Chapter 18 Practice Questions
1. The nurse in a clinic located in a high-rise building on a university campus has
noted that many clients who are supposed to receive care for HIV/AIDS have
missed their appointments. When questioned, several of the clients stated to the
nurse that the clinic is difficult to find and in an intimidating environment for a
client experiencing homelessness. Which variable does the nurse identify as being
inadequately addressed for these clients?
A. psychosocial background and culture
B. developmental stage of the clients
C. ethical and legal guides to practice
D. resources
2. A hospitalized client has become constipated in recent days, in spite of
maintaining a high fluid intake and taking oral stool softeners. The client reports
feeling mortified to attempt a bowel movement on a commode at the bedside,
where staff and other clients can hear. The nurse should respond by modifying
which resource?
A. Environment
B. Personnel
C. Equipment
D. Client and visitors
3. The nurse is delegating a task to the assistive personnel (AP). What is the best
instruction by the nurse?
A. "Notify me right away if the client's systolic blood pressure is 170 or greater."
B. "Let me know if the client's blood pressure becomes elevated."
C. "If the client's blood pressure falls outside normal limits, come get me."
D. "I need to know if the client's blood pressure changes from the normal baseline."
4. The charge nurse overhears two nurses talking about nursing interventions.
Which statement by one of the nurses indicates that further education is required?
A. "Nursing interventions must be consistent with standards of care and research
findings."
B. "Nursing interventions must be culturally sensitive and individualized for the
client."
C. "Nursing interventions must be compatible with other therapies planned for the
client."
D. "Nursing interventions must be approved by other members of the health care
team."
5. The nurse administers an insulin injection to a client with diabetes and informs
the client what is being done, demonstrating each step of preparing and giving the
injection. The nurse is promoting:
A. client self-care.
B. dependence of the client on the nurse.
C. client competence.
D. discipline of the client.
6. What role of the nurse is crucial to the prevention of fragmentation of care?
A. Advocate
B. Educator
C. Counselor
D. Coordinator
7. The client has diabetes and an elevated blood glucose level. During the nursing
assessment, the client states, "I can't afford the pill used to control my blood
sugar." What are appropriate actions by the nurse for this client? Select all that
apply.
A. Make a referral to the social worker to find what financial assistance is available
for the client.
B. Tell the client, "You have to set priorities, and taking this medication is a
financial priority."
C. Consult with the primary care provider about prescribing a medication that is
free at some stores.
D. Document the client statement in the assessment record and take no further
action.
E. Write a new nursing diagnosis "Noncompliance related to inability to afford
treatment."
8. The nurse is assessing a client with a diagnosis of hypertension. The client's
blood pressure is 178/88 mm Hg, an increase from 134/78 mm Hg at the previous
clinic visit. The nurse asks the client what has changed from the previous visit.
Which client statement identifies a potential factor interfering with the plan of care?
A. "My grandchildren have moved in with us while their parents are going through
financial difficulties."
B. "I am taking a cooking class at the community college to learn new healthy
cooking techniques."
C. "We moved to a new neighborhood that has several walking trails, but they are
all uphill and really difficult."
D. "My son gave me a blood pressure machine to monitor my blood pressure at
home, and I use it every day."
9. The client states to the nurse, "I do not know what they are doing for me. I see
so many doctors. One says one thing, another says something else." What are
appropriate action(s) by the nurse to assist the client in understanding the plan of
care? Select all that apply.
A. Make rounds with health care professionals when visiting the client.
B. Restate recommendations in simple terms that the client will understand.
C. Read the consultation and progress notes written by health care professionals.
D. Explain the plan of care to the client's family who can then discuss it with the
client.
E. Assist the client to identify and write questions for the health care professionals.
10. The staff on the unit implements a specific set of evidence-based interventions
for every client on the unit who has a central line inserted. These interventions
include, but are not limited to, hand hygiene, barrier precautions for insertion, and
skin antisepsis. Each member of the staff is involved and follows the steps
meticulously every day until the central line is removed. The staff is carrying out
which type of intervention?
A. care bundle
B. protocol
C. standing order
D. indirect care intervention