(Test Bank) Saunders Comprehensive Review For Nclex-Pn Exam

Silvestri, 4

Nursing

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4th Edition

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Test Bank for Saunders Comprehensive Review For Nclex-Pn Exam, The downloadable file consists of 341 pages, and the total size of the file is 2.56 MB. Purchase now only for highly discounted price.

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Saunders Comprehensive Review for NCLEX -PN Exam 4th Edition Linda A. Silvestri Test Bank Silvestri: Saunders Comprehensive Review for the NCLEX -PN® Examination, 4th Edition Chapter 6: Cultural Diversity MULTIPLE CHOICE 1. A nurse is providing discharge instructions to a Chinese client regarding prescribed dietary modifications. During the teaching session the client continually turns away from the nurse. Which of the following nursing actions is most appropriate? 1. Continue with the instructions, verifying client understanding. 2. Identify the importance of the instructions for the maintenance of health care. 3. Walk around the client so that the nurse continually faces the client. 4. Give the client a dietary booklet and return later to continue with the instructions. ANS: 1 Rationale: Most Chinese maintain a formal distance with each other, which is a form of respect. Many Chinese are uncomfortable with face -to-face communications, especially when there is direct eye contact. If the client turns away from the nurse during a conversation, the best action is to continue with the conversation. Walking around the client so that the nurse faces the client is in direct conflict with the cultural practice. Identifying the importance of the instructions for th e maintenance of health care may be viewed as degrading. Returning later to continue with the explanation may be viewed as a rude gesture. Test-Taking Strategy: Understanding the characteristics of this cultural group will assist in answering the question. Use the process of elimination. Eliminate options 2 and 4 first because these are nontherapeutic actions. From the remaining two options, note that option 1 is the most therapeutic. If you had difficulty with this question, review the communication practices of this cultural group. DIF: Level of Cognitive Ability: Application REF: Giger, J., & Davidhizar, R. (2004). Transcultural nursing: Assessment and interven tion. St. Louis: Mosby. OBJ: Client Needs: Psychosocial Integrity TOP: Content Area: Fundamental Skills MSC: Integrated Process: Teaching and Learning 2. A nurse is assisting in preparing a plan of care for a client who is a Jehovah’s Witness. The client has been told that surgery is necessary. Considering the client’s religious preferences, the nurse documents that: 1. Surgery is prohibited in this religious group. 2. The administration of blood and blood products is forbidden. 3. Medication administration is not allowed. 4. Faith healing is primarily practiced. ANS: 2 Rationale: In the Jehovah’s Witness religion, surgery is not opposed, but the administration of blood and blood products is forbidden. Medication is an acceptable practice except if the medication is derived from blood p roducts. Faith healing is forbidden in this religious group. Test-Taking Strategy: Understanding the characteristics of this religious group will assist in answering the question. Remember that the administration of blood and any associated blood products is forbidden in this religion. Review the characteristics of this religious group if you had difficulty with this question. DIF: Level of Cognitive Ability: Comprehension REF: Nies, M., & McEwen, M. (2007). Community health nursing: Promoting the health o f populations (4th ed.). St. Louis: Saunders. OBJ: Client Needs: Psychosocial Integrity TOP: Content Area: Fundamental Skills MSC: Integrated Process: Nursing Process/Implementation 3. A nurse is preparing to deliver a food tray to a client whose religion is Judaism. The nurse checks the food on the tray and notes that the client has received a roast beef dinner with whole milk as a beverage. Which of the following actions will the nurse take? 1. Deliver the food tray to the client. 2. Call the dietary department and ask for a new meal tray. 3. Replace the whole milk with fat-free milk. 4. Ask the dietary department to replace the roast beef with pork. ANS: 2 Rationale: In the Jewish religion, the dairy -meat combination is not acceptable. Pork and pork products are not allowed in the traditional Jewish religion. The only correct nursing action is to ask the dietary department to deliver a new meal tray. Test-Taking Strate gy: Use the process of elimination and knowledge that the dairy -meat combination is not acceptable in this religion to answer the question. This knowledge will assist in eliminating options 1, 3, and 4. Also note that option 2 is the umbrella option. Review the dietary rules of this religious group if you had difficulty with this question. DIF: Level of Cognitive Ability: Application REF: Harkreader, H., & Hogan, M. (2007). Fundamentals of nursing (3rd ed.). St. Louis: Saunders. OBJ: Client Needs: Psychosocial Integrity TOP: Content Area: Fundamental Skills MSC: Integrated Process: Nursing Process/Implementation 4. A nurse educator is describing the yin and yang theory of the ancient Chinese philosophy of Tao to a group of nursing students. The nurse explains that foods are classified as hot and cold in this theory and are transformed into yin and yang energy when me tabolized by the body. The nursing student understands this theory when the student verbalizes that a client who practices this belief: 1. Consumes cold foods when a “hot” illness is present 2. Consumes hot foods when a “hot” illness is present 3. Believes that yin foods are hot foods 4. Believes that yang foods are cold foods ANS: 1 Rationale: In the yin and yang theory, health is believed to exist when all aspects of the person are in perfect balance. Foods are classified as hot or cold and are transformed into yin and yang energy when metabolized by the body. Yin foods are cold, and yang foods are hot. Cold foods are eaten when one has a hot illness and hot foods are eaten when one has a cold illness. Test-Taking Strategy: Knowledge regarding the theory of yin and yang is required to answer this question. Remember that yin foods are cold and yang foods are hot; cold foods are eaten when one has a hot illness and hot foods are eaten when one has a cold illness. Review this theory if you are unfamiliar with it. DIF: Level of Cognitive Ability: Comp rehension REF: Nies, M., & McEwen, M. (2007). Community health nursing: Promoting the health of populations (4th ed.). St. Louis: Saunders. OBJ: Client Needs: Psychosocial Integrity TOP: Content Area: Fundamental Skills MSC: Integrated Process: Teaching and Learning 5. A nurse is planning to instruct the Hispanic -American client about nutrition and dietary restrictions. When developing the plan for the instructions, the nurse is aware that this ethnic group: 1. Enjoys foods that lack color, flavor, and texture 2. Primarily eats raw fish 3. Enjoys eating red meat 4. Views food as a primary form of socialization ANS: 4 Rationale: Mexican foods are rich in color, flavor, texture, and spiciness. In the Mexican culture, any occasion is seen as a time to celebrate with food and enjoy the companionship of family and friends. Because food is a primary form of socialization in the Mexican culture, Hispanic Americans may have difficulty adhering to a prescribed diet. Asian Ame ricans eat raw fish, rice, and soy sauce. European Americans prefer carbohydrates and red meat. Test-Taking Strategy: Knowledge regarding the food practices and preferences and the meaning of food in the Hispanic -American culture is required to answer this question. Remember that food is a primary form of socialization in the Mexican culture. If you had difficulty with this question, review the food preferences associated with this culture. DIF: Level of Cognitive Ability: Comprehension REF: Giger, J., & Davidhizar, R. (2004). Transcultural nursing: Assessment and intervention. St. Louis: Mosby. OBJ: Client Needs: Psychosocial Integrity TOP: Content Area: Fundamental Skills MSC: Integrated Process: Nursing Process/Planning 6. A nursing student is discussing cultural issues in a clinical conference. The nursing instructor asks the student to describe ethnocentrism. Which of the following if stated by the student indicates a lack of understanding of the issue of ethnocentrism? 1. “It is a tendency to view one’s own ways as best.” 2. “It is acting in a manner that is superior to other cultures.” 3. “It is believing that one’s own ways are the only acceptable way.” 4. “It is imposing one’s beliefs on individuals from another culture.” ANS: 4 Rationale: Ethnocentrism is a tendency to view one’s own ways 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 one’s own beliefs, values, and patterns of behavior on individuals from another culture. Test-Taking Strategy: Note the strategic words “lack of understanding.” Use the process of elimination, and note that options 1, 2, and 3 are comparable or alike. Additionally, knowledge of the concept of ethnocentrism will direct you to option 4. If you had difficulty with this question, review culturally related concepts. DIF: Level of Cognitive Ability: Comprehension REF: Nies, M., & McEwen, M. (2007). Community health nursing: Promoting the health of populations (4th ed.). St. Louis: Saunders. OBJ: Client Needs: Psychosocial Integrity TOP: Content Area: Fundamental Skills MSC: Integrated Process: Teaching and Learning 7. A nurse is assigned to collect data from a Hispanic -American client du ring the hospital admission. On initial meeting of the client, the nurse should plan to: 1. Greet the client with a handshake. 2. Avoid touching the client. 3. Avoid any affirmative nods during the conversations with the client. 4. Smile and use humor throughout the entire admission process. ANS: 1 Rationale: To demonstrate respect, compassion, and understanding, health care providers should greet Hispanic -American clients with a handshake. On establishing rapport, providers may further demonstrate approval and respect through touch, smiling, and affirmative nods of the head. Given the diversity of dialects and the nuances of language, cultura lly congruent use of humor is difficult to accomplish and therefore should be avoided. Test-Taking Strategy: Knowledge regarding the cultural communication patterns of the Hispanic American is required to answer this question. Note the strategic words “initial meeting.” Reading each option carefully and focusing on these strategic words will direct you to option 1. Review the characteristics of this cultural group if you had difficulty with this question. DIF: Level of Cognitive Ability: Application REF: Giger, J., & Davidhizar, R. (2004). Transcultural nursing: Assessment and intervention. St. Louis: Mosby. OBJ: Client Needs: Psychosocial Integrity TOP: Content Area: Fundamental Skills MSC: Integrated Process: Nursing Process/Planning 8. A nurse is providing care to a Cuban -American client who is terminally ill. Numerous family members are present most of the time, and many of the family members are very emotional. The most appropriate nursing plan is to: 1. Restrict the number of family members visiting at one time. 2. Inform the family that emotional outbursts are to be avoided. 3. Request permission to move the client to a private room, and allow the family members to visit. 4. Contact the physician to speak to the family regarding their behavior. ANS: 3 Rationale: In the Cuban culture, loud crying and other physical manifestations of grief are considered socially acceptable. Of the options provided, option 3 is the only option that identifies a culturally sensitive approach on the part of the nurse. Options 1, 2, and 4 are inappropriate nursing interventions. Test-Taking Strategy: Focus on the client(s) in the question, who are the family members. Use the process of elimination, recalling the characteristics of the culture and the importance of cultural sensitivity. This will direct you to option 3. If you had difficulty with this question, review the characteristics of this culture. DIF: Level of Cognitive Ability: Application REF: Giger, J., & Davidhizar, R. (2004). Transcultural nursing: Assessment and intervention. St. Louis: Mosby. OBJ: Client Needs: Psychosocial Integrity TOP: Content Area: Fundamental Skills MSC: Integrated Process: Nursing Process/Planning 9. A nurse is instructing a Native -American client regarding the procedure for collecting a urine sample. The nurse observes that the client continually stares at the floor during the instructional session. The nurse interprets this behavior as: 1. Rude 2. Disinterest 3. Embarrassment 4. Indicative that the client is paying close attention ANS: 4 Rationale: Native -American clients often stare at the floor when a nurse is talking. This culturally appropriate behavior indicates that the listener is paying close attention to the speaker. Options 1, 2, and 3 are inappropriate interpretations of the client’s behavior. Test-Taking Strategy: Knowledge regarding the culturally appropriate behaviors of Native - American clients is required to answer this question. Remember that Native -American clients often stare at the floor when a nurse is talking. This knowledge will direct you to option 4. If you had difficulty with this question, review the characteristics of this culture. DIF: Level of Cognitive Ability: Comprehension REF: Nies, M., & McEwen, M. (2007). Community health nursing: Promoting the health of populations (4th ed.). St. Louis: Saunders. OBJ: Client Needs: Psychosocial Integrity TOP: Content Area: Fundamental Skills MSC: Integrated Process: Nursing Process/Evaluation Silvestri: Saunders Comprehensive Review for the NCLEX -PN® Examination, 4th Edition Chapter 7: Ethical and Legal Issues Test Bank MULTIPLE CHOICE 1. A nurse who works on the night shift enters the medication room and finds a co-worker with a tourniquet wrapped around the upper arm. The co -worker is about to insert a needle, attached to a syringe containing a clear liquid, into the antecubital area. The appropriate initial action by the nurse is which of the following? 1. Call the police. 2. Call security. 3. Lock the co -worker in the medication room until help is obtained. 4. Call the nursing supervisor. ANS: 4 Rationale: Nurse practice acts require reporting impaired nurses. The board of nursing has jurisdiction over the practice of nursing and may develop plans for treatment and supervision. This incident needs to be reported to the nursing supervisor, who will then repor t to the board of nursing and other authorities as required. Option 3 is an inappropriate and unsafe action. Security may be called if a disturbance occurs, but there are no data in the question to support this. Therefore, this is not the appropriate initial action. Test-Taking Strategy: Use the principles of prioritizing when answering this question. Note the strategic words “appropriate initial” in the query of the question. Eliminate option 3 first because this is an inappropriate and unsafe action. Reca ll the lines of organization structure to assist in directing you to option 4. If you had difficulty with this question, review the nurse’s responsibilities when substance abuse is suspected or occurs. DIF: Level of Cognitive Ability: Application REF: Harkreader, H., & Hogan, M. (2007). Fundamentals of nursing care (3rd ed.). St. Louis: Saunders. OBJ: Client Needs: Safe and Effective Care Environment TOP: Content Area: Fundamental Skills MSC: Integrated Process: Nursing Process/Implementation 2. A licensed practical nurse (LPN) is providing instructions to a nursing assistant who is preparing to care for a deceased client whose eyes will be donated. The nurse intervenes if the nursing assistant does which of the following? 1. Elevates the head of the bed 2. Closes the client’s eyes 3. Places wet saline gauze pads and an ice pack on the eyes 4. Closes the client’s eyes and places a dry sterile dressing over the eyes ANS: 4 Test Bank 7-2 Rationale: When a corneal donor dies, the eyes are closed and gauze pads wet with saline are placed over them with a small ice pack. Within 2 to 4 hours the eyes are enucleated. The cornea is usually transplanted within 24 to 48 hours. The head of the bed should also be elevated. Option 4 would be an incorrect action by the nursing assistant. Test-Taking Strategy: Note that the subject relates to donation of the eyes. Also note the strategic words “the nurse intervenes” in the query of the question. These words indicate a negative event query and the need to select the incorrect action by the nursing assistant. This should assist in directing you to option 4. Review this procedure if you had difficulty with the question. DIF: Level of Cognitive Ability: Application REF: Lewis, S., Heitkemper, M., & Dirksen, S. (2007). Medical -surgical nursing: Assessment and management of clinical problems (7th ed.). St. Louis: Mosby. OBJ: Client Needs: Safe and Effective Care Environment TOP: Content Area: Fundamental Skills MSC: Integrated Process: Teaching and Learning 3. A hospitalized client tells the nurse that a living will is being prepared and that the lawyer will be bringing the will to the hospital today for witness signatures. The client asks the nurse for assistance in obtaining a witness to the will. The appropriate response to the client is which of the following? 1. “I will sign as a witness to your signature.” 2. “You will need to find a witness on your own.” 3. “I will call the nursing supervisor to seek assistance regarding your request.” 4. “Whoever is available at the time will sign as a witness for you.” ANS: 3 Rationale: Living wills are required to be in writing and signed by the client. The client’s signature must be either witnessed by specified individuals or notarized. Many states prohibit any employee, including a nurse of a facility where the declaring is receiving care, from being a witness. Option 2 is nontherapeutic and not a helpful response. The nurse should seek the assistance of the nursing supervisor. Test-Taking Strategy: Use the process of elimination. Options 1 and 4 are comparable or alike and should be eliminated first. Option 2 is eliminated because it is a nontherapeutic response. Review legal implications associated with wills if you had difficulty with this question. DIF: Level of Cognitive Ability: Application REF: Harkreader, H., & Hogan, M. (2007). Fundamentals of nursing care (3rd ed.). St. Louis: Saunders. OBJ: Client Needs: Safe and Effective Care Environment TOP: Content Area: Fundamental Skills MSC: Integrated Process: Nursing Process/Implementation 4. A nurse is assigned to care for a newly admitted client and is reviewing the physician’s orders. The nurse notes that the physician has prescribed a medication dose that is twice the amount that the client reports taking prior to admission. The appropriate nursing action is to: 1. Question the client regarding the accuracy of the reported dosage. 2. Consult with the registered nurse (RN). 3. Administer the medication as prescribed. Test Bank 7-3 4. Administer half of the prescribed dose and then notify the RN. ANS: 2 Rationale: If the nurse determines that a physician’s order is unclear or if the nurse has a question about an order, the nurse should consult with t he RN, who will then contact the physician before implementing the order. Under no circumstances should the nurse carry out the order unless the order is clarified. Questioning the client regarding the accuracy of the dosage of the medication may seem like a viable option, but this action may also cause the client to become upset. The nurse would not administer the medication, nor would the nurse administer an altered dosage. Test-Taking Strategy: Use the process of elimination to answer the question. Eliminate options 3 and 4 first by applying general principles related to medication administration and safety. For the remaining options, select option 2 because this is the action that will clarify the order and ensure a safe environment for the client. Review nursing guidelines related to implementing a physician’s orders if you had difficulty with this question. DIF: Level of Cognitive Ability: Application REF: Harkreader, H., & Hogan, M. (2007). Fundamentals of nursi ng (3rd ed.). St. Louis: Saunders. OBJ: Client Needs: Safe and Effective Care Environment TOP: Content Area: Fundamental Skills MSC: Integrated Process: Nursing Process/Implementation 5. A nurse is caring for a client with severe cardiac disease. While the nurse is caring for the client, the client states, “If anything should happen to me, please make sure that the doctors do not try to push on my chest and revive me.” The appropriate nursing action is to: 1. Tell the client that this procedure cannot legally be refused by a client if the physician feels that it is necessary to save the client’s life. 2. Tell the client that it is necessary to notify the physician of the client’s request. 3. Tell the client that the family must agree with the request. 4. Plan a client conference with the nursing staff to share the client’s request. ANS: 2 Rationale: External cardiac massage is one type of treatment that a client can refuse. The most appropriate nursing action is to notify the physician because a written do not resuscitate (DNR) order from the physician must be present on the client’s record. The DNR o rder must be reviewed or renewed on a regular basis per agency policy. Options 1 and 3 are inaccurate. Option 4 may be appropriate, but only after the physician is contacted and notified of the client’s request. Test-Taking Strategy: Focus on the subject, which is a DNR order. Options 1 and 3 are inaccurate and can be eliminated first. For the remaining options, the priority is to contact the physician. Review DNR procedures if you had difficulty with this question. DIF: Level of Cogn itive Ability: Application REF: Harkreader, H., & Hogan, M. (2007). Fundamentals of nursing (3rd ed.). St. Louis: Saunders. OBJ: Client Needs: Safe and Effective Care Environment TOP: Content Area: Fundamental Skills MSC: Integrated Process: Nursing Process/Implementation Test Bank 7-4 6. An adult client is brought to the emergency department by the emergency medical services team after being hit by a car. The name of the client is not known. The client has sustained a severe head injury and multiple fractures and is unconscious. An emergency craniotomy is required. In regard to informed consent for the surgical procedure, which of the following is the best initial action? 1. Call the police to identify the client and locate the family. 2. Obtain a court order for the surgical procedure. 3. Ask the emergency medical services team to sign the informed consent. 4. Transport the victim to the operating room for surgery. ANS: 4 Rationale: Generally there are only two instances in which the informed consent of an adult client is not needed. One instance is when an emergency is present and delaying treatment for the purpose of obtaining informed consent would result in injury or death to the client. The second instance is when the client waives the right to give informed consent. Option 2 is unnecessary, and option 3 is inappropriate. Although option 1 may be pursued, it is not the best initial action. Test-Taking Strategy: Use the process of elimination, and note the strategic words “best initial action.” Recall that when an emergency is present, delaying treatment for the purpose of obtaining informed consent will re sult in injury or death. This will direct you to option 4. Review the issues surrounding informed consent if you had difficulty with this question. DIF: Level of Cognitive Ability: Application REF: Harkreader, H., & Hogan, M. (2007). Fundamentals of nursi ng (3rd ed.). St. Louis: Saunders. OBJ: Client Needs: Safe and Effective Care Environment TOP: Content Area: Fundamental Skills MSC: Integrated Process: Nursing Process/Implementation 7. A client brought to the emergency department is dead on arrival (DOA). The family of the client tells the physician that the client had terminal cancer. The emergency department physician examines the client and asks the nurse to contact the medical examiner regarding an autopsy. The famil y of the client tells the nurse that they do not want an autopsy performed. Which response to the family is appropriate? 1. “It is required by federal law. Why don’t we talk about it, and why don’t you tell me how you feel?” 2. “The decision is made by the medical examiner.” 3. “I will contact the medical examiner regarding your request.” 4. “An autopsy is mandatory for any client who is DOA.” ANS: 3 Rationale: An autopsy is required by state law in certain circumstances, including the sudden death of a client and a death that occurs under suspicious circumstances. The client may have provided oral or written instructions regarding an autopsy following death. If an autopsy is not required by law, these oral or written requests will be granted. If no oral or written instructions were provided, state law determines who has the authority to consent for an autopsy. Most often, the decision rests with the surviving relative or next of kin. Test Bank 7-5 Test-Taking Strategy: Use knowledge regarding the laws and issues surrounding autopsy and therapeutic communication techniques to answer the question. Eliminate options 1 and 4 because these statements are not completely accurate. For the remaining options, option 3 is the therapeutic and appropriate response to the family. Review the issues and laws surrounding autopsy if you had difficulty with this question. DIF: Level of Cognitive Ability: Application REF: Harkreader, H., & Hogan, M. (2007). Fundamentals of nursing (3rd ed.). St. Louis: Saunders. OBJ: Client Needs: Safe and Effective Care Environment TOP: Content Area: Fundamental Skills MSC: Integrated Process: Nursing Process/Implementation 8. A nurse witnesses an accident on a highway and stops to provide assistance to the victim. The nurse notes that the client sustained a head injury and a compound fracture to the left leg. The nurse provides the appropriate care prior to transport of the victim to the hospital by ambulance. The client develops a severe bone infection at the site of the fracture that requires amputation of the leg and files suit against the nurse who provided care at the scene of the accident. Which of the following is accurate regarding the nurse’s immunity from this suit? 1. A Good Samaritan law will protect the nurse. 2. A Good Samaritan law will not protect the nurse. 3. A Good Samaritan law will provide immunity from suit even if the nurse accepted compensation for the care provided. 4. A Good Samaritan law protects laypersons and not professional health care providers. ANS: 1 Rationale: A Good Samaritan law is passed by state legislators to encourage nurses and other health care providers to provide care to a person when an accident, emergency, or injury occurs, without fear of being sued for the care provided. Its protection lies in preventing nurses or other health care providers from being sued for neglig ence in the care provided at the scene of the accident or during the emergency, even if further injury occurred because of the health care providers’ care. Called immunity from suit, this protection usually applies only if all of the conditions of the law are met, such as that the health care provider receives no compensation for the care provided and that the care given is not willfully and wantonly negligent. Test-Taking Strategy: Knowledge regarding the issues surrounding a Good Samaritan law is required to answer this question. Eliminate options 2 and 4 because they are comparable or alike. For the remaining options focus on the data in the question to direct you to option 1. Review the Good Samaritan law if you had difficulty with this question. DIF: Level of Cognitive Ability: Comprehension REF: Harkreader, H., & Hogan, M. (2007). Fundamentals of nursing (3rd ed.). St. Louis: Saunders. OBJ: Client Needs: Safe and Effective Care Environment TOP: Content Area: Fundamental Skills MSC: Integrated Process: Nursing Process/Evaluation Silvestri: Saunders Comprehensive Review for the NCLEX -PN® Examination, 4th Edition Chapter 8: Delegating, Managing, and Prioritizing Care Test Bank MULTIPLE CHOICE 1. A licensed practical nurse (LPN) has been assigned to assist a community nurse, who is the leader of a task force, to identify interventions for teenagers from a local community who are abusing drugs. At the first meeting of the task force, the group membe rs express concern that more information is needed to determine appropriate measures for the target teenagers. The LPN suggests which of the following to the community nurse to direct the group most effectively? 1. Prepare a survey that can be distributed to community members to determine their understanding of the drug abuse problem. 2. Initiate a drug abuse program in all of the schools. 3. Seek out the teenage drug abusers and refer them to drug abuse centers. 4. Prepare posters that can be distributed to the schools. ANS: 1 Rationale: Option 1 is the only option that addresses the subject of the question and will identify the additional information required by the task force. Options 2, 3, and 4 do not provide the additional information requ ired in order for the task force to proceed with the necessary task of the group. Test-Taking Strategy: Use the steps of the nursing process to answer the question. Additionally, focus on the subject of the question. Options 2, 3, and 4 relate to implement ation measures. The subject of the question is the need for further data. Option 1 is the only option that addresses the process of data collection. Review the procedures for implementing community task force work if you had difficulty with this question. DIF: Level of Cognitive Ability: Application REF: Nies, M., & McEwen, M. (2007). Community health nursing: Promoting the health of populations (4th ed.). St. Louis: Saunders. OBJ: Client Needs: Health Promotion and Maintenance TOP: Content Area: Fundamen tal Skills MSC: Integrated Process: Nursing Process/Planning 2. A licensed practical nurse (LPN) is planning the client assignments for the day. Which of the following is an appropriate assignment for the nursing assistant? 1. A client with difficulty swallowing food and fluids 2. A client who requires a 24-hour urine collection 3. A client requiring a colostomy irrigation 4. A client receiving continuous tube feedings ANS: 2 Test Bank 8-2 Rationale: The nurse must determine the most appropriate assignment based on the skills of the staff member and the needs of the client. In this case, the appropriate assignment for a nursing assistant would be to care for the client who requires urine collection. The client with difficulty swallowing food and fluids is at risk for aspiration. Colos tomy irrigations and tube feedings are not performed by unlicensed personnel. Test-Taking Strategy: Use the process of elimination and focus on the subject, assignment to a nursing assistant. Eliminate option 1 because this client is at risk for aspiration . From the remaining options select option 2 because this task is noninvasive. Review the principles of delegation if you had difficulty with this question. DIF: Level of Cognitive Ability: Application REF: Harkreader, H., & Hogan, M. (2007). Fundamentals of nursing care (3rd ed.). St. Louis: Saunders. OBJ: Client Needs: Safe and Effective Care Environment TOP: Content Area: Fundamental Skills MSC: Integrated Process: Nursing Process/Planning 3. A nursing instructor asks a nursing student to iden tify situations that indicate a secondary level of prevention in health care. Which statement, if made by the student, would indicate a need for further study of the levels of prevention? 1. Teaching a stroke client how to use a walker 2. Encouraging a client to take antihypertensive medications as prescribed 3. Screening for hypertension in a community 4. Encouraging a woman older than age 40 to obtain periodic mammograms ANS: 1 Rationale: Secondary prevention focuses on the early diagnosis and prompt treatme nt of disease. Tertiary prevention is represented by rehabilitation services. Options 2, 3, and 4 identify screening procedures and treatment of disease, whereas option 1 identifies a rehabilitative service. Test-Taking Strategy: Note the strategic words “ indicate a need for further study.” Use knowledge regarding the characteristics of the various levels of prevention to assist in directing you to the correct option. Note that option 1 is the option that is different from the other options because it identifies a rehabilitative service. Review the levels of prevention if you had difficulty with this question. DIF: Level of Cognitive Ability: Analysis REF: Harkreader, H., & Hogan, M. (2007). Fundamentals of nursing care (3rd ed.). St. Louis: Saunders. OBJ: Client Needs: Health Promotion and Maintenance TOP: Content Area: Fundamental Skills MSC: Integrated Process: Teaching and Learning 4. A licensed practical nurse (LPN) employed in a long -term care facility is asked to assist in planning implementation of a change in the method of documentation system in the nursing unit. Many problems have occurred as a result of the present documentation system, and the nurse manager determines that a change is required. The LPN understands that the initial step in the process of change is which of the following? 1. Plan strategies to implement the change. Test Bank 8-3 2. Identify potential solutions and strategies for the change process. 3. Set goals and priorities regarding the change process. 4. Identify the inefficiency that needs improvement or correction. ANS: 4 Rationale: When beginning the change process, the nurse should identify and define the problem or the inefficiency that needs improvement or correction. This important first step can prevent many future problems, because if the problem is not correctly identified, a plan for change may be aimed at the wrong problem. This is followed by goal setting, identifying potential solutions and strategies, and setting goals and priorities. The nurse then plans strategies to implement the change. Test-Taking Strategy: Knowledge regarding the change process is required to answer this question. Use the steps of the nursing process to assist in answering the question. Option 4 is the only option that identifies data collection. If you had difficulty with this question, review the steps of the change process. DIF: Level of Cognitive Ability: Analysis REF: Harkreader, H., & Hogan, M. (2007). Fundamentals of nursing care (3rd ed.). St. Louis: Saunders. OBJ: Client Needs: Safe and Effective Care Environment TOP: Content Area: Fundamental Skills MSC: Integrated Process: Nursing Process/Planning 5. A nursing instructor asks a nursing student to identify the priorities of care for an assigned client. The student correctly identifies the client needs that are the priority by telling the nursing instructor that: 1. Actual or life-threatening concerns are the priority. 2. Time constraint s related to the client’s needs are the priority. 3. Obtaining needed supplies to care for the client is the priority. 4. Completing care in a reasonable time frame is the priority. ANS: 1 Rationale: Setting priorities means deciding which client needs or problems require immediate action and which ones could be delayed until a later time because they are not urgent. Client problems that involve actual or life -threatening concerns are always considered first. Although time constraints, obtaining needed supplies, and completing care in a reasonable time frame are components of time management, these items are not the priority in planning care for the client, based on the options provided. Test-Taking Str ategy: Use principles related to prioritizing to answer the question. Noting the strategic words “life-threatening” will assist in directing you to option 1. Review the principles related to prioritizing if you had difficulty with this question. DIF: Level of Cognitive Ability: Comprehension REF: Harkreader, H., & Hogan, M. (2007). Fundamentals of nursing care (3rd ed.). St. Louis: Saunders. OBJ: Client Needs: Safe and Effective Care Environment TOP: Content Area: Fundamental Skills MSC: Integrated Process: Nursing Process/Planning Test Bank 8-4 6. A licensed practical nurse (LPN) employed in a long -term care facility is planning assignments for the clients on a nursing unit. The LPN needs to assign four clients and has another LPN and three nursing assistants on a nursing team. Which of the following clients should the nurse assign the LPN? 1. The client requiring a 24-hour urine collection 2. An older adult client requiring assistance with a bed bath 3. A client requiring frequent ambulation 4. A client with an abdominal wound requiring wound irrigations and dressing changes every 3 hours ANS: 4 Rationale: When delegating nursing assignments, the nurse needs to consider the skills and educational level of the nursing staff. Co llecting a 24 -hour urine, assisting with frequent ambulation, and giving a bed bath can be done by a nursing assistant. The LPN is skilled in wound irrigations and dressing changes, and this client should be assigned to this staff member. Test-Taking Strategy: Focus on the subject, assignment to an LPN. Options 1, 2, and 3 can be eliminated because these tasks are noninvasive and can be performe d by a nursing assistant. This should direct you to option 4. If you had difficulty with this question, review the principles related to delegation and assignment making. DIF: Level of Cognitive Ability: Application REF: Harkreader, H., & Hogan, M. (2007) . Fundamentals of nursing care (3rd ed.). St. Louis: Saunders. OBJ: Client Needs: Safe and Effective Care Environment TOP: Content Area: Fundamental Skills MSC: Integrated Process: Nursing Process/Planning 7. A licensed practical nurse (LPN) has received the assignment for the day shift. After making initial rounds and checking all of the assigned clients, which client will the LPN plan to care for first? 1. A client who is ambulatory 2. A client with a fever who is diaphoretic and restless 3. A client scheduled for physical therapy at 1:00 PM 4. A postoperative client who has just received pain medication ANS: 2 Rationale: The LPN would plan to care for the client who has a fever and is diaphoretic and restless first, because this client’s needs are the priority. It is best to wait for pain medication to take effect before providing care to the postoperative client. The clie nt who is ambulatory and the client scheduled for physical therapy later in the day do not have priority needs related to care. Test-Taking Strategy: Use principles related to prioritizing to answer the question. Read the question and each option carefully. Noting the strategic words “diaphoretic and restless” will assist in directing you to this option. Review the principles related to prioritizing if you had difficulty with this question. DIF: Level of Cognitive Ability: Application REF: Harkrea der, H., & Hogan, M. (2007). Fundamentals of nursing (3rd ed.). St. Louis: Test Bank 8-5 Saunders. OBJ: Client Needs: Safe and Effective Care Environment TOP: Content Area: Fundamental Skills MSC: Integrated Process: Nursing Process/Planning 8. A nursing instructor asks a nursing student to define a critical path. Which of the following statements, if made by the student, indicates a need for further understanding regarding critical paths? 1. “They are developed through the collaborative efforts of all members of the health care team.” 2. “They provide an effective way to monitor care and for reducing or controlling the length of hospital stay for the client.” 3. “They are developed based on appropriate standards of care.” 4. “They are nursing care plans and use the steps of the nursing process.” ANS: 4 Rationale: Critical paths are not specifically nursing care plans; however, they can take the place of a nursing care plan and actually map out the desired clinical progress of a client during acute care admission. Options 1, 2, and 3 appropriately describe the use of a critical path. Test-Taking Strategy: Note the strategic words “need for further understanding.” Remember that critical paths are not specifically nursing care plans. This will direct you to option 4. If you had difficulty answering this question, review the characteristi cs of critical paths. DIF: Level of Cognitive Ability: Analysis REF: Harkreader, H., & Hogan, M. (2007). Fundamentals of nursing (3rd ed.). St. Louis: Saunders. OBJ: Client Needs: Safe and Effective Care Environment TOP: Content Area: Fundamental Skills MSC: Integrated Process: Teaching and Learning