A nurse assesses drainage on a surgical dressing and documents the findings. Which
documentation is most informative?
" "Moderate amount of drainage."
" "No change in drainage since yesterday."
" "A 10-mm-diameter area of drainage at 1900 hours."
" "Drainage is doubled in size since last dressing change."
Rationale
A 10-mm-diameter area of drainage at 1900 hours is objective data and gives specific details
regarding the assessment and a timeframe. By providing size, it establishes parameters to
compare with previous assessments and to further evaluate the drainage. "Moderate amount of
drainage," "No change in drainage since yesterday," and "Drainage is doubled in size since last
dressing change" are not specific, objective, or measurable.
When planning discharge teaching for a young adult, the nurse should include the potential
health problems common in this age group. What should the nurse include in this teaching
plan?
Kidney dysfunction
Cardiovascular diseases
Eye problems, such as glaucoma
Accidents, including their prevention
Rationale
Accidents are common during young adulthood because of immature judgment and impulsivity
associated with this stage of development. Kidney dysfunction is not a problem specific to any
one stage of growth. Cardiovascular disease is a common health problem in middle adulthood.
Glaucoma is a common health problem in older adults.
A client has Clostridium difficile. The nurse is providing discharge instructions related to
decreasing the risk of transmission to family members. What would be appropriate to include
in the client's teaching?
Increase fluids.
, Increase fiber in the diet.
Wash hands with soap and water.
Wash hands with an alcohol-based hand sanitizer.
Rationale
Alcohol does not kill C. difficile spores. Use of soap and water is more efficacious than alcohol-
based hand rubs. Increased fluids and increased fiber do not decrease the risk of transmission
of C. difficile.
A client who is in the advanced stages of illness asks the nurse to contact pastoral services for
support. According to the Macmillan model, what is the best nursing intervention in this
situation?
Immediately involve pastoral services while caring for the client.
Involve the family member in the client’s care instead of pastoral support.
Listen to the client’s request for support then carry on with the clinical work.
Falsely promise that pastoral services has been contacted and plan to see the client.
Rationale
The Macmillan nurse usually has the knowledge of advanced practice and possesses specialty
training. This practice enhances the nurse to gain an in-depth knowledge about spiritual, social,
and psychologic needs and the pathophysiology of clients living with advanced diseases.
Therefore, the nurse involves pastoral services while caring for the client. Involving a family
member may decrease anxiety in the client but may not fulfill the wishes of the client. Just
listening to the client’s request without implementation or giving false promises can cause loss
of trust in the client.
During follow-up visits, the client’s child reports to the nurse, "I tell my parent every day
about what may happen if medications aren’t taken as prescribed. Despite that, my parent
does not take the medication regularly and is depressed." What can be inferred about the
client’s motivational level?
Not motivated
Intrinsically motivated
, Extrinsically motivated with self-determination
Extrinsically motivated without self-determination
Rationale
If the client is not motivated, then the client may not attempt to eradicate the illness and feel
depressed because of the illness. If the client is intrinsically motivated, then the client shows
more interest in taking their medications on their own rather than because of pressure from
other individuals. The client is motivated extrinsically with or without self-determination when
they may take medication regularly when reminded to do so or when pressured by others.
A nurse applies a cold pack to treat an acute musculoskeletal injury. Cold therapy decreases
pain by doing what?
Promoting analgesia and circulation
Numbing the nerves and dilating the blood vessels
Promoting circulation and reducing muscle spasms
Causing local vasoconstriction, preventing edema and muscle spasms
Rationale
Cold causes the blood vessels to constrict, which reduces the leakage of fluid into the tissues
and prevents swelling and therefore muscle spasms. Cold does promote analgesia but not
circulation. It may numb nerves but does not dilate blood vessels. Cold therapy also may numb
the nerves and surrounding tissues, thus reducing pain.
Which skill in critical thinking requires to be orderly in data collection?
Analysis
Inference
Evaluation
Interpretation
Rationale
, Interpretation is involved in the orderly collection of data. When information about a client is
collected with an open mind, then the skill called analysis is being used. When the data
collected about the client helps in solving an existing problem, then the skill called inference is
being used. Evaluation is used when the results of nursing actions are determined.
A client has been diagnosed with type 1 diabetes mellitus. When providing instructions on
sharps disposal, the nurse should instruct the client to place the syringes in what?
Bubble wrap/packaging wrap
A garbage bag in the trash can
A cardboard box with a firmly secured lid
A plastic liquid detergent bottle with a screw-top lid
Rationale
Most states (provinces) allow patients to place used needles/pen needles and lancets ( sharps)
in a household container such as a laundry detergent bottle, bleach bottle, or other opaque
sturdy plastic container with a screw-top lid. Some states (provinces) do have disposal drop-off
locations. Bubble wrap, a garbage bag, and cardboard put those who are handling the
containers at risk for needle sticks.
A nurse understands that the primary purpose for a client to undergo reconstructive surgery is
to do what?
Restore function and/or appearance
Replace an organ or tissue
Relieve or reduce symptoms
Remove or excise an organ or tissue
Rationale
The main function of reconstructive surgery is to restore function and/or appearance. This type
of surgery includes plastic surgery, a term that is interchangeable with reconstructive surgery. In
reconstructive surgery, repairs are made and malformations corrected that are congenital, a
result of disease processes, or from traumatic injury. Replacement of a tissue or organ is known
documentation is most informative?
" "Moderate amount of drainage."
" "No change in drainage since yesterday."
" "A 10-mm-diameter area of drainage at 1900 hours."
" "Drainage is doubled in size since last dressing change."
Rationale
A 10-mm-diameter area of drainage at 1900 hours is objective data and gives specific details
regarding the assessment and a timeframe. By providing size, it establishes parameters to
compare with previous assessments and to further evaluate the drainage. "Moderate amount of
drainage," "No change in drainage since yesterday," and "Drainage is doubled in size since last
dressing change" are not specific, objective, or measurable.
When planning discharge teaching for a young adult, the nurse should include the potential
health problems common in this age group. What should the nurse include in this teaching
plan?
Kidney dysfunction
Cardiovascular diseases
Eye problems, such as glaucoma
Accidents, including their prevention
Rationale
Accidents are common during young adulthood because of immature judgment and impulsivity
associated with this stage of development. Kidney dysfunction is not a problem specific to any
one stage of growth. Cardiovascular disease is a common health problem in middle adulthood.
Glaucoma is a common health problem in older adults.
A client has Clostridium difficile. The nurse is providing discharge instructions related to
decreasing the risk of transmission to family members. What would be appropriate to include
in the client's teaching?
Increase fluids.
, Increase fiber in the diet.
Wash hands with soap and water.
Wash hands with an alcohol-based hand sanitizer.
Rationale
Alcohol does not kill C. difficile spores. Use of soap and water is more efficacious than alcohol-
based hand rubs. Increased fluids and increased fiber do not decrease the risk of transmission
of C. difficile.
A client who is in the advanced stages of illness asks the nurse to contact pastoral services for
support. According to the Macmillan model, what is the best nursing intervention in this
situation?
Immediately involve pastoral services while caring for the client.
Involve the family member in the client’s care instead of pastoral support.
Listen to the client’s request for support then carry on with the clinical work.
Falsely promise that pastoral services has been contacted and plan to see the client.
Rationale
The Macmillan nurse usually has the knowledge of advanced practice and possesses specialty
training. This practice enhances the nurse to gain an in-depth knowledge about spiritual, social,
and psychologic needs and the pathophysiology of clients living with advanced diseases.
Therefore, the nurse involves pastoral services while caring for the client. Involving a family
member may decrease anxiety in the client but may not fulfill the wishes of the client. Just
listening to the client’s request without implementation or giving false promises can cause loss
of trust in the client.
During follow-up visits, the client’s child reports to the nurse, "I tell my parent every day
about what may happen if medications aren’t taken as prescribed. Despite that, my parent
does not take the medication regularly and is depressed." What can be inferred about the
client’s motivational level?
Not motivated
Intrinsically motivated
, Extrinsically motivated with self-determination
Extrinsically motivated without self-determination
Rationale
If the client is not motivated, then the client may not attempt to eradicate the illness and feel
depressed because of the illness. If the client is intrinsically motivated, then the client shows
more interest in taking their medications on their own rather than because of pressure from
other individuals. The client is motivated extrinsically with or without self-determination when
they may take medication regularly when reminded to do so or when pressured by others.
A nurse applies a cold pack to treat an acute musculoskeletal injury. Cold therapy decreases
pain by doing what?
Promoting analgesia and circulation
Numbing the nerves and dilating the blood vessels
Promoting circulation and reducing muscle spasms
Causing local vasoconstriction, preventing edema and muscle spasms
Rationale
Cold causes the blood vessels to constrict, which reduces the leakage of fluid into the tissues
and prevents swelling and therefore muscle spasms. Cold does promote analgesia but not
circulation. It may numb nerves but does not dilate blood vessels. Cold therapy also may numb
the nerves and surrounding tissues, thus reducing pain.
Which skill in critical thinking requires to be orderly in data collection?
Analysis
Inference
Evaluation
Interpretation
Rationale
, Interpretation is involved in the orderly collection of data. When information about a client is
collected with an open mind, then the skill called analysis is being used. When the data
collected about the client helps in solving an existing problem, then the skill called inference is
being used. Evaluation is used when the results of nursing actions are determined.
A client has been diagnosed with type 1 diabetes mellitus. When providing instructions on
sharps disposal, the nurse should instruct the client to place the syringes in what?
Bubble wrap/packaging wrap
A garbage bag in the trash can
A cardboard box with a firmly secured lid
A plastic liquid detergent bottle with a screw-top lid
Rationale
Most states (provinces) allow patients to place used needles/pen needles and lancets ( sharps)
in a household container such as a laundry detergent bottle, bleach bottle, or other opaque
sturdy plastic container with a screw-top lid. Some states (provinces) do have disposal drop-off
locations. Bubble wrap, a garbage bag, and cardboard put those who are handling the
containers at risk for needle sticks.
A nurse understands that the primary purpose for a client to undergo reconstructive surgery is
to do what?
Restore function and/or appearance
Replace an organ or tissue
Relieve or reduce symptoms
Remove or excise an organ or tissue
Rationale
The main function of reconstructive surgery is to restore function and/or appearance. This type
of surgery includes plastic surgery, a term that is interchangeable with reconstructive surgery. In
reconstructive surgery, repairs are made and malformations corrected that are congenital, a
result of disease processes, or from traumatic injury. Replacement of a tissue or organ is known
