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To remove a client's gown when she has an intravenous line, the nurse should:
- A. temporarily disconnect the intravenous tubing at a point close to the client and thread it through the gown.
- B. cut the gown with scissors.
- C. thread the bag and tubing through the gown sleeve, keeping the line intact.
- D. temporarily disconnect the tubing from the intravenous container and thread it through the gown.
Correct Answer: C
Rationale: Threading the bag and tubing through the gown sleeve keeps the system intact. Opening an intravenous line causes a break in a sterile system and introduces the potential for infection. Cutting a gown off is not an alternative except in an emergency. IV gowns, which open along sleeves, are widely available.
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Client self-determination is the primary focus of:
- A. malpractice insurance.
- B. nursing's advocacy for clients.
- C. confidentiality.
- D. health care.
Correct Answer: B
Rationale: Advocacy for clients by nurses is the primary focus of the client's right to autonomy and self-determination. Confidentiality involves the maintenance of the privacy of the client and information regarding him or her. Malpractice insurance is a type of insurance for professionals.
The nurse applies a warm, moist compress to the site where an IV solution has infiltrated. Which response is correct when the client asks the purpose of the compress?
- A. The application of moist heat will alter tissue sensitivity by producing numbness.
- B. The application of moist heat will decrease the metabolic needs of the involved tissues.
- C. The application of moist heat will stop the local release of histamine in the tissues.
- D. The application of moist heat will increase blood flow and accelerate tissue healing.
Correct Answer: D
Rationale: D: Warm compresses increase blood flow, promoting healing. A: Cold causes numbness. B: Heat increases metabolic needs. C: Cold reduces histamine release.
A safety measure to implement when transferring a client with hemiparesis from a bed to a wheelchair is:
- A. standing the client and walking him or her to the wheelchair.
- B. moving the wheelchair close to client's bed and standing and pivoting the client on his unaffected extremity to the wheelchair.
- C. moving the wheelchair close to client's bed and standing and pivoting the client on his affected extremity to the wheelchair.
- D. having the client stand and push his body to the wheelchair.
Correct Answer: B
Rationale: Moving the wheelchair close to client's bed and having him stand and pivot on his unaffected extremity to the wheelchair is safer because it provides support with the unaffected limb.
The method of splinting is always dictated by:
- A. Location of the injury and whether it is open or closed
- B. The severity of the client's condition and the priority decision
- C. The number of available rescuers and the type of splints
- D. All of the above
Correct Answer: B
Rationale: The severity of the client's condition and priority decision dictate splinting to ensure stabilization and prevent further injury, taking precedence over location or resources.
On first meeting, a new nurse manager makes eye contact, smiles, initiates conversation about the previous work experience of nurses, and encourages active participation by nurses in the dialogue. Her behavior is an example of:
- A. aggressiveness.
- B. passive aggressiveness.
- C. passiveness.
- D. assertiveness.
Correct Answer: D
Rationale: This nurse manager is demonstrating assertive behavior. Aggressive behavior dominates or embarrasses. Passive behavior is nervous or timid. Passive-aggressive behavior is dominating or manipulative without directness.