitus who requires the administration of NPH insulin before breakfast G. A client with a wound requiring dressing changes at 10 am and 2 pm H. A client preparing for discharge after surgery Awarded 0.0 points out of 1.0 possible points. 2. 44.ID: 9477017769 A case manager is reviewing the records of the clients in the nursing unit. Which note(s) in a client’s record indicate an unexpected outcome and the need for follow-up? Select all that apply. A. A client is performing his own colostomy irrigations. B. A client with a central venous catheter has a temperature of 100.6° F (38.1°C). Correct C. A client with a new diagnosis of diabetes mellitus is self- administering insulin. D. A client who has just undergone surgery has a urine output of more than 30 mL/hr. E. A client who has just undergone surgery is getting relief from the prescribed pain medication. Awarded 1.0 points out of 1.0 possible points. 2. 45.ID: 10465806715 A nurse on the day shift is assigned to care for four clients. List the clients in order of priority for nurse. Correct A. A client with asthma who had shortness of breath during the night B. A client scheduled to have a chest x-ray at 9 am C. A client scheduled for an echocardiogram at 10 am D. A client with pneumonia who is scheduled for discharge home Awarded 1.0 points out of 1.0 possible points. 2. 46.ID: 9477016816 A case manager is serving on a community task force on violence in schools. The members of the task force are planning to develop interventions to help prevent violence. According to the nursing process, the first activity that the nurse would suggest to the task force is: A. Teaching schoolchildren about the dangers of school violence B. Looking at what other communities are doing about school violence C. Distributing fliers that identify the causes of school violence to families in the community D. Conducting a community survey to assess community perceptions regarding school violence Correct Awarded 1.0 points out of 1.0 possible points. 2. 47.ID: 9477029418 A nurse planning care for her assigned clients understands that the purpose of the hospital’s standards of care is to: A. Identify methods of treatment B. Provide direction for the practice of nursing Correct C. Provide direction for care on the basis of the client’s diagnosis D. Identify new care methods on the basis of current medical research Awarded 1.0 points out of 1.0 possible points. 3. 48.ID: 9477018581 A registered nurse (RN) is supervising a nursing assistant ambulating a client with right-sided weakness. The RN would conclude that the nursing assistant is performing the procedure incorrectly after observing that the nursing assistant: A. Stands behind the client Correct B. Stands on the right side of the client C. Positions the free hand on the client’s shoulder D. Grasps the security belt in the midspine area of the small of the client’s back Awarded 1.0 points out of 1.0 possible points. 4. 49.ID: 9477018562 A registered nurse (RN) is watching as a new licensed practical nurse (LPN) administer an intramuscular (IM) injection in a client’s deltoid muscle. The RN determines that the LPN is performing the procedure correctly if the LPN: A. Administers the injection in the thigh B. Places the client in the Sims position C. Positions the client in a prone toe-in position D. Administers the injection 2 inches (5 cm) below the acromion process Correct Awarded 1.0 points out of 1.0 possible points. 5. 50.ID: 9477016396 A graduate nurse hired to work in a medical unit of a hospital is attending an orientation session. The nurse educator, discussing care maps, asks the graduate nurse whether she understands how a care map is used. Which response indicates understanding? A. “The care map is developed by a nurse and identifies nursing diagnoses.” B. “The care map is a plan that is used only by the nurse to provide client care.” C. “The care map outlines the day-to-day expected outcomes of care and the outcomes anticipated at discharge.” Correct D. “The care map is a standard plan, rather than an individualized one, that is developed strictly by a nurse and used for a client with a particular diagnosis.” Awarded 1.0 points out of 1.0 possible points. 6. 51.ID: 9477014223 The nurse is preparing client assignments for the day. Which client should the nurse assign to a nursing assistant? A. A client scheduled for a liver biopsy B. An unconscious client who requires oral care Correct C. A client who has just undergone cardiac catheterization D. A client who is getting up to ambulate for the first time after surgery Awarded 1.0 points out of 1.0 possible points. 7. 52.ID: 9477022367 A nurse manager tells the nursing staff that they will need to comply with the mandatory overtime policy that the hospital has implemented. Later that day, the nurse manager overhears a nurse complaining about the policy and telling other nurses that she will not work the overtime if she has made other plans after her regular shift. What is the best approach for the nurse manager to use in dealing with the conflict? A. Ignoring the complaints B. Avoiding assigning the nurse mandatory overtime C. Confronting the nurse regarding her behavior regarding the overtime policy Correct D. Providing a positive reward system for the nurse so that the nurse will agree to work the mandatory overtime Awarded 1.0 points out of 1.0 possible points. 8. 53.ID: 9477028706 A nurse manager is planning client assignments for the day. Which of the following clients should the nurse assign to the nursing assistant (unlicensed assistive personnel)? A. A client scheduled for a cardiac stress test B. A client who had a mastectomy 2 days ago C. A client scheduled for a laparoscopic cholecystectomy D. A client with renal calculi whose urine must be strained Correct Awarded 1.0 points out of 1.0 possible points. 9. 54.ID: 9477016331 A registered nurse (RN) must determine how best to assign co-workers (another RN and one licensed practical nurse [LPN]) to provide care to a group of clients. Which of the following is the best assignment? A. The RN is assigned to care for a woman with newly diagnosed leukemia who has a newborn at home. Correct B. The LPN is assigned to provide discharge teaching about dressing changes and medications to a 35-year-old man. C. The LPN is assigned to care for a client with newly diagnosed diabetes mellitus who will need to be taught how to self-administer insulin. D. The RN is assigned to care for a 75-year-old woman, hospitalized for dehydration, who is being discharged home today with no medications. Awarded 1.0 points out of 1.0 possible points. 10. 55.ID: 9477020866 A client who had a stroke has left-side weakness and is having difficulty holding utensils while eating. To which of these services does the nurse suggest a referral? A. Home care B. Social services C. Physical therapy D. Occupational therapy Correct Awarded 1.0 points out of 1.0 possible points. 11. 56.ID: 9477017732 A case manager is reviewing notations made in clients’ records. Which note indicates an unexpected outcome and the need for immediate follow-up? A. A client who has sustained a stroke dresses herself. B. A client exhibits signs of increased intracranial pressure after a craniotomy. Correct C. Normal neurological findings are noted in a client with a cerebral aneurysm. D. A client with a spinal cord injury transfers himself from a bed to a wheelchair. Awarded 1.0 points out of 1.0 possible points. 12. 57.ID: 9477022343 A client with diabetes mellitus who takes a daily dose of NPH insulin has a hard time drawing the insulin into a syringe because he has difficulty seeing the markings on the syringe. To which of the following services does the nurse suggest a referral? A. Home care Correct B. Social services C. Physical therapy D. Occupational therapy Awarded 1.0 points out of 1.0 possible points. 13. 58.ID: 9477027562 A nurse is planning client assignments for the day. Which of the following assignments is the least appropriate for the nursing assistant? A. Assisting a client with dysphagia in eating Correct B. Providing hygiene to a client with dementia C. Ambulating a client with Parkinson’s disease D. Assisting a client with an above-the-knee amputation in showering Awarded 1.0 points out of 1.0 possible points. 14. 59.ID: 9477018599 A nurse is assigned to care for four clients. Which client should the nurse assess first? A. A client scheduled for a colonoscopy B. A client preparing for discharge after surgery C. A client requiring a tube feeding through a gastrostomy tube D. A client with a tracheostomy who is receiving humidified oxygen by way of a tracheostomy mask Correct Awarded 1.0 points out of 1.0 possible points. 15. 60.ID: 9477025868 A nurse is planning the client assignments for the shift. Which client should the nurse assign to the nursing assistant? A. A client who needs a blood transfusion B. A client with diarrhea on whom contact precautions have been imposed Correct C. A client with angina who needs to be ambulated for the first time since admission D. A client with a draining abdominal wound that requires frequent dressing changes Awarded 1.0 points out of 1.0 possible points. 16. 61.ID: 9477016840 A nurse is assisting a new nursing graduate with organizational skills in delivering client care. The nurse determines that the new nursing graduate needs assistance with time management if he: A. Allows time for unexpected tasks B. Prioritizes client needs and daily tasks C. Gathers supplies before beginning a task D. Documents task completion and client information at the end of the day Correct Awarded 1.0 points out of 1.0 possible points. 17. 62.ID: 9477014285 A new nurse employed at a community hospital is reading the organization’s mission statement. The new nurse understands that this statement: A. Describes the benefits available to employees B. Outlines what the organization plans to accomplish Correct C. Identifies the policies and procedures of the organization D. Defines the rules of the organization that the employees must follow Awarded 1.0 points out of 1.0 possible points. 18. 63.ID: 9477029489 A nurse, newly employed by a home health agency, is told that the organization’s decision-making process is centralized. The nurse determines that this means that the authority to make decisions is vested in: A. Every employee B. A few individuals, such as the board of directors Correct C. All nursing employees, pharmacists, and hospital physicians D. Many individuals, with decisions filtering down to the individual employee Awarded 1.0 points out of 1.0 possible points. 19. 64.ID: 9477014264 A nurse employed in a community hospital as a nurse manager understands that in this position, the term authority most appropriately refers to: A. Being responsible for what staff members do B. Accepting the responsibility for the actions of others C. Carrying the legal responsibility for others’ performance of tasks D. The official power to see that an organizational decision is enforced Correct Awarded 1.0 points out of 1.0 possible points. 20. 65.ID: 9477029402 A nursing instructor asks a nursing student to describe accountability. Which statement(s) by the student indicate(s) an accurate description of accountability? Select all that apply. A. “Accountability can be delegated.” B. “You are responsible for your own actions.” Correct C. “It carries legal implications for task performance.” Correct D. “You must answer for the care that you ask others to complete.” Correct E. “It refers to the process of answering or being responsible for what occurs.” Correct Awarded 4.0 points out of 4.0 possible points. 21. 66.ID: 9477022304 A registered nurse is in charge of the emergency department (ED) during the night shift. A client arrives at the ED for treatment after a sexual assault. The nurse has never cared for anyone who has been raped. To determine the necessary actions in regard to this client’s injury, the nurse should: A. Ask a licensed practical nurse B. Call the nurse in charge of the day shift C. Ask the police officers who brought the client to the ED D. Check the unit policy for the protocol for the care of clients who have been sexually assaulted Correct Awarded 1.0 points out of 1.0 possible points. 22. 67.ID: 9477029467 A nurse educator describes the standards of care formulated by the American Nurses Association to a group of new nursing graduates hired by the hospital. Which of the following options are accurate descriptions of these standards of care? Select all that apply. A. Are specific guidelines B. Define professional practice Correct C. Have some similarity to policies and procedures Correct D. Are statements that relate only to the agency in which the nurse is employed E. Are authoritative statements that describe a common or acceptable level of client care or performance Correct Awarded 3.0 points out of 3.0 possible points. 23. 68.ID: 9477018533 In which situation is the nurse upholding the ethical principle of fidelity? A. Allowing a client to decide when to receive daily hygiene care B. Inserting a 19-gauge intravenous catheter into a client requiring a blood transfusion C. Providing complete information regarding treatment options to a client with newly diagnosed cancer D. Contacting the health care provider about the client’s request to incorporate complementary therapies for pain into the treatment plan Correct Awarded 1.0 points out of 1.0 possible points. 24. 69.ID: 9477014279 Which of the following situations is an example of the use of evidence-based practice in the delivery of client care? A. Encouraging a client who has had a stroke to consume thin liquids and foods B. Blowing on a fingerstick site to dry it after cleaning the site with an alcohol swab C. Immediately picking up a dislodged radiation implant with gloved hands and placing it in a lead container D. Pouring 1 to 2 mL of sterile solution that will be used for wound cleansing into a plastic-lined waste receptacle before pouring the solution into a sterile basin Correct Awarded 1.0 points out of 1.0 possible points. 25. 70.ID: 9477027594 A nurse is preparing for the admission of a client with pulmonary tuberculosis. Which of the following actions reflects the use of evidence-based practice in the care of the client? A. Keeping the door to the client’s room closed Correct B. Using a surgical mask when entering the client’s room C. Placing the client in a semiprivate room with a cohort client D. Fitting the client for an N95 or HEPA (high-efficiency particulate air) mask to be worn at all times Awarded 1.0 points out of 1.0 possible points. 26. 71.ID: 9477030438 A nurse manager asks a nurse to work overtime because of a short-staffing problem. The nurse has made plans to do her Christmas shopping after work and does not want to work overtime. What is the most assertive response by the nurse to her nurse manager? A. “I’m not working overtime today.” B. “You know how I hate to work overtime.” C. “I will if you need me, but I am not happy about this.” D. “I have plans after work and will not be able to work overtime.” Correct Awarded 1.0 points out of 1.0 possible points. 27. 72.ID: 9477017715 A nurse manager arrives at work and is immediately faced with several activities that require his attention. Which activity will the nurse manager attend to first? A. Stocking the medication closet B. Client assignments for the day Correct C. A phone message from a client’s wife D. A phone message from employee health services Awarded 1.0 points out of 1.0 possible points. 28. 73.ID: 9477020835 A nurse who has been employed in a hospital for 8 weeks is consistently taking extended lunch breaks. The nurse’s behavior has caused problems with client care during lunch hours. What is the appropriate way for the nurse manager to deal with this situation? A. Ignoring the situation B. Asking other staff members to cover for the nurse C. Documenting the problem in the nurse’s personnel file D. Confronting the nurse to discuss the behavior and initiate problem-solving measures Correct Awarded 1.0 points out of 1.0 possible points. 29. 74.ID: 9477030422 A health care provider repeatedly asks a nurse to write his verbal prescriptions in his clients’ charts after he makes his rounds. The nurse is uncomfortable with writing the prescriptions and explains this to the physician, but the health care provider tells the nurse that she will be reported if she does not write the prescriptions. How should the nurse manage this conflict? A. Fulfilling the physician’s request B. Discussing the situation with the nurse manager Correct C. Reporting the health care provider to the chief of medicine at the hospital D. Stating to the physician, “I don’t really care whether you report me. I am not writing your prescriptions.” Awarded 1.0 points out of 1.0 possible points. 30. 75.ID: 9477024229 A nurse manager notes that an employee is constantly calling in sick. Which action should the nurse manager take initially to handle this problem? A. Reporting the employee to administration B. Documenting the employee’s behavior in the personnel file C. Telling the employee that she will be fired if she calls in sick again D. Reminding the employee of the employment standards of the agency Correct Awarded 1.0 points out of 1.0 possible points. 31. 76.ID: 9477025882 A nursing staff member approaches a nurse manager and announces that another nurse is not using alcohol swabs to clean the intravenous port when administering intravenous push medications. What is the appropriate way for the nurse manager to handle this situation? A. Telling the nurse that it is inappropriate to report other nurses B. Providing an in-service educational session on aseptic technique for everyone on the nursing unit C. Informing the nurse who reported the occurrence that intravenous ports do not need to be cleaned with alcohol before medication administration D. Reviewing the skills checklist of the nurse who is not using aseptic technique to determine whether the nurse has ever performed this skill and had her technique validated Correct Awarded 1.0 points out of 1.0 possible points. 32. 77.ID: 10465904561 A nurse on the day shift receives her client assignments for the day. List the clients in order of their priority for assessment. Incorrect A. A client with gastroenteritis and diarrhea B. A client with suspected gallbladder disease who is scheduled for an ultrasound of the abdomen C. A client with heart failure whose condition has been stable since the administration of furosemide (Lasix) D. A client with a herniated disc who is scheduled to be discharged today The correct order is: E. A client with heart failure whose condition has been stable since the administration of furosemide (Lasix) F. A client with gastroenteritis and diarrhea G. A client with suspected gallbladder disease who is scheduled for an ultrasound of the abdomen H. A client with a herniated disc who is scheduled to be discharged today Awarded 0.0 points out of 1.0 possible points. 2. 78.ID: 9477016378 A nurse is preparing the client assignments for the day. One of the registered nurses on the team has just learned that she is pregnant. Which client does the nurse refrain from assigning to the pregnant team member? A. A client with a solid sealed cervical radiation implant Correct B. A client with diarrhea for whom enteric precautions are in effect C. A client with metastatic cancer who is receiving a continuous infusion of intravenous morphine sulfate D. A client for whom contact precautions have been implemented and who requires frequent wound irrigations Awarded 1.0 points out of 1.0 possible points. 2. 79.ID: 9477030455 A client has signed the informed consent for mastectomy of the left breast. On the morning of the surgical procedure, the client asks the nurse several questions about the procedure that make it obvious that she has does not have an adequate comprehension of the procedure. What is the most appropriate response by the nurse? A. Telling the client that it is her surgeon’s responsibility to explain the procedure B. Contacting the surgeon and requesting that she visit the client to answer her questions Correct C. Informing the client that she has the right to cancel the surgical procedure if she wishes D. Telling the client that she needed to ask these questions before signing the informed consent for surgery Awarded 1.0 points out of 1.0 possible points. 3. 80.ID: 9477026681 A nurse sees another nurse changing an intravenous (IV) solution because the wrong solution is infusing into the client. The nurse who changed the IV solution does not report the error. What should the nurse who observed the error do first? A. Call the client’s health care provider B. Document the error in the client’s chart C. Report the nurse who changed the IV solution D. Ask the nurse whether she intends to report the error Correct Awarded 1.0 points out of 1.0 possible points. 4. 81.ID: 9477017744 A nurse leader in a medical-surgical unit overhears the nursing staff openly discussing a client and stating that the client is “uncooperative and a real pain to care for.” The nurse leader would most appropriately manage this issue by: A. Discouraging the judgmental comments Correct B. Ignoring the comments made about the client C. Reporting the nurses’ comments to administration D. Leaving articles about judgmental opinions in the nurses’ report room Awarded 1.0 points out of 1.0 possible points. 5. 82.ID: 9477016312 A client receives cefazolin sodium (Ancef) by way of the intravenous route. During the infusion, the client begins exhibiting signs of an allergic reaction. The client states that his skin is itchy, and the nurse notes that the skin is warm and flushed, with a red rash on the arms, chest, and back. The nurse immediately discontinues the medication, further assesses the client, contacts the physician, and begins to document the reaction in an incident report. The nurse most accurately documents which of the following? A. The client had an allergy to cefazolin sodium. B. The health care provider was notified because a rash developed while the client was receiving cefazolin sodium. C. The client is apparently allergic to cefazolin sodium, as indicated by warm, flushed skin and a rash on the arms, chest, and back. D. During an infusion of cefazolin sodium, the client complained that his skin was itchy. The client’s skin was warm and flushed, with a red rash on the arms, chest, and back. The health care provider was notified. Correct Awarded 1.0 points out of 1.0 possible points. 6. 83.ID: 9477022358 A nurse who works in a medical care unit is told that she must float to the intensive care unit because of a short-staffing problem on that unit. The nurse reports to the unit and is assigned to three clients. The nurse is angry with the assignment because she believes that the assignment is more difficult than the assignment delegated to other nurses on the unit and because the intensive care unit nurses are each assigned only one client. The nurse should most appropriately: A. Refuse to do the assignment B. Tell the nurse manager to call the nursing supervisor C. Ask the nurse manager of the intensive care unit to discuss the assignment Correct D. Return to the medical care unit and discuss the assignment with the nurse manager on that unit Awarded 1.0 points out of 1.0 possible points. 7. 84.ID: 9477020858 A client with a left arm fracture complains of severe diffuse pain that is unrelieved by pain medication. On further assessment, the nurse notes that the client experiences increased pain during passive motion, compared with active motion, of the left arm. On the basis of these assessment findings, which action should the nurse take first? A. Contacting the health care provider Correct B. Reassessing the client in 30 minutes C. Checking to see whether it is time for more pain medication D. Encouraging the client to continue active range of motion exercises of the left arm Awarded 1.0 points out of 1.0 possible points. 8. 85.ID: 9477028785 A client with terminal cancer is receiving a continuous intravenous infusion of morphine sulfate. On assessment of the client, what does the nurse check first? A. Pulse B. Urine output C. Temperature D. Respiratory status Correct Awarded 1.0 points out of 1.0 possible points. 9. 86.ID: 9477031456 A nurse is preparing to administer medications to a client by way of a nasogastric (NG) tube. Before administering the medication, the nurse must first: A. Check the client’s apical pulse B. Check the placement of the tube Correct C. Check when the last feeding was given D. Check when the last medications were given Awarded 1.0 points out of 1.0 possible points. 10. 87.ID: 9477029434 A health care provider asks the nurse who is caring for a client with a new colostomy to ask the hospital’s stoma nurse to visit the client and assist the client with care of the colostomy. The nurse initiates the consultation, understanding that the stoma nurse will be able to influence the client because of his: A. Expert power Correct B. Reward power C. Referent power D. Coercive power Awarded 1.0 points out of 1.0 possible points. 11. 88.ID: 9477018588 An emergency department nurse is performing an assessment of a client who has sustained circumferential burns of both legs. What should the nurse assess first? A. Heart rate B. Radial pulse rate C. Peripheral pulses Correct D. Blood pressure (BP) Awarded 1.0 points out of 1.0 possible points. 12. 89.ID: 9477014273 A nurse employed at a hospital is asked by a nurse manager to review the organizational chart. The nurse reviews the chart so that he will: A. Understand the organization’s reason for existence B. Be familiar with the organization’s line of authority Correct C. Be familiar with the beliefs and values of the organization D. Be aware of the geographical area that the organization serves Awarded 1.0 points out of 1.0 possible points. 13. 90.ID: 9477031420 A nurse manager discusses staff empowerment with the nursing team. The nurse manager explains that staff empowerment: A. Allows the staff to make every decision regarding employee scheduling B. Fosters the growth of others so that they are less dependent on the leader Correct C. Means that the staff has the power to reprimand and punish any individual who is not meeting the standards of care delivery D. Indicates that the nurse leader will make decisions regarding the nursing unit and expects that the staff will comply with the changes Awarded 1.0 points out of 1.0 possible points. 14. 91.ID: 9477018573 The nurse notes that a health care provider has documented the following prescription in a client’s record: Furosemide (Lasix) 40 mg stat once. What action should the nurse take? A. Contacting the health care provider Correct B. Administering the medication C. Drawing up the medication in a syringe D. Planning to have the nurse on the next shift administer the medication Awarded 1.0 points out of 1.0 possible points. 15. 92.ID: 9477016899 A 17-year-old client arrives at the clinic and asks to be examined because she believes that she has contracted a sexually transmitted infection. In regard to informed consent, the nurse tells the client that: A. She will need to sign an informed consent form Correct B. Her mother or father will need to be contacted for permission to treat her C. Anyone over the age of 18 years may sign a consent form for her treatment D. A consent form is not needed if the problem is a sexually transmitted infection Awarded 1.0 points out of 1.0 possible points. 16. 93.ID: 9477026601 An 18-year-old client is brought to the emergency department (ED) by emergency medical services after sustaining life-threatening injuries in an automobile accident. The client is unconscious and requires an emergency splenectomy. A nurse in the ED assists in quickly preparing the client for surgery and tries to contact the client’s parents but is unsuccessful. In regard to informed consent for the surgery: A. The nurse understands that consent is not needed Correct B. The nurse will contact the hospital clergy to provide informed consent C. The nurse will sign informed consent on behalf of the client and ask another nurse to witness the signature D. The nurse will prepare the client to undergo mechanical ventilation until the client’s parents can be contacted Awarded 1.0 points out of 1.0 possible points. 17. 94.ID: 9477022316 A nurse is supervising a new nursing graduate in various procedures. Which of the following actions by the new nursing graduate constitutes a negligent act? A. Giving a verbal report to the nurse on the oncoming shift B. Checking neurological signs in a client with a head injury C. Using clean gloves to change a gastrostomy tube dressing Correct D. Contacting a health care provider about a change in a client’s blood pressure Awarded 1.0 points out of 1.0 possible points. 18. 95.ID: 9477027574 A nurse is reviewing the notes written by a nurse on a previous shift. Which note in the client’s record reflects the correct use of guidelines for documentation? A. The client seems anxious B. The client’s intake was 360 mL Correct C. The client’s wound is healing well D. The client is voiding large amounts Awarded 1.0 points out of 1.0 possible points. 19. 96.ID: 9477022339 A nurse is reading the nurse practice act for the state in which she is employed. The nurse uses the information in this act to: A. Identify healthcare policies in her state B. Know how to perform certain procedures C. Be aware of the role of the professional nurse Correct D. Be aware of hospital and long-term care facilities policies Awarded 1.0 points out of 1.0 possible points. 20. 97.ID: 9477026656 A client whose right leg is in skeletal traction complains of pain in the leg. Which action should the nurse take first? A. Realigning the client Correct B. Asking the client to wiggle her toes C. Removing some of the traction weights D. Medicating the client with the prescribed analgesic Awarded 1.0 points out of 1.0 possible points. 21. 98.ID: 9477027553 A nurse is performing suctioning through an adult client’s tracheostomy tube. The nurse notes that the client’s oxygen saturation is 89% and terminates the procedure. Which action would the nurse take next? A. Calling the health care provider B. Calling the respiratory therapist C. Rechecking the pulse oximetry reading D. Oxygenating the client with 100% oxygen Correct Awarded 1.0 points out of 1.0 possible points. 22. 99.ID: 9477022348 A nurse is assisting a client with a closed chest tube drainage system in bathing. As the nurse is turning the client onto his side, the chest tube is disconnected. What should the nurse do first? A. Call the health care provider B. Clamp the chest tube with a Kelly clamp C. Instruct the client to inhale and hold his breath D. Submerge the end of the chest tube in a bottle of sterile water Correct Awarded 1.0 points out of 1.0 possible points.