The nurse selects the best site for insertion of an IV catheter in the client's right
arm. Which documentation should the nurse use to identify placement of the IV
access?
A.Left brachial vein
B.Right cephalic vein
C.Dorsal side of the right wrist
D.Right upper extremity
(ANS- B
Rationale:
The cephalic vein is large and superficial and identifies the anatomic name of the
vein that is accessed, which should be included in the documentation (B). The
basilic vein of the arm is used for IV access, not the brachial vein (A), which is too
deep to be accessed for IV infusion. Although veins on the dorsal side of the right
wrist (C) are visible, they are fragile and using them would be painful, so they are
not recommended for IV access. (D) is not specific enough for documenting the
location of the IV access.
When assisting a client from the bed to a chair, which procedure is best for the
nurse to follow?
A.Place the chair parallel to the bed, with its back toward the head of the bed and
assist the client in moving to the chair.
B.With the nurse's feet spread apart and knees aligned with the client's knees, stand
and pivot the client into the chair.
C.Assist the client to a standing position by gently lifting upward, underneath the
axillae.
,D.Stand beside the client, place the client's arms around the nurse's neck, and
gently move the client to the chair.
(ANS- B
Rationale:
(B) describes the correct positioning of the nurse and affords the nurse a wide base
of support while stabilizing the client's knees when assisting to a standing position.
The chair should be placed at a 45-degree angle to the bed, with the back of the
chair toward the head of the bed (A). Clients should never be lifted under the
axillae (C); this could damage nerves and strain the nurse's back. The client should
be instructed to use the arms of the chair and should never place his or her arms
around the nurse's neck (D); this places undue stress on the nurse's neck and back
and increases the risk for a fall.
The nurse is preparing an older client for discharge. Which method is best for the
nurse to use when evaluating the client's ability to perform a dressing change at
home?
A.
Determine how the client feels about changing the dressing.
B.
Ask the client to describe the procedure in writing.
C.
Seek a family member's evaluation of the client's ability to change the dressing.
D.
Observe the client change the dressing unassisted.
(ANS- D
Rationale:
Observing the client directly (D) will allow the nurse to determine if mastery of the
skill has been obtained and provide an opportunity to affirm the skill. (A) may be
,therapeutic but will not provide an opportunity to evaluate the client's ability to
perform the procedure. (B) may be threatening to an older client and will not
determine his ability. (C) is not as effective as direct observation by the nurse.
A female nurse is assigned to care for a close friend, who says, "I am worried that
friends will find out about my diagnosis." The nurse tells her friend that legally she
must protect a client's confidentiality. Which resource describes the nurse's legal
responsibilities?
A.
Code of Ethics for Nurses
B.
State Nurse Practice Act
C.
Patient's Bill of Rights
D.
ANA Standards of Practice
(ANS- B
Rationale:
The State Nurse Practice Act (B) contains legal requirements for the protection of
client confidentiality and the consequences for breaches in confidentiality. (A)
outlines ethical standards for nursing care but does not include legal guidelines. (C
and D) describe expectations for nursing practice but do not address legal
implications.
One week after being told that she has terminal cancer with a life expectancy of 3
weeks, a female client tells the nurse, "I think I will plan a big party for all my
friends." How should the nurse respond?
A.
, "You may not have enough energy before long to hold a big party."
B.
"Do you mean to say that you want to plan your funeral and wake?"
C.
"Planning a party and thinking about all your friends sounds like fun."
D.
"You should be thinking about spending your last days with your family."
(ANS- C
Rationale:
Setting goals that bring pleasure are appropriate and should be encouraged by the
nurse (C) as long as the nurse does not perpetuate a client's denial. (A) is a negative
response, implying that the client should not plan a party. (B) puts words in the
client's mouth that may not be accurate. The nurse should support the client's goals
rather than telling the client how to spend her time (D).
After a needlestick occurs while removing the cap from a sterile needle, which
action should the nurse implement?
A.
Complete an incident report.
B.
Select another sterile needle.
C.
Disinfect the needle with an alcohol swab.
D.
Notify the supervisor of the department immediately.
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