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an initial assessment of an infant, a home health nurse notices that the infantis wearing a soiled piece of braided yarn around the neck. Which action by the nurse is most
Leave the yarn in place, but wash it with a
cloth and mild soap.
Ask about its
significance and suggest that it be placed more safely on the body.
Explain that the
yarn offers no benefit and ask the parents to remove it.
D. Remove the yarn
because it is soiled and could lead to strangulation.
- Ask about its
- significance and suggest that it be placed more safely on the body.
A Native American client who has a low grade fever tells the nurse on the reservation that he will only use a sweat lodge to treat his illness. Which approach by the nurse would be the most therapeutic?
Explain to the client that the sweat lodge is
likely to worsen the fever.
physician and ask him or her to talk to the medicine man of the tribe.
monitor the client’s status.
D. Ask the client’s family to convince him not to
use the sweat lodge
- C. Continue
- to monitor the client’s status
A male nurse
needs to check the vital signs and oxygen saturation level of a female client
from a different culture. As the nurse
approaches, the client moves to the other side of the bed and draws up the
blanket. What is the best nursing action
at this time?
Invite a family
member to be present and to assist with the oxygen saturation reading.
Ask a female
nurse to perform the procedures.
assessments without acknowledging her reaction.
the client, explain the procedure and ask for permission to continue.
- touching the client, explain the procedure and ask for permission to continue
A nurse is caring
for two clients who have had abdominal surgery.
One client is of Hispanic heritage, who writhes in pain and moans when
touched. The other is an Asian client,
who appears calm and rarely verbalizes pain or discomfort. The nurse appropriately draws which
Hispanic client is exaggerating his pain.
Asian client is
not experiencing pain.
Two clients have
different culturally influenced ways of coping with pain.
Hispanic client may be exhibiting drug-seeking
C. Two clients havedifferent culturally influenced ways of coping with pain.
A hospice nurse
in a small Appalachian community is caring for a client at home who is an
active member of the community church.
As death nears, the minister and several members of the congregation
come together in the home for a “death watch.”
Which action by the nurse is most therapeutic?
Ask the minister to have church members come
in scheduled time blocks to avoid overcrowding.
religious beliefs and allow family and minister unlimited access to the client.
Allow family and
three other visitors at a time to stay with the client, but keep everyone else
in the next room.
Explain that the
watch will not be a problem as long as it does not conflict with medical care.
B. Observe client’sreligious beliefs and allow family and minister unlimited access to the client.
nurse is providing postmortem care for a client. Which intervention would be
appropriate prior to allowing the family to visit? Select all that apply.
1. Prepare the body to look as clean and natural as possible.
2. Keep the sheet over the client's face until the family is comfortably seated
in the room.
3. Wear sterile gloves to pack the anal canal with gauze.
4. Remove the external tubes and drains.
5. Call the physician to verify the time of death before taking the body to the
90-year-old client expresses a wish to die at home after being told that an
esophageal stricture prevents swallowing. The client refuses a feeding tube.
The family fully supports this decision. What would be the most appropriate
resource for the nurse to call?
1. Hospice care
2. The rabbi
3. An attorney
4. the medical examiner's office
nurse anticipates that which client newly diagnosed with a terminal illness is
least likely to have difficulty facing his or her mortality?
1. A 71-year-old female whose grandson, sister, and best friend died over the
past 6 months.
2. A 59-year-old male who never married, is an only child, and whose parents
are both healthy.
3. A 70-year-old male who has planned his funeral and enjoys riding his
motorcycle at high speeds in rural areas.
4. A 68-year-old female who is an atheist.
mental health nurse is counseling a client who is grieving his father's death.
Based on Rando's process of bereavement, in what order would the mental health
nurse expect a client to make the following statements as he moves through the
bereavement process? Select all that apply.
1. "This is the second anniversary of my father's death."
2. "My father was an alcoholic, so every Christmas I make certain that local
AA groups have coffee and chocolates to help the members through the
3. "It was so much fun to rummage through the antique stores
4. "It's too difficult to be around his stepfamily, so I visit friends on
5. "The homestead has run down since his death. It was hard to drive past
and see the lack of care in his vegetable garden."
While talking to adult children of a dying male client, the nurse finds
them tearful, with ambivalent feelings toward the client. The client often
expresses beliefs of a wasted life. The children say that their father often
showed love but followed it with criticism, anger, and emotional abuse. The
nurse would suggest which intervention as most likely to be helpful at this
1. Listen to relaxation tapes before visiting each other. If negative feelings
arise, listen to the tapes together.
2. Have a nurse stay in the room when a family member visits the client
so the nurse can intervene with conflict resolution if problems arise.
3. Assure the client and children that what matters is the present and
the future, not the past. Encourage the children to spend more time with their
4. Videotape each adult child speaking of a time when their father
showed love, while the client tells of a special love for each child. Plan a
time for them to watch the tape together.
The nurse working with a terminally ill client wishes to support the
client’s decisions concerning end-of-life care. To do this appropriately, the
nurse should plan to do which of the following?
1. Be comfortable in assisting the client with euthanasia when
requested to do so.
2. Ask another nurse to provide care if the client has a belief system
that differs from own belief system.
3. Respect the client’s wishes about death to the extent possible by
4. Encourage the client to request a do-not-resuscitate order because
of terminal illness.
The nurse concludes that which behaviors indicate grief resolution in a
bereaved client whose husband died a year ago? Select all that apply.
1. Becoming future-oriented when discussing details of everyday life.
2. Considering the opinions of the deceased prior to making decisions
about everyday life.
3. Experiencing occasional waves of grief triggered by pictures or
4. Sharing stories of good times that the client and her husband shared
over the years.
5. Being unable to visit places that hold happy memories of times spent
with her husband.
A client is dying, is in great pain, and refuses anything for relief
that alters his sensorium. The nurse checks the psychosocial data part of the
medical record, expecting that which religion is likely to be practiced by the
client? Select all that apply.
The family of a client dying from heart failure is concerned about
making certain their mother is comfortable as she goes through the dying
process. Which statement indicates to the nurse that the family understands
that lack of fluid and nutrition can promote comfort as a client dies? Select
all that apply.
1. “There will be less nausea and vomiting, since gastrointestinal
secretions will be decreased.”
2. “Natural analgesia from the body’s endorphin production will help
with pain control.”
3. “A dry mouth will not be a problem, even after fluids are
4. “Coughing and mucus production will continue, even after the fluids
5. “Swelling and edema might decrease once we stop giving fluids.”
A newly hired nurse is beginning to work with dying clients in a
hospice unit. In which order does the nurse expect to move through the stages
of adaptation when working with this population? Place these stages in expected
order of occurrence.
1. Deep compassion.
2. Emotional survival.
5. Emotional arrival.
why role stress is more prevalent now
than ever before in nursing.
Increased role stress can be attributed to:
The nursing shortage and increased job
requirements that are often highly
uncertain, unexpected, and unpredictable.
socialization, rapid organizational
change, and accelerated technology.
role responsibilities and
obligations of nurses that are often vague,
ambiguous, and conflicting
which of Benner's (2001) Stages of
Nursing Expertise, has the nurse
experienced enough real situations to make
judgments about them?
Stage 1 Novice
Stage 2 Advanced Beginner
Stage 3 Competent Practitioner
professional nurse's perceived role comes into conflict with the role
performed, which of the following occurs?
B. transition or reality
C. Role expectation
- Transition or reality
A new RN who is recently off
orientation is preparing for a busy day on a
medical nursing unit. Prioritize the
tasks and place the options in order. All options must be used.
Irrigate a NG tube on a client who had a colectomy the previous day
Flush a poorly draining urinary catheter on an older adult client.
Check vital signs on a 30 year old client with a BP of 114/68 and a HR of 94
Change a dressing on a client with an infected diabetic foot ulcer.
begin a unit of packed RBC’s for a client with a Hematocrit of 23.2%
The nurse preceptor observes the new RN administering
medications. The receptor concludes there is a risk for
medication error when the new RN takes which action?
Answers a physicians page while passing medications
uses military time to document
asks for help with a dosage calculation
does not give a medication that the client questions.
A client with cancer has decided to
treatment. Although the nurse would like the client to continue treatment, the
nurse recognizes the client is competent and supports the client’s decision
using which ethical principle?
The health care provider orders a
medicine in a dose that is
considered toxic. The nurse administers the medication to the client, who later
suffers a cardiac arrest and dies. What consequence can the nurse expect from
this situation? Select all that apply.
health care provider can be charged with negligence, being the person who
ordered the drugs.
the employing agency, only the hospital can
be charged with negligence.
nurse and the physician may be terminated
from employment to prevent a charge of negligence to the hospital.
will not be charged, as this event
could happen to any reasonable person.
nurse can be charged for negligence for administering the toxic dose.
A nurse and a teacher are discussing
legal issues related to
practice of their professions. The teacher asks what the functions are of the
Nurse Practice Act (NPA) in the state. The nurse would include which thoughts
in the response? Select all that apply.
schools of nursing
ethical standards of behavior
3. Protect the public
4. Define the scope of practice
liability insurance rates
A staff nurse concerned about
confidentiality would take which action while carrying out assign duties?
the records of clients not assigned to the
nurse to become more familiar with disease process.
information about a client with nurses
from the unit to which the client may eventually be transferred.
the client’s family to review the medical
record to obtain answers to their questions.
4. Share information about the client with
those involved in planning nursing care.
The nurse working in an acute care
environment would utilize
which strategies to reduce the risk of malpractice litigation? Select all that
any errors with the client and family in
incident reports on file.
3. Maintain expertise in practice.
opinions to clients when the situation
5. Reports unsafe staffing levels to
Which intervention would the
nurse use to implement Imogene King’s theory of goal attainment?
A. Interactions with the
B. Determining how the client
adapts to stress
C. Purposeful transactions
D. Listing self-care deficits
The client is being taught to
self-administer insulin. Learning goals most likely will be attained when they
are established by the.
A. Nurse and client because both
need to be responsible for teaching.
B. Physician and client because the
physician is the manager of care and the client is the main participant.
C. Client because the client is best able to identify his or her own needs and
how to meet those needs.
D. Client, nurse, and physician so the client can participate in planning care
with the nurse and physician.
Which of the following is not a
concept related to personal systems in Imogene King’s theory?
C. Body image
Which nursing theory states that
'nursing is the interpersonal process of action, reaction, interaction and
A. Roy's adaptation model
B. Self-care deficit theory
C. Imogene King's theory
D. Roger's unitary human beings
Leininger's theory of cultural care diversity
and universality specifically addresses:
A. Caring for clients from unique cultures
B. Understanding the humanistic aspects of life
C. Identifying variables affecting a client's response to a stressor
D. Caring for clients who cannot adapt to internal and external environmental
A nurse is preparing a client who is scheduled
to have a right modified radical mastectomy. Which of the following statements
accurately describes the nurse’s role in the informed consent process?
the client’s questions about information she did not understand.
that the client received the information and understands the procedure.
the pain that the client could encounter after surgery.
information regarding the client’s alternative options for treatment.
The health care provider orders a medication in
a dose that is considered toxic. The nurse administers the medication to the
client, who later suffers a cardiac arrest and dies. What consequence can the
nurse expect from this situation? Select all that apply.
healthcare provider can be charged with negligence, being the person who
ordered the dose.
the employing agency, only the hospital can be charged with negligence.
nurse and physician may be terminated from employment to prevent a charge of
negligence to the hospital.
will not be charged, as this event could happen to any reasonable person.
nurse can be charged with negligence for administering the toxic dose.
The nurse working in an acute care environment
would utilize which strategies to reduce the risk of malpractice litigation?
Select all that apply.
any errors with the client and family in detail.
incident reports on file.
expertise in practice.
opinions to clients when the situation warrants.
unsafe staffing levels to supervisor
A nurse and teach are discussing legal issues
related to the practice of their profession. The teacher asks what the
functions are of the Nurse Practice Act (NPA) in that state. The nurse would
include which thoughts in a response? Select all that apply.
schools of nursing.
ethical standards of behavior.
the scope of nursing practice.
the liability insurance rates.
A staff nurse concerned about maintaining client
confidentiality would take which action while carrying out assigned duties?
the records of clients not assigned to the nurse to become more familiar with
information about a client with nurses from the unit to which the client may
eventually be transferred.
the client’s family to review the medical record to obtain answers to their
information about the client with those involved in planning nursing care.
A nursing graduate who graduated 6 months ago is
preparing to retake the NCLEX after failing in his first attempt. What must he provide to the Board?
application and fee
letter of recommendation
An official transcript
of the above
None of the above
first-time applicant for licensure in Alabama may request a nonrenewable
temporary permit to practice nursing. This temporary permit shall expire under
which of the following circumstances? (Select all that apply)
If the applicant fails the licensing
Once a license is issued
The applicant is denied licensure
d. The applicant is difficult to work
content is acceptable as continuing education for license renewal? (Select all
Specialty areas of nursing practice
Nursing research, theory, and practice
Clinical technology, procedures, and
recent nursing graduate is working on a medical-surgical unit under a temporary
permit until her license is issued.
Which of the following requires intervention by the unit manager?
a. The Nursing Graduate is providing AM care to a
b. The Nursing Graduate is providing
nursing care to a COPD patient under the supervision of one of the staff
The Nursing Graduate has been assigned
Charge duties because the Charge Nurse had to leave the unit for personal
d. None of the above
experienced RN has just had his license revoked. What must he do to reinstate
his license? (Select all that apply)
Complete and submit an Application to
Reinstate a Nursing License
Wait a minimum of 1 year from the date
of revocation prior to applying for reinstatement
Present substantial evidence that his
license should be reinstated.
d. Schedule a meeting with a member of
the Board of Nursing to expedite the process.
1. What are the sciences underpinning nursing
A Nursing science, information science, and computer
science, computer science, and business
science, information science, and allied health sciences
science, medical science, and computer science
1. What are the tools and methods used
in computer and information sciences?
technologies, structures, management, and communication
Communication technologies, management structures, and networks
C Information technology, structures, management, and
technology, management, communication, and networks
1. The best description of telehealth is
which of the following?
is part of communication and information system technology.
seeks to deliver quality care to patients in remote places.
assists nurses to deliver care to patients in underserved areas
D Telehealth removes time and distance barriers from
the delivery of health care services or related health care activities.
1. The Health Insurance Portability and
Accountability Act (HIPAA) requires improved efficiency of health care
delivery. Which of the following is a way to improve efficiency?
Structuring nursing data and information
ergonomics in computer design
C Standardizing electronic data interchange
access to patient records
1. Which type of automated system is
part of the patient safety strategy?
automated history and physical record
medication administration record
C Physician order entry system