Question

A nurse is reinforcing teaching about vancomycin with a client who has an infection. Which of the following information should the nurse include in the teaching?

Answer 1

Correct Answers:

“Notify your provider if you experience any changes in your hearing."

Rationale :

🟦 Vancomycin is associated with ototoxicity, especially at high serum levels or with prolonged therapy.

🟦 Changes such as tinnitus, hearing loss, or a feeling of fullness in the ears may indicate early toxicity.

🟦 Prompt reporting allows the provider to check serum drug levels and adjust the dose to prevent permanent damage.

🟦 Monitoring for hearing changes is a critical safety teaching point when educating clients on vancomycin use.

🟦 Early recognition helps prevent irreversible auditory complications.

“Discontinue the medication once your symptoms subside.”

🟦 Stopping antibiotics early can lead to incomplete eradication of infection.

🟦 This increases the risk of antibiotic resistance and relapse.

“Expect your urine to turn pink or red while taking this medication.”

🟦 Vancomycin does not discolor urine.

🟦 This finding is more commonly associated with other medications or foods.

“Decrease your fluid intake to 1000 mL per day.”

🟦 Adequate hydration is important to reduce the risk of nephrotoxicity.

🟦 Fluid restriction is not routinely recommended with vancomycin.

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Answer 2

Correct Answers:

Deep vein thrombosis

Rationale :

🟦 Deep vein thrombosis (DVT) is a recognized hospital-acquired injury because it can develop during hospitalization due to immobility, venous stasis, and endothelial injury.

🟦 Prolonged bed rest, surgery, and acute illness increase the risk of clot formation in hospitalized clients.

🟦 DVT is considered preventable with appropriate nursing interventions, such as early ambulation, compression devices, and anticoagulant prophylaxis.

🟦 Because it arises as a complication of care or hospitalization, it is classified as a hospital-acquired condition.

🟦 Preventing DVT is a key patient safety and quality improvement priority in healthcare settings.

Diabetes mellitus:

🟦 Diabetes mellitus is a chronic metabolic disorder that typically develops over time.

🟦 It is not caused by hospitalization or healthcare delivery.

Hypertension:

🟦 Hypertension is a long-term cardiovascular condition related to genetics and lifestyle factors.

🟦 It is not considered a hospital-acquired injury.

Hypothyroidism:

🟦 Hypothyroidism results from endocrine dysfunction, often autoimmune in origin.

🟦 It does not arise as a consequence of inpatient care.

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Answer 3

Correct Answers:

Utilizing clean gloves to remove the dressing and clean supplies for the new dressing

Rationale :

🟦 Using clean gloves to remove the soiled dressing demonstrates proper medical asepsis, as the old dressing is already contaminated and does not require sterility.

🟦 Applying the new dressing with sterile supplies reflects surgical asepsis, which is necessary to protect the incision from microorganisms.

🟦 This approach correctly separates clean technique for contaminated tasks from sterile technique for wound protection.

🟦 Maintaining sterility during application reduces the risk of surgical site infection.

🟦 This combination represents best practice for a sterile dressing change.

Utilizing clean gloves to remove the dressing and clean supplies for the new dressing:

🟦 Clean supplies are insufficient for covering a surgical incision.

🟦 This increases the risk of introducing pathogens into the wound.

Donning clean goggles, gown, and gloves to dress the wound:

🟦 Personal protective equipment protects the nurse, not the wound.

🟦 Sterile supplies are still required to maintain surgical asepsis.

Donning sterile gloves to remove the wound dressing and clean gloves for the new dressing:

🟦 Sterile gloves are unnecessary for removing a contaminated dressing.

🟦 Using clean gloves for the new dressing breaks sterile technique.

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Answer 4

Correct Answers:

Orthostatic hypotension increases a client's risk of a fall.

Rationale :

🟦 Orthostatic hypotension causes a sudden drop in blood pressure when a client changes position, leading to dizziness, lightheadedness, or syncope.

🟦 These symptoms significantly increase the risk of loss of balance and falls, especially in older adults or hospitalized clients.

🟦 Falls related to orthostatic hypotension can result in serious injuries, including fractures and head trauma.

🟦 Recognizing this risk allows nurses to implement preventive strategies, such as slow position changes and assistance with ambulation.

🟦 Fall prevention is a key nursing priority when managing clients with orthostatic hypotension.

Orthostatic hypotension is indicated by a decrease in diastolic blood pressure of 5 mm Hg:

🟦 This decrease is not sufficient to meet diagnostic criteria.

🟦 Orthostatic hypotension requires a larger drop in blood pressure.

Orthostatic hypotension increases a client's risk of a pulmonary embolus:

🟦 Pulmonary embolus is associated with venous thromboembolism, not blood pressure changes.

🟦 There is no direct link between orthostatic hypotension and PE.

Orthostatic hypotension is indicated by a decrease in systolic blood pressure of 10 mm Hg:

🟦 Diagnostic criteria require a drop of at least 20 mm Hg systolic or 10 mm Hg diastolic.

🟦 A 10-mm Hg systolic decrease alone does not meet the definition.

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Answer 5

Correct Answers:

History of hypertension
History of smoking
History of rheumatoid arthritis
Cholesterol level

Rationale :

🟦 History of hypertension increases cardiac workload and contributes to endothelial damage, accelerating atherosclerosis and coronary artery disease.

🟦 History of smoking exposes the cardiovascular system to nicotine and carbon monoxide, which promote vasoconstriction, inflammation, and plaque formation.

🟦 Rheumatoid arthritis is a chronic inflammatory condition; persistent systemic inflammation increases the risk of atherosclerotic cardiovascular disease.

🟦 An elevated cholesterol level (275 mg/dL) reflects increased LDL cholesterol, a major contributor to plaque buildup and coronary artery disease.

Daily exercise:

🟦 Regular physical activity is cardioprotective, improving lipid profiles and blood pressure control.

🟦 This finding lowers, rather than increases, heart disease risk.

Fasting glucose level:

🟦 A fasting glucose of 90 mg/dL is within the normal range.

🟦 Normal glucose does not increase cardiovascular risk in this context.

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Answer 6

Correct Answers:

"I am responsible for ensuring that a delegated task is completed."

Rationale :

🟦 The nurse who delegates retains accountability for the outcome of the delegated task, even though another individual performs it.

🟦 Delegation does not transfer responsibility; the delegating nurse must ensure the task is completed correctly and safely.

🟦 This includes providing clear instructions, appropriate supervision, and follow-up evaluation.

🟦 Understanding accountability reflects correct application of professional nursing standards.

🟦 This statement demonstrates accurate knowledge of safe and effective delegation principles.

“It is the duty of the delegate to perform a task without asking questions when it is delegated.”

🟦 Delegates are encouraged to ask questions if clarification is needed.

🟦 Open communication promotes safety and reduces errors.

🟦 “The nurse manager is responsible for delegating nursing tasks during each shift.”

🟦 Delegation is the responsibility of the licensed nurse providing care, not solely the nurse manager.

🟦 Bedside nurses routinely delegate tasks within their scope of practice.

“There are 4 rights of delegation.”

🟦 There are five rights of delegation: right task, right circumstance, right person, right direction/communication, and right supervision/evaluation.

🟦 Stating four rights reflects incomplete knowledge.

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Answer 7

Correct Answers:

790

Rationale :

🟦 IV bolus = 150 mL

🟦 Juice 4 oz × 30 mL/oz = 120 mL

🟦 Hot tea 6 oz × 30 mL/oz = 180 mL

🟦 Water = 100 mL

🟦 Clear broth 8 oz × 30 mL/oz = 240 mL

🟦 Total intake:

🟦 150 + 120 + 180 + 100 + 240 = 790 mL

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Answer 8

Correct Answers:

Nurses might focus on a client's physiological needs over psychosocial needs when communicating during care.

Rationale :

🟦 During busy or high-acuity care situations, nurses may prioritize physiological needs such as pain control, vital signs, or treatments over psychosocial communication.

🟦 This shift in focus can unintentionally reduce opportunities for therapeutic communication, emotional support, and active listening.

🟦 Awareness of this tendency helps nurses intentionally balance task-oriented care with effective interpersonal communication.

🟦 Holistic nursing practice requires addressing both physical and emotional needs during client interactions.

🟦 Recognizing factors that influence communication improves client satisfaction and outcomes.

Clients who have developmental deficits are less distracted by environmental noises than clients who do not have these deficits:

🟦 Clients with developmental deficits are often more sensitive to environmental stimuli.

🟦 Noise and distractions can significantly impair communication.

Nurses caring for clients experiencing a highly emotional situation report that communication is rarely affected:

🟦 Strong emotions such as fear, anxiety, or grief commonly impair communication.

🟦 Emotional distress can limit a client’s ability to process information.

Hearing loss is considered a developmental factor that has minimal effect on nurse-client communication:

🟦 Hearing loss is a sensory factor, not developmental.

🟦 It can have a significant impact on communication if not accommodated.

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Answer 9

Correct Answers:

FLACC

Rationale :

🟦 The FLACC scale (Face, Legs, Activity, Cry, Consolability) is specifically designed to assess pain in infants and nonverbal clients.

🟦 A 3-month-old infant cannot self-report pain, making observational tools essential.

🟦 FLACC evaluates behavioral and physical indicators that reliably reflect pain intensity in young infants.

🟦 This scale is widely validated for postoperative pain assessment in pediatric clients under 2 years of age.

🟦 Using FLACC allows the nurse to provide timely and appropriate pain management.

Oucher:

🟦 The Oucher scale is intended for children who can understand numbers or pictures, usually older than infancy.

🟦 It requires some level of cognitive and communicative ability.

Word-Graphic Rating Scale:

🟦 This scale requires the client to verbalize pain intensity.

🟦 Infants are unable to use word-based or numeric descriptors.

FACES:

🟦 The FACES scale is appropriate for young children who can point to a face that matches their pain.

🟦 A 3-month-old infant lacks the developmental ability to use this tool.

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Answer 10

Correct Answers:

59

Rationale :

🟦 Convert pounds to kilograms using the standard nursing conversion: lb × 0.45

🟦 132 lb × 0.45 = 59.4 kg

🟦 Rounded to the nearest whole number = 59 kg

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QLexNursing

1 :
A nurse is reinforcing teaching about vancomycin with a client who has an infection. Which of the following information should the nurse include in the teaching?

2 :
A nurse is assisting with an in-service about hospital-acquired injuries to a group of staff. Which of the following conditions should the nurse include in the teaching as an example of a hospital-acquired injury?

3 :
The nurse is caring for a patient with an incision. Which actions will best indicate an understanding of medical and surgical asepsis for a sterile dressing change?

4 :
A nurse is reinforcing teaching with a newly licensed nurse about orthostatic hypotension. Which of the following information should the nurse include?

5 :
A nurse is assisting with the care of a client.

Answer Options

6 :
A nurse is reinforcing teaching about delegation with a newly licensed nurse indicates understanding? Which of the following statements if made by the newly licensed nurse

8 :
A nurse is discussing factors that influence communication with a group of newly licensed nurses. Which of the following information should the nurse include?

9 :
A nurse is assisting with the care of a 3-month-old infant following a surgical procedure. Which of the following pain scales should the nurse use to determine the infant's pain level?

10 :
Your patient weighs 132 pounds. How much does your patient weigh in kilograms? Round to the nearest whole number

QLexNursing

1 : A nurse is reinforcing teaching about vancomycin with a client who has an infection. Which of the following information should the nurse include in the teaching?

2 : A nurse is assisting with an in-service about hospital-acquired injuries to a group of staff. Which of the following conditions should the nurse include in the teaching as an example of a hospital-acquired injury?

3 : The nurse is caring for a patient with an incision. Which actions will best indicate an understanding of medical and surgical asepsis for a sterile dressing change?

4 : A nurse is reinforcing teaching with a newly licensed nurse about orthostatic hypotension. Which of the following information should the nurse include?

5 : A nurse is assisting with the care of a client.

Answer Options

6 : A nurse is reinforcing teaching about delegation with a newly licensed nurse indicates understanding? Which of the following statements if made by the newly licensed nurse

8 : A nurse is discussing factors that influence communication with a group of newly licensed nurses. Which of the following information should the nurse include?

9 : A nurse is assisting with the care of a 3-month-old infant following a surgical procedure. Which of the following pain scales should the nurse use to determine the infant's pain level?

10 : Your patient weighs 132 pounds. How much does your patient weigh in kilograms? Round to the nearest whole number

1 :
A nurse is reinforcing teaching about vancomycin with a client who has an infection. Which of the following information should the nurse include in the teaching?

2 :
A nurse is assisting with an in-service about hospital-acquired injuries to a group of staff. Which of the following conditions should the nurse include in the teaching as an example of a hospital-acquired injury?

3 :
The nurse is caring for a patient with an incision. Which actions will best indicate an understanding of medical and surgical asepsis for a sterile dressing change?

4 :
A nurse is reinforcing teaching with a newly licensed nurse about orthostatic hypotension. Which of the following information should the nurse include?

5 :
A nurse is assisting with the care of a client.

6 :
A nurse is reinforcing teaching about delegation with a newly licensed nurse indicates understanding? Which of the following statements if made by the newly licensed nurse

8 :
A nurse is discussing factors that influence communication with a group of newly licensed nurses. Which of the following information should the nurse include?

9 :
A nurse is assisting with the care of a 3-month-old infant following a surgical procedure. Which of the following pain scales should the nurse use to determine the infant's pain level?

10 :
Your patient weighs 132 pounds. How much does your patient weigh in kilograms? Round to the nearest whole number