RNSG 1424 Clinical Decision Making Leadership and Management Chapter 40 – 43

RNSG 1424 Clinical Decision Making Leadership and Management Chapter 40 – 43 Question 1 See full question 51s Report this Question An infant is brought to the emergency department. The infant is limp and has central cyanosis, a heart rate of 60 beats/minute, and a respiratory rate of 12 breaths/minute. The parents state that they have an advance directive for their infant, who has a terminal illness. A nurse's initial action should be to: You Selected: • ask to see a copy of the advance directive. Correct response: • ask to see a copy of the advance directive. Explanation: Remediation: Add a Note Question 2 See full question 13s Report this Question A 15-year-old girl visits the neighborhood clinic seeking information on "how to keep from getting pregnant." What should the nurse say in response to her request? You Selected: • "Can you tell me about the precautions you're taking now?" Correct response: • "Can you tell me about the precautions you're taking now?" Explanation: Add a Note Question 3 See full question 22s Report this Question A nurse explains the guidelines for the unit's seclusion room to a client with an impulse control disorder. Which client statement indicates that the nurse has adequately communicated the client's rights? You Selected: • "Although I don't think I will, I can ask to go into seclusion, but I know you can make me go into the seclusion room." Correct response: • "Although I don't think I will, I can ask to go into seclusion, but I know you can make me go into the seclusion room." Explanation: Remediation: Add a Note Question 4 See full question 1m 7s Report this Question A nursing assistant escorts a client in the early stages of labor to the bathroom. When the nurse enters the client's room, she detects a strange odor coming from the bathroom and suspects the client has been smoking marijuana. What should the nurse do next? You Selected: • Explain to the client that smoking poses a danger of explosion because oxygen tanks are stored close by. Correct response: • Notify the physician and security immediately. Explanation: Remediation: Add a Note Question 5 See full question 14s Report this Question To promote comfort and optimal respiratory expansion for a client with chronic obstructive pulmonary disease during sexual intimacy, the nurse can suggest the couple do what? You Selected: • Raise the affected partner’s head and upper torso on pillows. Correct response: • Raise the affected partner’s head and upper torso on pillows. Explanation: Remediation: Add a Note Question 6 See full question 12s Report this Question A nurse overhears a fellow staff member talking about the mother of a child for whom the staff nurse is caring. The nurse is telling others private information that the mother had shared. What is the best response by the nurse overhearing the conversation? You Selected: • Talk to the staff member privately about this. Correct response: • Talk to the staff member privately about this. Explanation: Add a Note Question 7 See full question 21s Report this Question While assessing a male neonate whose mother desires him to be circumcised, the nurse observes that the neonate’s urinary meatus appears to be located on the ventral surface of the penis. The nurse notifies the healthcare provider because the nurse suspects which disorder? You Selected: • hypospadias Correct response: • hypospadias Explanation: Remediation: Add a Note Question 8 See full question 27s Report this Question A mother expresses concern because her 3-year-old son frequently fondles his penis. The mother does not know the best approach for the child's behavior. What is the nurse's best response to the mother? You Selected: • "This behavior is normal for a child of his age." Correct response: • "This behavior is normal for a child of his age." Explanation: Add a Note Question 9 See full question 1m 4s Report this Question A school nurse assesses that an 8-year-old child is preoccupied with sexual comments and activities. The nurse is concerned that the child may have been sexually abused at home. What is the nurse’s best response to this situation? You Selected: • Notify the local Child Protective Services. Correct response: • Notify the local Child Protective Services. Explanation: Remediation: Add a Note Question 10 See full question 43s Report this Question A nurse is assessing a client in the recovery room who has had a vaginal hysterectomy. Which assessment finding should the nurse bring to the healthcare provider’s immediate attention? You Selected: • Foley catheter draining urine at 10 mL/hour Correct response: • Foley catheter draining urine at 10 mL/hour Explanation: Remediation: Add a Note Question 11 See full question 18s Report this Question The nurse is providing preoperative instructions to a client who is having a transurethral resection of the prostate. What should the nurse tell the client? You Selected: • “Expect blood in your urine in the first couple of days following the procedure.” Correct response: • “Expect blood in your urine in the first couple of days following the procedure.” Explanation: Remediation: Add a Note Question 12 See full question 11s Report this Question When providing client teaching about continuous bladder irrigation following prostate surgery, what should the nurse tell the client? You Selected: • “The purpose of the irrigation is to keep bladder drainage clear and to prevent the formation of blood clots in the bladder.” Correct response: • “The purpose of the irrigation is to keep bladder drainage clear and to prevent the formation of blood clots in the bladder.” Explanation: Remediation: Add a Note Question 14 See full question 39s Report this Question The nurse is interviewing a pediatric client and family in a clinic after the client had a fever at home. The parent said she gave the client one adult acetaminophen earlier in the day because she ran out of children’s acetaminophen. What is the nurse’s next action? Select all that apply. You Selected: • Teach the parent not to use adult medications with children. • Inform the healthcare provider of the acetaminophen dose. • Document that the parent administered adult acetaminophen. Correct response: • Continue to complete the physical assessment of the client. • Inform the healthcare provider of the acetaminophen dose. • Teach the parent not to use adult medications with children. • Document that the parent administered adult acetaminophen. Explanation: Add a Note Question 15 See full question 45s Report this Question A pediatric nurse is caring for a 12-year-old client with gonorrhea who is to receive penicillin G 0.6 million units IM as an initial dose. The pharmacy supplies the medication, which is labeled 2.4 million units/4 mL. How many milliliters would the nurse safely administer to this client? Record your answer as a whole number. Your Response: • 1 Correct response: • 1 Explanation: Add a Note Question 16 See full question 1m 40s Report this Question A nurse is caring for a client with a prescription for hydromorphone 2 mg I.V. as needed for pain. The client is reporting pain at a 10/10 and is requesting to be medicated. When trying to retrieve the prescribed hydromorphone, the nurse is unable to access the computerized automated dispensing cabinet (ADC) because of an expired password. What is the most appropriate action by the nurse? You Selected: • Explain to the client there will be a delay in receiving pain medication and then contact information services to reset password. Correct response: • Ask another nurse to administer the medication to the client while contacting information services to reset password. Explanation: Add a Note Question 17 See full question 1m 56s Report this Question The nurse is writing a medication order that a health care provider provided by telephone. What should be included when writing the order? Select all that apply. You Selected: • route of administration • medication ordered • medication dosage • date the order is written Correct response: • date the order is written • medication dosage • route of administration • medication ordered Add a Note Question 18 See full question 13s Report this Question A client who is legally blind must undergo a colonoscopy. The nurse is helping the healthcare provider obtain informed consent. When obtaining informed consent from a client who is visually impaired, the nurse should take which step? You Selected: • Read the consent form to the client and ask if there are any questions. Correct response: • Read the consent form to the client and ask if there are any questions. Explanation: Remediation: Add a Note Question 19 See full question 49s Report this Question A client who was discharged earlier in the day returns to the nursing unit and demands acetaminophen with codeine. The client is advised that the client is no longer being treated on the unit and this medication cannot be administered. The client states, "I know where you park your cars, and you'd better watch out when you leave here tonight." What is the next step that the nurse should take? You Selected: • Call the nursing supervisor. Correct response: • Call the police. Add a Note Question 20 See full question 35s Report this Question The nurse is providing care to several clients. In which situation would the nurse be able to accept a verbal order from the healthcare provider? You Selected: • The client has just been admitted to the unit from the emergency department. Correct response: • The client is hemorrhaging from a surgical wound. Question 1 See full question 3m 39s Report this Question A nurse is conducting a physical assessment on an adolescent who does not want her parents informed that she had an abortion in the past. Which statement best describes the information security measures the nurse would implement in this situation? You Selected: • Respect the adolescent's wishes and maintain her confidentiality. Correct response: • Respect the adolescent's wishes and maintain her confidentiality. Explanation: Add a Note Question 2 See full question 52s Report this Question A client tells a nurse that she's in a nontraditional same-sex relationship. The woman's partner is the healthcare surrogate for the client and her fetus. The sperm donor, who is their best friend, has waived parental rights. If the client can't make healthcare decisions for the fetus, who's responsible for making them? You Selected: • the client's partner Correct response: • the client's partner Explanation: Remediation: Add a Note Question 3 See full question 24s Report this Question A client is having elective surgery under general anesthesia. Who is responsible for obtaining the informed consent? You Selected: • the surgeon Correct response: • the surgeon Explanation: Remediation: Add a Note Question 4 See full question 32s A client is diagnosed with genital herpes (herpes simplex virus type 2, or HSV-2). What information should the nurse give to the client about managing this health problem? You Selected: • Reducing stressful life events may decrease the incidence of herpetic outbreaks. Correct response: • Reducing stressful life events may decrease the incidence of herpetic outbreaks. Explanation: Remediation: Add a Note Question 5 See full question 14s Report this Question A right orchiectomy is performed on a client with a testicular malignancy. The client expresses concerns regarding his sexuality. What information should the nurse give the client to address his concerns? The client: You Selected: • should retain normal sexual drive and function. Correct response: • should retain normal sexual drive and function. Explanation: Remediation: Add a Note Question 6 See full question 1m 10s The nurse is instructing a sexually active female who is taking isoniazid (INH). What should the nurse tell the client? Isoniazid: You Selected: • decreases the effectiveness of hormonal contraceptives. Correct response: • decreases the effectiveness of hormonal contraceptives. Explanation: Remediation: Add a Note Question 7 See full question 1m 17s Report this Question A client who is positive for human immunodeficiency virus (HIV) tells the nurse that the client's significant other is the only family member who knows the client's health status. What should the nurse do to keep the client's health status confidential? Select all that apply. You Selected: • Ask all family members, except the client's significant other, to wait outside when she's educating the client. • Use the hospital code for HIV when documenting care. Correct response: • Use the hospital code for HIV when documenting care. • Ask all family members, except the client's significant other, to wait outside when she's educating the client. Explanation: Add a Note Question 8 See full question 1m 19s Report this Question A 15-year-old primiparous client is being cared for in the hospital’s birthing center after vaginal birth of a viable neonate. The neonate is being placed for adoption through a social service agency. Four hours postpartum, the client asks if she can feed her baby. Which response would be most appropriate? You Selected: • “I'll bring the baby to you for feeding.” Correct response: • “I'll bring the baby to you for feeding.” Explanation: Remediation: Add a Note Question 9 See full question 18s Report this Question A 50-year-old man has a long history of type 1 diabetes, which is poorly controlled. What does diabetes greatly increase the man’s risk of experiencing? You Selected: • erectile dysfunction Correct response: • erectile dysfunction Explanation: Remediation: Add a Note Question 10 See full question 1m 24s A nurse is admitting a client to the palliative unit and discussing advanced directives. Which statement made by the client leads the nurse to believe the client requires clarification around advanced directives? You Selected: • “This will stop my daughter-in-law from putting me in a home.” Correct response: • “This will stop my daughter-in-law from putting me in a home.” Explanation: Remediation: Add a Note Question 11 See full question 38s Report this Question The nurse is instructing a competent client in their legal rights regarding ECT (electroconvulsive therapy). Which statement by the client suggests further explanation is needed? You Selected: • "Since I was an Emergency Involuntary Commitment, I will be unable to sign the ECT form myself." Correct response: • "Since I was an Emergency Involuntary Commitment, I will be unable to sign the ECT form myself." Explanation: Remediation: Add a Note Question 12 See full question 22s The school nurse is counseling a female client who is concerned about an incident that occurred at a school dance. The young client describes becoming drowsy and disoriented after drinking punch and waking up hours later in the back of a stranger’s car. What is the most appropriate advice for the nurse to give the adolescent? You Selected: • “It’s possible that you were raped and will need information on pregnancy testing.” Correct response: • “It’s possible that you were raped and will need information on pregnancy testing.” Explanation: Add a Note Question 13 See full question 17s Report this Question A client is admitted to the hospital. The graduate nurse is completing a nursing assessment and asks if the client has an advanced directive. The client asks for an explanation of advanced directives. The registered nurse preceptor would intervene if she heard the graduate nurse inform the client that an advance directive is: You Selected: • a legal document initiated by the physician to give the client “do not resuscitate” (DNR) status. Correct response: • a legal document initiated by the physician to give the client “do not resuscitate” (DNR) status. Explanation: Remediation: Add a Note Question 14 See full question 1m 55s Report this Question A client and her partner come to the clinic stating they have been unable to have sexual intercourse. The female client states she has pain and her “vagina is too tight.” The client was raped at age 15 years of age. Which nursing problem is most appropriate for this client? You Selected: • Sexual dysfunction related to sexual trauma Correct response: • Sexual dysfunction related to sexual trauma Explanation: Add a Note Question 15 See full question 1m 47s Report this Question A client is admitted to the hospital for frottage and refuses to talk about the problem. Which response from the nurse would be appropriate? Select all that apply. You Selected: • “I need to understand why you are here.” • “I understand this must be difficult for you.” • “It is important that you answer a few questions.” Correct response: • “I need to understand why you are here.” • “I understand this must be difficult for you.” • “It is important that you answer a few questions.” Explanation: Add a Note Question 16 See full question 3m 25s Report this Question A student nurse inserts a nasogastric tube and begins a tube feeding without a radiological confirmation. The client develops pneumonia and is transferred to the intensive care unit. Which parties are liable for negligence? Select all that apply. You Selected: • the assigned nurse • the student nurse • the nursing instructor Correct response: • the student nurse • the nursing instructor • the assigned nurse Explanation: Add a Note Question 17 See full question 23s Report this Question The nurse in the preoperative setting is preparing the client for surgery. During completion of the preoperative checklist the client states, "I have a question about my surgery." What is the nextaction by the nurse? You Selected: • Contact the surgeon to answer the client's question. Correct response: • Contact the surgeon to answer the client's question. Explanation: Remediation: Add a Note Question 18 See full question