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,A nurse is searching electronic databases for clinical research about behavioral indicators of pain
in an infant. Which of the following online sources should the nurse select to research this
infant care issue?
1. Cumulative Index to Nursing and Allied Health Literature (CINAHL)
2. The Nursing Minimum Data Set
,3. The Omaha System
4. The Nursing Interventions Classification (NIC)
Rat: The nurse should select the Cumulative Index to Nursing and Allied Health Literature
(CINAHL) to locate clinical research about health-related client care issues. CINAHL is a
cumulative index that the nurse can search electronically to locate reliable data related to the
specific topic being researched.
A nurse is caring for a client who has dysphagia following a stroke. Which of the following
actions should the nurse take to facilitate safe swallowing and decrease the risk of aspiration?
1. Delay the client's meal-time if he is fatigued.
2. Instruct the client to tilt his head to the side when swallowing.
3. Assist the client with fluid intake by inserting it into the client's mouth with a syringe.
4. Encourage the client to focus on a television program during meal time. Delay the client's
meal-time if he is fatigued.
Rat: To facilitate safe swallowing and decrease the risk of aspiration, the nurse should
encourage the client to rest prior to meal-time. If the client is fatigued, the nurse should delay
the meal-time and give the client time to rest.
A nurse in a long-term care facility is performing a fall risk assessment on a newly admitted
client using the Timed Up and Go (TUG) test. The client reports using a tripod cane for
ambulation. Which of the following actions should the nurse take when using this test?
1. Observe the client ambulating a distance of 3 m (10 feet) during the TUG test.
2. Instruct the client to perform the TUG test without the use of the cane.
3. Assist the client to stand up from the chair when starting the TUG test.
4. Advise the client to use the arms of the chair to stand when starting the TUG test.
Rat: The nurse should mark a spot 3 m (10 feet) away from the client's sitting location. The
nurse should instruct the client to stand, ambulate to the marked spot, turn, ambulate back to
, the chair, and sit down. The nurse should observe the client's ability to perform the test and use
a stopwatch to time the client. The nurse should identify that the client is at increased risk of
falls if it takes longer than 14 seconds to complete the test.
A nurse in an emergency is caring for an infant who requires emergency surgery. The infant is
accompanied by his 16-year-old mother and his maternal grandfather. Which of the following
actions should the nurse take when assisting with informed consent?
1. Witness consent obtained from the infant's mother.
2. Inform the family that informed consent is not needed due to emergency surgery.
3. Notify the maternal grandfather that he is required to give informed consent.
4. Request that a court-appointed representative provide informed consent.
Rat: The nurse should assist in obtaining informed consent from the infant's mother by
witnessing her signature. Statutory guidelines indicate that a minor, even if unemancipated, can
provide consent for her infant. Unemancipated minors can also legally provide informed
consent for STI treatment, substance use treatment, and care related to pregnancy in some
states.
A nurse is planning care to prevent a catheter-related blood stream infection for a client who is
receiving IV fluid therapy. Which of the following interventions should the nurse include in the
plan?
1. Change bags of IV solution every 72 hr.
2. Perform hand hygiene before touching the IV tubing.
3. Use hydrogen peroxide to cleanse the IV insertion site.
4. Assess the IV insertion site every 12 hr for redness.
Rat: The nurse should perform thorough hand hygiene before touching any part of the infusion
system or the client to reduce the risk of catheter-related blood stream infections.