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over the fibrinolysin and is deficit?
a) tells the client to scan the environment
b) approaches the client from the unaffected side
c) places the bedside articles on the affected side
d) moves the commode and cahir to the affected side
6. A nursing instructor asks the nursing student to describe the
definition of a critical path. Which of the following statements, if
made by the student, indicates a need for further understanding
regarding critical paths?
a) they are developed through the collaborative efforts of all
members of the health care team
b) they provide an effective way of monitoring care and for
reducing or controlling the length of hospital stay for the client
c) they are developed based on appropriate standards of care
d) they are nursing care plans and use the steps of the nursing
process
7. A community health nurse is working with a disaster relief
following a tornado. The nurse's goal for the community is to
prevent as much injury and death as possible from the
uncontrollable event. Finding safe housing for survivors,
providing support to families, organizing counseling, and
securing physical care when needed allexamples of which type
of prevention?
a) primary level of prevention
b) secondary level of prevention
c) tertiary level of prevention
d) aggregate care prevention
8. The nurse manager is planning to implement a change in the
nursing unit from team nursing to primary nursing. The nurse
anticipates that there will be resistance to the change during the
change process. The primary technique that the nurse would use
in implementing this change is which of the following?
a) introduce the change gradually
b) confront the individuals involved in the change process
c) use coercion to implement the change
d) manipulate the participants in the change process
9. A nurse manager is providing an educational session to
nursing staff members about the phases of viral hepatitis. The
nurse manager tells the staff that which clinical manifestation(s)
are primarily characteristic of preicteric phase?
a) right upper quadrant pain
b) fatigue, anorexia and nausea
c) jaundice, dark-colored urine, and clay-colored stools
d) pruritus
10. A nurse is preparing a plan of care for a client who will be
hospitalized for insertion of an internal cervical radiation implant.
Which nursing intervention should the nurse implement in
preparation for the arrival of the client?
a) prepare a private room at the end of the hallway
b) place a sign on the door that indicates that visitors are limited
to 60-minute visits
c) assign one primary nurse to care for the client during the
hospital stay
d) place a linen bag outside of the client's room for discarding
linens after morning care
11. A nursing student is developing a plan of care for a client with
a chest tube that is attached to a Pleur-Evac drainage system.
The nurse intervenes if the student writes which incorrect
intervention in the plan?
a) position the client in semi-fowler's position
b) add water to the suction chamber as it evaporates
c) tape the connection sites between the chest tube and
the drainage system
d) instruct the client to avoid coughing and deep breathing
12. A nurse is caring for a client who has just had a plaster leg
cast applied. The nurse would plan to prevent the development
of compartment syndrome is instructing the licensed practical
nurseassigned to care for the client to:
a) elevate the limb and apply ice to the affected leg
b) elevate the limb and cover the limb with bath blankets
c) place the leg in a slightly dependent position and apply ice to
the affected leg
d) keep the leg horizontal and apply ice to the affected leg
13. A registered nurse (RN) is supervising a licensed practical
nurse (LPN) administering an intramuscular (IM) injection of iron
to an assigned client. The RN would intervene if the LPN is
observed to perform which of the following?
a) changing the needle after drawing up the dose and before
injection
b) preparing an air lock when drawing up the medication
c) using a Z-track method for injection
d) massaging the injection site after injection
14. A nursing student develops a plan of care for a client with
paraplegia who has a risk for injury related to spasticity of the leg
muscles. On reviewing the plan, the co-assigned nurse identifies
which of the following as an incorrect intervention.
a) use of padded restraints to immobilize the limb
b) performing range of motion to the affected limbs
c) removing potentially harmful objects near the spastic limbs
d) use of prescribed muscle relaxants as needed
15. A registered nurse (RN) is observing a licensed practical
nurse (LPN) preparing a client for treatment with a continuous
passive motion (CPM) machine. Which observation by the RN
would indicate that the LPN is performing an incorrect action?
a) places the client's knee in a slightly externally rotated position
b) keeps the client's knee at the hinged joint of the machine
c) assesses the client for pressure areas at the knee and the
groin
d) checks the degree of extension and flexion and the speed of
the CPM machine per the physician's orders
a) autocratic
b) situational
c) democratic
d) laissez-faire
38. A charge nurse knows that drug and alcohol use by nurses is
a reason for the increasing numbers ofdisciplinary cares by the
Board of Nursing. The charge nurse understands that when
dealing with a nurse with such an illness, it is most important to
assess the impaired nurse to determine:
a) the magnitude of drug diversion over time
b) if falsification of clients records occurred
c) the types of illegal activities related to the abuse
d) the physiological impact of the illness on practice
39. A nurse manager is planning to implement a change in the
method of the documentation system for the nursing unit. Many
problems have occurred as a result of the present
documentation system, and the nurse manager determines that
a change is required. The initial step in the process of change for
the nurse manager is which of the following?
a) plan strategies to implement the change
b) set goals and priorities regarding the change process
c) identify the inefficiency that needs improvement or correction
d) identify potential solutions and strategies for the change
process
40. A nurse receives a telephone call from the emergency
department and is told that a child with a diagnosis of tonicclonic seizures will be admitted to the pediatric unit. The nurse
prepares for the admission of the child and instructs assistant to
place which items at the bedside?
a) a tracheostomy set and oxygen
b) suction apparatus and an airway
c) an endotracheal tube and an airway
d) an emergency cart and laryngoscope
41. When assessing the client with the vest restraint (security
device) at the beginning of day shift, which observation by the
charge nurse would indicate that the nurse who placed the vest
restraint on the client failed to follow safety guidelines?
d) ask the second nurse to refrain from eating and drinking in the
client area
c) keeps the child dry while on the cooling blanket to reduce the
risk of frostbite
d) checks the skin condition of the child before, during, and after
the use of the cooling blanket
52. A nursing instructor asks a nursing student to identify
situations that indicate a secondary level of prevention in health
care. Which situation, if identified by the student, would indicate
the need for further study of the levels of prevention?
a) teaching s stroke client how to use a walker
b) screening for hypertension in a community group
a) a foot board
b) extra pillows
c) a bed trapeze
d) an electric bed
a) plans to transfer the client to the intensive care unit
57. A registered nurse is observing a nursing student auscultate
the breath sounds of a client. The registered nurse intervenes if
the nursing student performs which incorrect action?
1) C
- In team nursing, nursing personnel are led
by a registered nurse leader in providing care
to a group of clients. Option A identifies
functional nursing. Option B identifies a
component of case management. Option D
identifies primary nursing.
2) D
- Confrontation is an important strategy to
meet resistance head on. Face-to-face
meetings to confront the issue at hand will
allow verbalization of feelings, identification of
11) D
- It is important to encourage the client to
cough and deep breathe when a chest tube
drainage system is in place. This will assist in
facilitating appropriate lung re-expansion.
Water is added to the suction chamber as it
evaporates to maintain the full suction level
prescribed. Connections between the chest
tube and the drainage system are taped to
prevent accidental disconnection. The client is
positioned in semi-Fowlers to facilitate ease
in breathing.
12) A
- Compartment syndrome is prevented by
controlling edema. This is achieved most
optimally with the use of elevation and
application of ice. Options B, C, and D are
incorrect.
13) D
- The site should not be massaged after
injection because massaging could cause
staining of the skin. Proper technique for
administering iron by the IM route includes
changing the needle after drawing up the
medication and before giving it. An air lock
and Z-track technique both should be used.
The medication should be given in the upper
outer quadrant of the buttock, not in an
exposed area such as the arms or thighs.
14) A
- Range-of-motion exercises are beneficial in
stretching muscles, which may diminish
spasticity. Removing potentially harmful
objects is a good safety measure. Use of
muscle relaxants also is indicated if the
spasms cause discomfort to the client or pose
a risk to the clients safety. Use of limb
restraints will not alleviate spasticity and
could harm the client.
15) A
- In the use of a CPM machine, the leg should
be kept in a neutral position and not rotated
either internally or externally. The knee should
be positioned at the hinge joint of the
machine. The nurse should monitor for
Option
29) D
Case
management
represents
an
interdisciplinary health care delivery system
to promote appropriate use of hospital
personnel and material resources to maximize
hospital revenues while providing for optimal
client care. It manages client care by
managing the client care environment.
30) C
- Variances are actual deviations or detours
from the critical paths. Variances can be either
positive or negative, or avoidable or
unavoidable and can be caused by a variety of
things. Positive variance occurs when the
client achieves maximum benefit and is
discharged earlier than anticipated. Negative
variance occurs when untoward events
prevent a timely discharge. Variance analysis
occurs continually in order to anticipate and
recognize negative variance early so that
appropriate action can be taken. Option B is
the only option that identifies the need for
further action.
31) D
- The family or a legal guardian can make
treatment decisions for the client who is
unable to do so. Once the decision is made,
the physician writes the order. Generally, the
family makes decisions in collaboration with
physicians, other health care workers, and
other trusted advisors. Although a written
order by the physician is necessary, the nurse
first checks for documentation of the family's
request. Unless special circumstances exist, a
court order is not necessary. Although some
health care agencies may require reviewing
such requests via the Ethics Committee, this is
not the nurse's first action.
32) A
- The proposed project is research and
includes human subjects. Although options B,
C, and D need to be considered, they are all
secondary to the overriding principle of the
37) A
41) C
38) D
- A nurse must be able to function at a level
that does not affect the ability to provide safe,
quality care. The highest priority is to
determine how the illness affects the nurse's
ability to practice. The other options will be
addressed if an investigation is carried out.
39) C
- When beginning the change process, the
nurse should identify and define the problem
that needs improvement or correction. This
important first step can prevent many future
problems, because, if the problem is not
correctly identified, a plan for change may be
aimed at the wrong problem. This is followed
by goal setting, prioritizing, and identifying
potential
solutions
and
strategies
to
implement the change.
40) B
- Tonic-clonic seizures cause tightening of all
body muscles followed by tremors. Obstructed
airway and increased oral secretions are the
major complications during and following a
seizure. Suction is helpful to prevent choking
and cyanosis. Options A and C are incorrect
because inserting an endotracheal tube or a
tracheostomy is not done. It is not necessary
to have an emergency cart (which contains a
laryngoscope) at the bedside, but a cart
should be available in the treatment room or
on the nursing unit.
42)D
- Chlamydia is a sexually transmitted disease.
Caregivers cannot acquire the disease during
administration
of
care,
and
standard
precautions are the only measure that needs
to be used.
43) C
- Proper care of an indwelling urinary catheter
is especially important to prevent prolonged
infection or reinfection in the client with
cystitis. The perineal area is cleansed
thoroughly using mild soap and water at least
twice a day and following a bowel movement.
The drainage bag is kept below the level of
the bladder to prevent urine from being
trapped in the bladder, and, for the same
reason, the drainage tubing is not placed or
looped under the client's leg. The tubing must
drain freely at all times.
44) D
- A client with acute glomerulonephritis
commonly experiences fluid volume excess
and fatigue. Interventions include fluid
restriction as well as monitoring weight and
intake and output. The client may be placed
on bed rest or at least encouraged to rest,
because a direct correlation exists between
proteinuria, hematuria, edema, and increased
activity levels. The diet is high in calories but
low in protein. It is unnecessary to monitor the
temperature as frequently as every 2 hours.
45) D
investigation. Options
accurate interventions.
A,
B,
and
are
49) D
- Nurses are encouraged not to accept verbal
orders from the physician because of the risks
of error. The only exception to this may be in
an emergency situation, and then the nurse
must follow agency policy and procedure.
Although the client will be informed of the
change in the treatment plan, this is not the
appropriate action at this time. The physician
needs to write the new order. It is
inappropriate to ask another individual other
than the physician to write the order.
50) C
- Nurse Practice Acts require reporting the
suspicion of impaired nurses. The Board of
Nursing has jurisdiction over the practice of
nursing and may develop plans for treatment
and supervision. This suspicion needs to be
reported to the nursing supervisor, who will
then report to the Board of Nursing.
Confronting the colleague may cause conflict.
Asking the colleague to go to the nurses'
lounge to sleep for awhile does not safeguard
clients.
51) A
- While on a cooling blanket, the child should
be covered lightly to maintain privacy and
reduce shivering. Options B, C, and D are
important interventions to prevent shivering,
frostbite, and skin breakdown.
52) A
- Secondary prevention focuses on the early
diagnosis and prompt treatment of disease.
Tertiary prevention is represented by
rehabilitation services. Options B, C, and D
identify screening procedures. Option A
identifies a rehabilitative service.
53) B
- When the nurse asks a "why" question of the
client, the nurse is requesting an explanation
54) D
- When communicating with a hearingimpaired client, the nurse should speak in a
normal tone to the client and should not
shout. The nurse should talk directly to the
client while facing the client, and he or she
should speak clearly. If the client does not
seem to understand what is being said, the
nurse should express the statement
differently. Moving closer to the client and
toward the better ear may facilitate
communication, but the nurse needs to avoid
talking directly into the impaired ear.
55) A
- After tonsillectomy, suction equipment
should be available, but suctioning is not
performed unless there is an airway
obstruction. Clear, cool liquids are
encouraged. Milk and milk products are
avoided initially because they coat the throat;
this causes the child to clear the throat,
thereby increasing the risk of bleeding. Option
C is an important intervention after any type
of surgery.
56) C
- A trapeze is essential to allow the client to
lift straight up while being moved so that the
58) D
- The skin is cleansed with soap and water
(not Betadine), denatured with alcohol, and
allowed to air-dry before electrodes are
applied. The other three options are correct.
59) A
- A quiet, restful environment is provided as
part of seizure precautions. This includes
undisturbed times for sleep, while using a
nightlight for safety. The client should be
accompanied during activities such as bathing
and walking, so that assistance is readily
available and injury is minimized if a seizure
begins. The bed is maintained in low position
for safety.
60) B
- According to category-specific (respiratory)
isolation precautions, a client with TB requires
a private room. The room needs to be wellventilated and should have at least six
exchanges of fresh air per hour and should be
ventilated to the outside if possible. Therefore,
option 2 is the only correct option.