10. Answer B.

Calling the supervisor is a secondary measure after confronting the nurse and relieving the nurse of her duties. You cannot always assume the supervisor will be immediately available, and client safety should be addressed first. When another nurse is unable to perform her nursing duties due to substance abuse, she should not be allowed to continue them, as client safety is a primary concern. Ignoring the situation is against the professional code of conduct for nurses. Angelina needs to be relieved of her duties. She probably would not benefit from a lecture in her condition. 11. Answer D. Skin care around a nasogastric tube is a routine task that is appropriate for UAPs. The other tasks would be appropriate for a PN or RN to do since they are advanced skills or require evaluation. 12. Answer B. Clients have a right to informed consent which includes information about medications, treatments, and diagnostic studies. 13. Answer B. Secrets are inappropriate in therapeutic relationships and are counterproductive to the therapeutic efforts of the interdisciplinary team. Secrets may be related to risk for harm to self or others. The nurse honors and helps clients to understand rights, limitations, and boundaries regarding confidentiality. 14 . Answer B. This client is the most stable with minimal risk of complications or instability. The nurse can utilize basic nursing skills to care for this client. 15. Answer C. Obtain more details of the clients claim of abuse. The advocacy role of the professional nurse as well as the legal duty of the reasonable prudent nurse requires the investigation of claims of abuse or violation of rights. The nurse is legally accountable for actions delegated to others. The application of the nursing process requires that the nurse gather more information, further assessment, before documentation or the reporting of the complaint. 16. Answer D. Supervise a nursing assistant for skin care. The nursing assistant can inspect the skin while giving hygiene care, but the nurse should supervise skin care since assessment and analysis are needed. 17. Answer B. The nurse must maintain the clients right of confidentiality. Since he is not the clients physician and does not have a medical need to see her chart, he should not be allowed to read the chart without written permission from the client, who is above the age of majority. Since he is not the clients physician and does not have a medical need to see her chart, he should not be allowed to read the chart without written permission from the client, who is above the age of majority. It is not the attending surgeon who can give permission for him to review the chart, it is the client.The client must give written permission for unauthorized persons to review her chart. This client had surgery today and is probably not alert enough to give legal permission, which must be written. 18. Answer A. Culture is an important variable in the assessment of individuals. To work effectively with clients, the nurse must be aware of a cultural distinctive qualities 19. Answer B. It cannot be legally assumed that the client consents to a procedure for which he has not given consent. This is not legally defensible. All invasive procedures require informed consent. The surgery is prescheduled and described as exploratory and therefore is not an emergency. If the client is an adult and has not been declared incompetent the client must sign the form. This client should not have surgery performed without written consent. The nurse must notify the physician immediately. The client has been premedicated for surgery and is not alert. He cannot give legal consent when under the influence of mind-altering drugs. The client is an adult and there is no evidence that he has been declared incompetent to make his own decisions. The surgery is exploratory. There is no indication it is for an immediately life-threatening condition. It is not appropriate to ask the next of kin to sign his consent form. 20. Answer D. The clients spiritual needs must be met within the framework of his personal belief systems, even if those beliefs differ from those of the nursing staff. The clients spiritual

needs must be met within the framework of his personal belief systems, even if those beliefs differ from those of the nursing staff. The clients spiritual needs must be met within the framework of his personal belief systems, even if those beliefs differ from those of the nursing staff. The clients spiritual needs must be met within the framework of his personal belief systems, even if those beliefs differ from those of the nursing staff. 21. Answer B. TPN solutions should be changed every 24 hours in order to prevent bacterial overgrowth due to hypertonicity of the solution. Option 1 is incorrect; medication therapy can continue during TPN therapy. Option 3 is incorrect; flushing is not required because the initiation of TPN does not require a client to remain on bed rest during therapy. However, other clinical conditions of the client may affect mobility issues and warrant the clients being on bed rest. 22. Answer B. There is potential for a lowered pain tolerance to exist with diminished adaptative capacity. 23. Answer C. Although all of the options above are correct, the first and most important piece of information in this clients pain assessment is what the client is telling you about the pain the clients report. 24. Answer A. Weighing significantly less than ideal body weight increases the number and surface area of bony prominences which are susceptible to pressure ulcers. Thus, malnutrition is a major risk factor for decubiti, due in part to poor hydration and inadequate protein intake. 25. Answer A. When a person with weakness on one side uses a cane, there should always be two points of contact with the floor. When Ms. Kelly. moves the cane forward, she has both feet on the floor, providing stability. As she moves the weak leg, the cane and the strong leg provide support. Finally, the cane, which is even with the weak leg, provides stability while she moves the strong leg. She should not hold the cane with her weak arm. The use of the cane requires arm strength to ensure that the cane provides adequate stability when standing on the weak leg. The cane should be held in the left hand, the hand opposite the affected leg. If Ms. Kelly. moved the cane and her strong foot at the same time, she would be left standing on her weak leg at one point. This would be unstable at best; at worse, impossible 26. Answer A. Stiffness of a joint may indicate the beginning of a contracture and/or early muscle atrophy. Soreness of the gums is not related to immobility. Short-term memory loss is not related to immobility. Decreased appetite is unlikely to be related to immobility. 27. Answer D. Food and fluids are necessary. However, Mr. Wilsons hyperactivity does not allow him to sit quietly to eat. Finger foods "on the run will provide needed nourishment. When hyperactivity decreases, then approach Mr. Wilsons. regarding hygiene and grooming needs. Medications will be ordered. However, a thorough evaluation must be done first. Mr. Wilson has been assaultive with the landlord and it is reasonable to expect that he may be with peers and staff. His mental illness produces a hyperactive state and poor judgment and impulse control. External controls such as limiting of unit privileges will assist in feelings of security and safety. 28. . Answer C. This is an open-ended question which is nonjudgemental and allows for further discussion. The topic is also nonthreatening yet will give the nurse insight into the clients view of events leading up to admission. It is the only option that is client centered. The other options focus on the pills. 29. Answer A. Giving broad opening statements and making observations are examples of therapeutic communication. The other options are too specific or focused to be therapeutic. 30. D.The nurse is using the technique of exploring because shes willing to delve further into the clients concern. She isnt presenting reality or making observations or simply restating. The nurse is encouraging the client to explore his feelings. 31. D. Among Jehovahs Witnesses, surgery is not prohibited, but the administration of blood and blood products is forbidden. Faith healing is forbidden in this religious group. Administration of medication is an acceptable practice, except if the medication is derived from blood products. 32. A. Coping mechanisms are behavior used to decrease stress and anxiety. In response to

a death, ineffective coping is manifested by an extremem behavior that in some cases may be harmful to the individual physically or psychologically. 33. C.Ethnocentrism is a tendency to view ones own way of life as the most desirable, acceptable, or best and to act in a superior manner toward another culture. Cultural imposition is the tendency to impose ones own beliefs, values, and patterns of behavior on individuals from another culture. 34. Answer A.The nature of the accident, the childs pain, and the unfamiliar facility environment support a nursing diagnosis of Anxiety. A diagnosis of Hypothermia related to head injury isnt appropriate because the child is alert and oriented, indicating that a head injury, if present, isnt severe and is unlikely to cause hypothermia. Unlike the homecoming of a new baby or riding a bicycle for the first time, a car accident isnt a maturational crisis. 35. Answer C.Open-ended questions allow the teen to share information and feelings. Asking personal questions not related to the situation jeopardizes the trust that must be established because the adolescent may feel as though hes being probed with unnecessary questions. Writing everything down during the interview can be a distraction and wont allow the nurse to observe how the adolescent behaves. Discussing the nurses thoughts and feelings may bias the assessment and is inappropriate when interviewing any client. 36. Answer B. The client and her husband are working together for a common goal. Hes offering support, and theyre sharing the experience of childbirth, making Readiness for enhanced family coping related to participation in pregnancy and delivery an appropriate nursing diagnosis. The other options suggest that the couple have a problem that isnt indicated in the question. 37. Answer C. Spiritual distress related to experienced loss most accurately describes theproblem; therefore, nursing care should be based on this diagnosis. Families may not have altered family process or suffer from ineffective coping. Although the family may feel powerless, this isnt the most accurate diagnosis. 38. Answer B. When talking with adolescents, its best to get their viewpoints and thoughts first. Doing so promotes therapeutic communication. Asking whether the mother knows or about the babys father focuses the attention away from the adolescent. Making a statement about her being too young to be pregnant is a value judgment and inappropriate. 39. Answer D.By age 9 or 10, most children have an adult concept of death. Caregivers should discuss death with them in terms consistent with their developmental stage. School-age children respond well to concrete explanations about death and dying. Preschoolers, not schoolage children, typically view death as temporary and reversible. School-age children may fantasize about the unknown aspects of death; these fantasies may increase their anxiety. Although a child may fear death, accurate information about death can ease anxiety. 40. Answer A. Shutting off the beds electricity should be the initial step. The nurse should not touch the client until the bed is checked for faulty grounding. An electrician should assess the equipment. Oxygen should be discontinued until the equipment is cleared. 41. Answer A.Asking about the significance of the amulet in a nonthreatening manner is the first step in conveying respect for the clients religion/culture. Immediately passing judgment and instructing against the use of the necklace rejects the individuality of the client and their ethnic diversity. Asking why as the initial response does not convey acceptance and might impair communication and incite client defensiveness.

42. Answer C.The nurses first response is to assess that the person is actually choking and then rapidly proceed to intervene using the Heimlich. Back blows are not indicated in adults with obstructed airways and might actually create a complete obstruction by dislodging a foreign body that was only partially blocking the airway. 43. Answer D. Bronchi normally expand and lengthen during inspiration and shorten during expiration. Asthma causes spasm of the smooth muscles in the bronchi and bronchioles, resulting in an even tighter airway on exhalation and prolonged exhalation. Inspirations increase in rate in an effort to relieve hypoxia. At the beginning of the attack, the cough is nonproductive and results from bronchial edema. Then the mucus becomes profuse and rattly, with a cough producing frothy, clear sputum. Gas trapping is the central feature of asthma. It is caused by allowing more air to enter alveoli than can escape from them through the narrowed airways. Gas trapping also causes an increased depth and rate of respirations. The wheeze starts during the expiratory phase because of the extreme narrowing of the bronchus on exhalation. As obstruction increases, wheezes become more high pitched and continuous. 44. Answer D. Weakness and fatigue are common in congestive heart failure. Dyspnea is common in congestive heart failure. Tachycardia is common in congestive heart failure. Oliguria is not usually seen in congestive heart failure. Diuretics are a mainstay treatment in congestive heart failure. The nurse would expect urine output. Weakness, fatigue, dyspnea, and tachycardia are clinical manifestations of congestive heart failure. 45. Answer A. Until the lung incision seals, there will be air leaking from it, which will be collected and drained by the chest tube; option b would be correct if the air leak had stopped and later reappeared; the suction control chamber is separate from the water seal chamber in a typical chest drainage device. 46. Answer C. Once CPR is started, it is to be continued using the approved technique until such time as a provider pronounces the client dead or the clientbecomes stable. American Heart Association studies have shown that the 2 person technique is most effective in sustaining the client. It is not appropriate to relieve the first nurse or to leave the room for equipment. The clients advanced directives should have been filed on admission and choices known prior to starting CPR. 47. Answer D. In a client with hypertension, weakness in the extremities is a sign of cerebral involvement with the potential for cerebral infarction or stroke. Cerebral infarctions account for about 80% of the strokes in clients with hypertension. The remaining 3 choices indicate mild fluid overload and are not medical emergencies. 48. Answer C. Thestages of grief includes: Denial, Anger, Bargaining, Depression and Acceptance. The stage of denial is when the patient is unable to acknowledge the existence of the diagnosis. In this stage, the patient would seek more opinions from other doctors because she cannot accept the fact of her diagnosis. Options A and D are an example of the stage anger, in which she asks a lot of questions regarding the reason of her sickness. Option D shows the acceptance of the patient. 49. Answer A. Touching to provide support is a form of therapeutic communication. The use of touch reinforces caring feelings. Option B is non therapeutic. Option C is incorrect because the nurse is not in the position to tell the patients family of her prognosis. It is only done by the patient or when the patient requests the nurse to do so. Option D may correct but is not the best answer indicated in this situation. 50. Answer C. Mrs. Estrada is undergoing the process of depression which is a normal in coping with the grief process. In order to be therapeutic for this patient, the nurse should accept this behavioural adaptation of the patient, since it is just normal. Options A, B and D are non therapeutic because this conditions do not allow the normal process of grieving.