Scenario (MOC): A client with a compound fracture of the left femur is being admitted to the Med-Surg unit. Which of the following actions is best for the nurse to take? There is one correct answer.

1. Ask the assistive personnel (AP) to obtain the client’s vital signs while the nurse obtains a history from the parents.
2. Ask the LPN to assess the peripheral pulses of the client’s left leg while the nurse
   completes the admission forms.
3. Ask the LPN to stay with the client and parents while the nurse obtains phone orders from the primary health care provider.
4. Ask the AP to obtain equipment for the client’s care while the nurse talks with the client and the family.

Step 1: Reword the question in your own words to provide clarity to the question.

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Step 2: Eliminate answer choices based on your knowledge of priorities & indicate reason for eliminating the specific answer. Enter the word “CORRECT” for the correct answer.

1. ____________________________________________________________

Provide two (2) Nursing Diagnosis for the Nursing Care Plan that address the highest priority for this client.

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For the following questions, please rewrite the questions in your own words on the lines below the answer choices.

1. A registered nurse (RN) is developing a plan of care for a client admitted with pneumonia. Which tasks can the RN delegate to the nursing assistive personnel (NAP)? Select all that apply.

A. Bathing the client
B. Shaving the client
C. Providing oral care
D. Administering lubricating eye drops
E. Performing a sterile dressing change

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2. A client is given a diagnosis of terminal cancer, and the health-care
   provider suggests hospice services for the family. The family is hesitant
   and asks the nurse what hospice can provide. Which responses given by
   the nurse are appropriate? Select all that apply.

A. “Hospice services assist the family with funeral planning.”
B. “Hospice services ensure the client is comfortable and the pain is controlled.”
C. “Hospice services allow the client to preserve dignity during the dying process.”
D. “Hospice services provide spiritual care for the client within the client’s culture.”
E. “Hospice services can provide chemotherapeutic medications for treatment.”

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3. A 65-year-old patient is admitted to the hospital with heart failure. The patient’s best friend accompanies her on admissions. They have been sharing a home since they each were widowed 3 years ago. Both women have grown children who live out of state. Using the family nursing approach, how can the nurse best intervene?

A. Involve the friend and children in the patients care, discharge planning and home care.
B. Encourage the friend to wait until discharge to provide care for the patient at home.
C. Explains to the friend that for confidentiality reasons she cannot be involved in the patients care.
D. . Encourages liberal visiting hours by the friend and the patient’s children.

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4. A patient and his wife are 2 years from retirement when he is diagnosed with lung cancer. although with delayed childbearing, developmental stages can vary among families, which typical stage of family development is this couple likely experiencing?

A. Family launching young adults
B. Post parental family
C. Family with frail elderly
D. Family with teenagers and young adults

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5. What should the nurse keep in mind when learning about cultures? Select all that apply.

A. Culture is universal and dynamic.
B. Cultural beliefs contribute to individuality.
C. Culture exists only in nonmaterial possessions.
D. Culture is passed down throughout generations.
E. Culture consists of common beliefs and practices.
F. Cultural assumptions and habits are unconscious.

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6. You are trying to become more assertive in your communication with clients
   and other healthcare professionals. Which of the following should you do?
   Select all that apply?

A. Question care decisions openly and honestly.
B. Use “you” statements.
C. Focus on the participants, not the issue.
D. Make eye contact.
E. Use “fogging” to help accept criticism without becoming anxious or defensive.
F. Use negative inquiry.

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7. Which of the following is a procedure that uses both sterile technique and principles of
   medical asepsis?

A. Starting an IV line
B. Administering oral medication
C. Insertion of urinary catheter
D. Assisting a client brush his/her teeth

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8. When educating a client on nail care of the feet, what important aspects should be included?
   A. Cut deep into the lateral corners
   B. Cut cuticle back with cuticle clipper
   C. Trim nail with nail clipper if diabetic, file nail
   D. Encourages biting of the finger

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9. A patient arrives at the hospital presenting impaired gas exchange. The nurse understands that some of the possible etiologies for this problem include: Select all that apply.

A. Pulmonary embolus, caused by an obstruction of the pulmonary arterial circulation by a foreign substance (e.g., blood clots or fat).
B. Pulmonary hypertension, in which the high pressure causes right-sided heart failure over time, reducing the amount of blood pumped into the pulmonary circulation.
C. Hyperventilation, which halts the physiological mechanisms associated with input and output of oxygen and carbon dioxide that occur in the alveoli tissue.
D. Spinal cord injuries, that may compromise nerve transmissions between the brain and areas below the level of injury, such as the diaphragm, a muscle related to the respiration.
E. Unstable breathing patterns, such as apnea and eupnea, most common in preterm infants and older adults, which causes absence of breathing and, therefore, impaired gas exchange.

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10. A 74-year-old female patient in the postoperative department has a risk of blood clots. What should be done to prevent clot formation. Select ALL that apply.
    A. Turn the patient frequently
    B. Sufficient dilution of the intravenous medications administered
    C. Reduce fluid intake
    D. Provide anticoagulant therapy.