ATI Fundamentals & Basics

A client has fallen in the bathroom. Which of the following is the priority nursing action?

Assess the client's level of consciousness *Safety first. Before proceeding with the assessment or taking vital signs assess the level of consciousness. *Complaints of pain, any joint or bone deformity may provide evidence of fractures or dislocations. *Inspection of the skin will determine lacerations, contusions, or hematomas that may need to be treated. *After a report to the provider, additional x-rays or exams may be ordered.

A nurse is caring for multiple clients on the acute care unit. Which action demonstrates effective time management?

Cluster activities that are to be performed on the same client *Clustering activities that are to be performed on the same client or are in close physical proximity is a time-saving strategy that helps prevent unnecessary walking.

What is an appropriate angle of insertion for an intradermal injection?

15°

What is an appropriate angle of insertion for a subcutaneous injection?

45°

A school nurse discovers a teacher who has collapsed in the hallway. Which of the following of actions is the nurse's priority?

Confirm unresponsiveness *The first action the nurse should take using the nursing process is to assess that the client is unresponsive.

A nurse's neighbor is scheduled for elective surgery. The neighbor's provider indicated that a moderate amount of blood loss is expected during the surgery, and the neighbor is anxious about acquiring an infection from a blood transfusion. Which of the following is appropriate for the nurse to suggest?

Donating autologous blood before the surgery *Autologous blood transfusion is the collection and reinfusion of the client's own blood. *With preoperative autologous blood donation, the blood is drawn from the client 3 to 5 weeks before an elective surgical procedure and stored for transfusion at the time of the surgery. *While blood bank tests greatly reduce the risks of acquiring certain infectious diseases, these risks can not be eliminated entirely. *Autologous blood is the safest form of blood transfusion; exclusive use of a client's own blood eliminates exposure to transfusion-transmitted infection.

A nurse is auscultating the breath sounds of a client who has asthma. When the client exhales, the nurse hears continuous high-pitched squeaking sounds. The nurse should document this as which of the following?

Wheezes *Wheezes are continuous, high-pitched squeaking sounds, first evident on expiration, but possibly evident on inspiration as the airway obstruction of asthma worsens. *Wheezes are often audible without a stethoscope.

Within the context of the nurse client relationship, congruence on the part of the nurse implies

using communication tools in a genuine and spontaneous manner *Congruence is an expression of genuineness on the part of the nurse accomplished by consistently using therapeutic verbal and nonverbal communication.

At a well-child visit, the parents report that their toddler occasionally touches and fondles her genital area. The parents ask the nurse if this behavior is something to be concerned about. Which of the following is a correct response?

Awareness of body structures and sensations is normal and expected *Genital self-stimulation by the toddler is normal and expected. It is a new area to explore, similar to exploring the toes at an earlier age, but it has pleasurable sensations too! *It should be ignored unless the behavior becomes pervasive, and then it should still be ignored and the child should be distracted to come and do some fun and exciting activity

A nurse on a rehabilitation unit is transferring a client from a bed to a chair. To avoid a back injury, which of the following techniques should the nurse use?

Bend at the knees while maintaining a wide stance and a straight back, with the client's hands on the nurse's shoulders, and the nurse's hands under the client's axillae *Bending at the knees results in the use of the large muscles of the legs. *Keeping the back straight avoids using the small, easily injured back muscles. *When the client's hands rest on the nurse's shoulders, security is provided for the client. *Placing the hands under the client's axillae avoids placing pressure on the chest, which can be uncomfortable for the client.

A nurse is assessing a client who has diabetes mellitus and is experiencing foot pain. Which of the following are signs and symptoms of an infection? (Select all that apply.)

Bradycardia is incorrect. *Tachycardia, not bradycardia, is a sign of infection. Increased neutrophils is correct. *Increased neutrophils is a sign of infection. *Through the process of phagocytosis, these specialized WBC, called neutrophils and monocytes, ingest and destroy microorganisms. Increased RBC is incorrect. *Increased RBC are not associated with the presence of an infection. Increased platelets is incorrect. *Increased platelets are not associated with the presence of an infection. Localized edema is correct. *Localized edema is a sign of infection. *Edema occurs as injury causes tissue necrosis. *The body releases histamine, bradykinin, prostaglandin, and serotonin, which increases the permeability of small blood vessels. *Fluid, protein, and cells enter interstitial spaces and the accumulated fluid appears as localized swelling or edema.

A nurse is providing dietary education for a client with cholecystitis. Which of the following food choices made by the client indicates a need for further teaching?

Broccoli with cheese sauce *Cholecystitis is characterized by inflammation of the gallbladder. *The gallbladder stores and releases bile that aids in the digestion of fats. *Fat intake should be limited to reduce stimulation of the gallbladder. *Other foods that may be contraindicated include coffee, broccoli, cauliflower, Brussels sprouts, cabbage, onions, legumes, and highly seasoned foods.

A nurse is preparing to administer a flu vaccine, which of the following techniques should the nurse use to locate the deltoid muscle?

By palpating the lower edge of the acromion process and measuring 4 finger-widths below to the midpoint and center of the lateral aspect of the upper arm *Palpating the lower edge of the acromion process and measuring 4 finger-widths below the midpoint and the center of the lateral aspect of the upper arm would be the correct location to administer the medication.

A nurse is providing discharge teaching for a client who has heart failure and has a new prescription for furosemide (Lasix). Which of the following foods should the nurse include in the client's diet plan?

Cantaloupe *High ceiling loop diuretics promote the excretion of potassium from the body. *Cantaloupe is high in potassium and is a good food choice for a client who needs to increase dietary potassium intake.

A client has a new tracheostomy. Which of the following interventions should the nurse include when performing tracheostomy care?

Change tracheostomy ties when soiled *Tracheostomy ties should be changed once a day or when soiled. *Secure new ties in place before removing old soiled ones to prevent accidental decannulation. *One or two fingers should be able to be placed between the tie tape and the neck.

A nurse is caring for a client who has a new colostomy. When demonstrating how to change the ostomy appliance and provide stoma care, which of the following actions should the nurse take?

Clean the peristomal skin with mild soap and water *Unless the facility's protocol or the provider's prescription specifies otherwise, this is an appropriate way for the nurse to cleanse the client's peristomal skin. *The nurse should use a mild, non-moisturizing soap and rinse well to avoid adhesion problems.

A nurse is assessing a client during admission to a behavioral health unit. Which source of information will the nurse find most helpful?

Client concerns *Information obtained directly from the client (client concern) is the most accurate and provides the best information available to the nurse. *The client is considered to be a primary source of information.

A nurse is caring for a client who has just had a mastectomy and has a closed wound suction device (Hemovac) in place. Which nursing action will ensure proper operation of the device?

Collapsing the device whenever it's one half to two thirds full of air *A closed wound self-suction device has a drainage catheter connected to a spring-loaded drum. *It must be collapsed periodically to create the enough suction to pull fluid into the collection area of the device. *As drainage or air accumulates, it is emptied and the device recompressed.

A nurse is assessing a client who is immobile for complications. Which of the following does the nurse expect to find? (Select all that apply.)

Contractures of extremities is correct. *Contractures of extremities are a complication of immobility because of disuse of muscles and joints. Decreased pain is incorrect. *Increased pain, not decreased pain, is a complication of immobility. Diarrhea is incorrect. *Constipation, not diarrhea, is a complication of immobility. Crackles in the lungs is correct. *Crackles in the lungs are a complication of immobility due to pulmonary stasis. Pressure ulcers is correct. *Pressure ulcers are a complication of immobility due to increased pressure on bony prominences.

A nurse is caring for a client who is neutropenic. Which of the following foods are appropriate for this client?

Cooked spinach and celery *Clients who are neutropenic are at increased risk for the development of infection. *The reduced numbers of neutrophils and other white blood cells can limit the presence of common infection manifestations. *The focus of care for client with neutropenia is on keeping the client's own normal flora under control and preventing the transmission of organisms. *Raw or fresh foods may be a source of bacteria. *The client should avoid raw fruits and vegetables, undercooked meats, eggs, or fish.

While measuring a client's vital signs, the nurse notices an irregularity in the heart rate. Which nursing action is appropriate?

Count the apical pulse rate for 1 full min, and describe the rhythm in the chart *If the pulse is irregular, it must be counted for a full minute to obtain an accurate rate. *The irregularity should be described in the client's medical record

A nursing is caring for a client who is 1 day postoperative following abdominal surgery. What is the first action the nurse should take after discovering that a client's wound has eviscerated?

Cover the incision with a moist sterile dressing *A wound open to air could easily become contaminated, leading to peritonitis, and any exposed organ tissue could dry out *Covering the wound with a moist sterile dressing is the first action the nurse should take to protect the client.

A nurse is teaching a client who has influenza about cough etiquette. Which of the following instructions should the nurse include?

Cover the nose and mouth with a tissue when coughing *The nurse should instruct the client to cover his nose and mouth with a tissue when coughing. *This prevents transmission of microorganisms. Tissues should be discarded in the nearest trash container.

A client being discharged following abdominal surgery will be performing his own dressing changes at home. It is most important for the nurse to include which of the following in the discharge plan?

Demonstration of appropriate hand hygiene *Very often, the home environment does not lend itself to the practice of surgical asepsis (sterile technique), and the client is usually taught to use medical asepsis (clean technique). *However, the client is still at risk for the transmission of micro-organisms that may cause an infection, and the nurse must help the client improvise with the resources available. *Proper hand hygiene is the most important and most basic strategy for preventing and controlling the transmission of pathogens.

A nurse is caring for a client who is requesting prescription pain medication. Which of the following actions should the nurse perform first?

Determine the location of the pain *Using the nursing process, assessment of the location of the pain is the priority action by the nurse.

A graduate nurse is caring for a client who is on neutropenic precautions. Which of the following actions by the nurse would require further teaching by the charge nurse?

Discarding an empty blood bag and blood tubing in the client's beside trash can *The empty blood bag and tubing are considered to be biohazard waste and should be disposed of in a red bag or bin that will be incinerated rather than taken to a landfill.

A client who is unstable and requires frequent vital signs has an electronic blood pressure machine automatically measuring his blood pressure every 15 min. However, the machine is reading the client's blood pressure at more frequent intervals, and the readings are not similar. The nurse checks the machine settings and observes the additional readings, but the problem continues. Which of the following is the appropriate nursing action?

Disconnect the machine, and measure the blood pressure manually every 15 min *If reliability of the monitoring equipment is questioned, a manual process should be used. *Also, malfunctioning equipment could pose a safety risk for the client, so it must be removed.

A nurse is working to develop a therapeutic relationship with a client. The nurse understands that which of the following is an example of the termination phase of a therapeutic relationship?

Discussing the client's new skill sets This option describes the termination phase of the relationship. Reviewing the client's demographic information. This option describes the preinteraction phase, which is done before meeting the client.

A nurse is providing the family of a client with acquired immunodeficiency syndrome (AIDS) education in preparation for discharge. A family member asks about appropriate clean up of blood or body fluids. Which of the following is the correct response by the nurse?

Disinfect the area with a 10% bleach solution after initial cleaning *A solution of 1 part bleach to 10 parts water (10% solution) is the disinfecting agent of choice after blood or body fluids are initially cleaned up and disposed of (at home in a sealed plastic bag and placed in the regular trash), and the area is initially cleansed with soap and water.

Which of the following should a group of community health nurses plan as part of a primary prevention program for occupational pulmonary diseases?

Elimination of the exposure *Primary prevention measures are those intended to prevent the onset of a targeted disorder. *Elimination of the exposure is the best way to avoid the undesirable outcome. *The primary prevention of occupational diseases is achieved only through the reduction or elimination of exposures to chemical, physical, or biological hazards, for example, by wearing personal protective equipment

The nurse is caring for a client who has pneumonia. Which of the following actions should the nurse take to thin the client's respiratory secretions?

Encourage the client to increase fluid intake *Increasing fluids promotes liquefaction and thinning of pulmonary secretions, which facilitates expectoration to clear the lungs.

A nurse receives a phone call from a client's family member who asks the nurse for an update on the client's condition. Which of the following actions should the nurse take to maintain the client's confidentiality?

Encourage the family member to contact the client directly for information *Nurses may not release medical information without the client's consent. *Therefore, the nurse should encourage the family member to contact the client directly for more information.

A nurse is caring for a client after an open radical prostatectomy. Which of the following interventions is the highest priority in the immediate postoperative period?

Encourage use of patient-controlled analgesia (PCA) as needed *Assessment of the client's pain level, along with monitoring the effectiveness of pain management given through patient-controlled analgesia, is the priority intervention in the immediate postoperative period.

A nurse is changing a dressing on a preschool-aged child who has a healing wound on a lower extremity. Which of the following nonpharmacologic comfort measures would be most appropriate for this child?

Encouraging the child to watch a favorite cartoon on television *Cartoons would be a very attractive distraction, and distraction is a powerful nonpharmacologic comfort intervention which works well with this developmental age.

A client reports awaking from sleep by contractions that are occurring every five minutes and lasting 30-40 seconds. Which of the following questions should the nurse ask to assess for true labor versus false labor?

"Have you noticed any bloody show or fluid coming from your vagina?" *Vaginal discharge of blood or fluid may indicate cervical dilation, and potentially rupture of membranes. *False labor is characterized by painless, irregular, and intermittent contractions that decrease in frequency, duration, and intensity with walking or position changes. *Contractions are felt in the lower back or above the umbilicus and often stop with comfort measures (like oral hydration). There is usually no vaginal discharge with false labor.

A nurse is caring for a client who has received an electrical burn. With permission from the client, the nurse is answering questions from the family. Which of the following is an appropriate response to the family's concerns?

"He has received an electrical burn. His condition is stable, and we will update you with any changes." *This response by the nurse is appropriate because it provides concrete information without medical jargon, and offers ongoing support.

A client returning from the surgical suite following a vaginal hysterectomy is awake and asking for something to drink. Her postoperative diet prescription reads: Clear liquids; advance diet as tolerated. Which of the following is appropriate for the nurse to tell the client?

"I am going to listen to your abdomen." *A common reason clients experience nausea and vomiting after surgery is delayed gastric emptying time or decreased peristalsis. *The nurse must auscultate the client's abdomen to determine the presence of bowel sounds before clear liquids.

A client is about to have a nasogastric tube (NG) inserted. The nurse explains the procedure and is ready to begin the insertion when the client says, "No way! You are not putting that hose down my throat. Get away from me." Which of the following statements is an appropriate nursing response?

"I can see that this is upsetting you." *This response addresses the client's feelings. *It uses the communication tools of reflecting and restating, which encourage communication by the client.

A nurse is teaching parents how care for their newborn. Which of the following statements indicates a good understanding of how to use a bulb syringe to suction excess mucous from the infant's airway?

"I should suction my baby's mouth before the nose." *The mouth should always be suctioned before the nose to prevent aspiration during the gasp response that occurs when the nose is suctioned.

A nurse is educating a client on restful sleep. Which of the following statements by the client would alert the nurse that further teaching is necessary?

"I watch television until I fall asleep." *When activities other than sleeping, like watching TV, are done in bed, they are not correlated to the expectation of sleep like simply lying down to sleep. *The nurse should facilitate maintenance of the client's usual bedtime routines as appropriate.

A nurse is providing teaching for a client who has neutropenia and is receiving chemotherapy. Which of the following client statements indicates an understanding of the teaching? (Select all that apply.)

"I will avoid crowds." *The client who is immunocompromised should avoid crowds while undergoing chemotherapy to reduce the risk of infection. "I will take my temperature daily." *The client who is immunocompromised should take daily temperature readings and report an elevated temperature to the provider.

A nurse is discussing the use of condoms with a female client. Which of the following statements by client represents a need for further teaching?

"I will remove the condom 30 minutes after intercourse." *To avoid any semen spillage onto the vulva or the vaginal area, the condom must be removed the same time as the penis. *To do that the condom rim should be held in place while the penis is withdrawn from the vagina.

A nurse is providing discharge education for a female client diagnosed with Chlamydia. Which statement made by the client would indicate the need for further instruction?

"I will return to the clinic in one month for re-screening." *No test for cure is required, but all women should be rescreened for re-infections 3 to 12 months after treatment because of high risk for pelvic inflammatory disease (PID). *There is less evidence of the need for re-screening of treated men, but it should be considered.

A nurse is responsible to check that an assistive personnel (AP) uses appropriate personal protection equipment while caring clients. Which of the following statements made by the AP indicates an appropriate understanding of standard precautions techniques?

"I will wear gloves and gown when bathing a client who has open skin lesions." *A nurse following standard precautions would select appropriate personal protective equipment when in direct contact with a client's bodily fluids.

An assistive personnel (AP) says to the nurse, "This client is incontinent of stool three or four times a day. I get angry, and I think that the client is doing it just to get attention. I think we should put adult diapers on her." Which is the appropriate nursing response?

"It is very upsetting to see an adult client regress." *This response illustrates the therapeutic communication tool of restating and clarifying. *It encourages the AP to express any feelings about the client soiling the bed for attention.

A client is admitted to the hospital after being on bed rest at home. The client has been incontinent and smells strongly of urine. His spouse, who has been caring for him at home, states that she is sorry and embarrassed about the unpleasant smell. Which response by the nurse is therapeutic?

"It must be difficult to care for someone who is confined to bed." *This response addresses the feelings of the client (the spouse, in this case) by using the communication tool of showing empathy. *It also facilitates therapeutic communication because it is nonjudgmental and encourages the spouse to express her feelings.

A nurse is talking with a client who is about to start using transcutaneous electrical nerve stimulation (TENS) to manage chronic pain. Which of the following client statements indicates to the nurse the need for further teaching?

"It's unfortunate that I have to be in the hospital for this treatment." *TENS units are portable. *The client can use his TENS unit at home or wherever he chooses.

A client being admitted to a nursing unit asks the nurse, "My friend has carpal tunnel syndrome and said I would probably get it too because of my work. What can I do to prevent it?" Which of the following statements would be the nurse's best response?

"Keep your wrists in a neutral position or wear wrist braces for support." *Repetitive motions that stress the wrist due to bending or twisting are most frequently associated with carpal tunnel syndrome. *For example assembly line workers have a very high incidence of carpal tunnel syndrome. *There may be a hereditary predisposition as well due to an inborn narrowing of the carpel tunnel where the median nerve passes through the wrist. *The key to prevention is to avoid the twisting, bending motions of the wrist and minimize repetitive motions. *Take breaks, stretch and exercise the wrists as well as back and shoulders. *A wrist brace will help to maintain neutral position.

A nurse is educating a parent of a newborn about safety measures. Which of the following statements made by the client would indicate a need for further teaching?

"Once my baby begins to roll over it is okay to use a small pillow in the crib." *It is never safe to have a pillow or a soft surface in the crib because of the danger of suffocation.

A home health nurse is making an initial assessment visit to an older adult client who has type 1 diabetes mellitus. The nurse should use which of the following statements to evaluate the client's ability to measure blood glucose accurately?

"Please use your glucometer and show me the results." *Asking for a return demonstration is an effective way to assess a client's ability to complete a psychomotor activity. *The nurse should carefully observe the client performing the activity to validate the client's understanding of the procedure.

A nurse is teaching a client recovering from a cerebrovascular accident how to dress. The client has residual hemiplegia, so the nurse instructs the client to do which of the following when putting on a shirt?

"Slide your weaker arm through its sleeve first." *This method allows the client optimal use of the strong arm in getting the shirt on over the weaker arm.

A nurse is assessing a client admitted with a sudden onset of severe back pain of unknown origin. Which statement would be most effective for the nurse use to elicit further information from this client about his pain?

"Tell me how you are feeling right now." *This is an open-ended statement that allows the client to respond to the nurse with the widest range of information.

A nurse is providing preoperative teaching for a client who will undergo abdominal surgery. The nurse explains that the client will wear antiembolism stockings after the procedure. When the client asks what the stockings do, which of the following is an appropriate nursing response?

"They'll improve your circulation to keep blood from pooling in your legs." *Antiembolism stockings promote venous return from the legs, thus helping to prevent venous thrombosis (clot formation) and peripheral edema.

A nurse is providing a tour of the labor and delivery unit to expectant parents. Which statement made by the mother indicates a need for further education?

"We will need to remove the baby's ankle identification band during diaper changes." *This statement indicates a need for further education. *The mother, newborn, and significant other are identified by plastic identification bands with permanent locks that must be cut to be removed. *Per most hospitals' policies, newborns will be provided with both ankle and armband identification. *These identification bands should not be removed for any reason until the newborn is discharged from the hospital.

A client began having sleeping problems 6 months ago soon after being diagnosed with cancer. Prior to that, the client had good physical health, however, the client's spouse of 50 yr died 1 yr ago this week. The client tells the nurse, "I'd be better off dead because I am totally worthless." Which of the following is an appropriate nursing response?

"You have been feeling very sad and alone for some time now." *Clients who are depressed have difficulty expressing their feelings. *This response by the nurse uses the therapeutic communication tools of empathy, and reflecting to help the client become more aware and accepting of his feelings.

An older adult client appears agitated when the nurse requests that the client's dentures be removed prior to surgery and states, "I never go anywhere without my teeth." Which of the following is an appropriate nursing response?

"You seem worried. Are you concerned someone may see you without your teeth?" *The nurse uses two therapeutic communication tools in this response. *One is empathy, which is shown by focusing on the client's feelings. *The other is validation/clarification with which the nurse seeks to validate the reason for the client's feelings. TEST-TAKING STRATEGY: In answering this communication question, you are correct in selecting a response that recognized and responded to the client's feelings.

A nurse is preparing an IM injection of two medications in the same syringe to give as a single injection. (Order the steps of the process by placing the options in the correct sequence.)

(1) Draw up a volume of air equal to the volume of the medication from vial A. (2) Inject into vial A the volume of air equal to the amount of medication to withdraw from vial A. (3) Draw up a volume of air equal to the medication dose from vial B. (4) Withdraw the prescribed amount of medication from vial B. (5) Withdraw the prescribed amount of medication from vial A. *To mix medications from two vials in the same syringe, the nurse should first draw up a volume of air equal to the volume of the medication dosage from vial A. *The nurse should then inject into vial A the volume of air equal to the amount of medication to withdraw from vial A, making sure the needle does not touch the medication. *Next, the nurse should withdraw the needle from vial A and draw up the amount of air equal to the volume of the dose from vial B. *The nurse should inject that air into vial B, and without withdrawing the needle, draw up the medication dose from vial B. *After replacing the needle with a fresh sterile needle, the nurse can withdraw the prescribed amount of medication from vial A. *The medications are then ready to administer.

A nurse is caring for a child and identifies an extravasation at the intravenous site. Identify the order the nurse should perform the following actions. (Move the steps into the box on the right, placing them in the selected order of performance. All steps must be used.)

(1) Stop the infusion. (2) Elevate the extremity. (3) Notify the provider. (4) Perform prescribed treatment. (5) Remove the IV line. *The nurse should first stop the infusion. *Next, the nurse should elevate the extremity. *The provider should be notified next, followed by performing prescribed treatment. *Finally, the IV line should be removed.

What is a soap suds enema?

*A soapsuds enema acts as an irritant to increase peristalsis, thus facilitating the removal of the stool. *A soapsuds enema is usually given to cleanse the bowel completely after digital removal of an impaction.

What is aplastic anemia?

*Aplastic anemia is caused by a failure of the bone marrow to produce sufficient numbers of red blood cells. *Hematuria, or hemoglobin present in the urine, is not a manifestation of aplastic anemia.

What is iron deficiency anemia?

*Iron deficiency anemia is a condition in which red blood cells contain decreased levels of hemoglobin. *Hematuria, or hemoglobin present in the urine, is not a manifestation of iron deficiency anemia.

What is a tap water enema?

*Tap water enemas were previously used to cleanse the bowel but are now contraindicated because of the risk of fluid and electrolyte imbalances. *Tap water, which is hypotonic, can be drawn into the cells, causing fluid overload (hypervolemic state).

How long should a client limit the length of a bath to?

*The client should limit the length of the bath to no longer than 10 to 15 min. *Remaining in warm water for an extended length of time can cause vasodilation, which can cause the client to feel lightheaded or dizzy.

A nurse is working with a newly graduated nurse who is caring for a client receiving a continuous IV infusion. The newly graduated nurse identifies that her client's IV has infiltrated. Which of the following reported findings would be normal?

*The infusion rate has stopped although the tubing is not kinked *There is swelling around the insertion site. *There is no blood return when the tubing is aspirated.

Why would a nurse INSPECT the abdomen?

*When inspecting the abdomen for distension, the nurse should observe for bloating, a shiny appearance, as well as tight-looking skin for ascites. *Bruising indicates a bleeding disorder or injury to the abdomen.

A nurse is caring for a client who is receiving oxygen at 2 L/min via a nasal cannula. What oxygen concentration is the client receiving?

28% *A flow rate of 2 L/min delivers an oxygen concentration of approximately 28%.

A fire in a first floor operating room is forcing evacuation of clients from a second floor unit to another building. Which of the following clients would have the highest priority for the charge nurse to evacuate?

A client receiving IV antibiotics every six hours for a leg ulcer *The client with a leg ulcer can walk unassisted without an IV pole. In a hospital evacuation, unlike triage and evacuation outside of the hospital, the most stable, ambulatory clients will be evacuated first, followed by those who need assistance with mobility (wheelchairs) or equipment (tubes, catheters), and finally those who need to be moved by stretcher or in their hospital beds. *The prevailing concept is to move as many clients as quickly and safely as possible from the area.

A nurse in a rehabilitation unit is assessing a group of clients who have traumatic brain injuries. Which of the following clients is a priority for a referral?

A client who coughs after drinking liquids *A client who coughs after drinking liquids is at risk for aspiration. *Therefore, this client is at the greatest risk for injury and has the priority need for a referral to a speech therapist.

When should a jacket harness be used?

A jacket harness is used with caution to prevent a client from falling out of a chair.

What is a third heart sound?

A low-pitched sound after the second heart sound *S3 is caused by rapid ventricular filling during diastole. *It is best heard at the mitral area, with the client lying on the left side. *S3 is commonly heard in children and young adults. *In older adults and those with heart disease, an S3 often indicates heart failure.

What is a heart murmur?

A swishing or a whistling quality *Heart murmurs are caused by turbulent blood flow through valves or ventricular outflow tracts. *Low- and medium-frequency sounds are more easily heard with the bell of the stethoscope applied lightly to the skin; high frequency sounds are more easily heard with a diaphragm. *A murmur may be a sign of valvular disease.

A nurse is caring for a client who is 2 days postoperative following abdominal surgery. The nurse should be concerned about which of the following findings?

A wound dressing with thick, light green drainage *Thick, light-green drainage indicates infection. *This is the finding that should cause concern; the nurse should report this to the surgeon immediately.

When initiating cardiopulmonary resuscitation (CPR), the nurse must confirm which of the following assessment findings prior to beginning chest compressions?

Absence of pulse *Prior to beginning chest compressions, it is essential that the nurse assess for the absence of a pulse. *The carotid site is assessed for 5 to 10 seconds. *If no pulse is felt, then chest compressions are begun. *Performing chest compressions on a client who has a pulse can lead to cardiac dysrhythmias and death.

A nurse is caring for an older adult client who has kyphosis. Which of the following interventions should the nurse suggest to the client to prevent further musculoskeletal compromise?

Adding calcium and vitamin D supplements *Kyphosis is an anteroposterior or forward bending of the thoracic spine that results in a loss of height and a humped-back appearance. *A common cause is osteoporosis, a metabolic, age-related disease in which bone demineralization causes loss of bone tissue and decreased bone mass. *Bone resorption exceeds bone formation, resulting in fragile, porous bones that easily fracture. *The client can prevent further bone loss by eating calcium-rich foods and supplementing the diet with calcium and vitamin D, which enhances calcium absorption.

A hospital has been notified that possible bioterrorist activity has taken place at a large sporting event nearby. A nurse has been put in charge of preparing a holding area to meet the needs of victims who report headache, dizziness, anxiety and shortness of breath, and are noted to have a bitter almond odor to their breath. What medication should the nurse be prepared to administer?

Amyl Nitrate *The victims' symptoms are consistent with cyanide poisoning. *Amyl Nitrate is given for cyanide poisoning.

For which of the following clients would benefit most from use of a walker?

An 82-year-old female client post right hip replacement that has had two falls in the past week *Walkers are needed for clients with balance problems or those that cannot support their own weight.

What is ankylosis?

Ankylosis is an immobility and consolidation of a joint, often a result of disuse.

A postoperative client's knee dressing becomes completely saturated with blood 1 hr after transfer to the clinical unit. Which of the following is an appropriate nursing action?

Apply direct pressure to the operative site *Most bleeding can be stopped with direct pressure, unless a major artery has been severed. *The surgeon must be notified because, in some cases, the client must return to the surgical suite for ligation of the bleeding vessels.

A nurse in an urgent care center is caring for a client who fell and injured her ankle. The ankle appears swollen and ecchymotic. While the client waits for the technician to take x-rays, which of the following are appropriate nursing interventions? (Select all that apply.)

Apply ice to the ankle is correct. *Ice helps reduce swelling and pain. Encourage range of motion of the foot is incorrect. *The client should avoid any movement that could cause further pain and tissue injury. Provide the client with a light snack is incorrect. *Depending on the extent of the injury, for example, if she has a bimalleolar fracture, she might require an open reduction at an acute-care hospital. *Until the nurse knows the extent of the injury, the client should remain NPO. Apply a compression bandage is correct. *Wrapping an elastic bandage around the ankle can help reduce edema and pain. Elevate the foot is correct. *Elevation can help reduce edema and pain.

A nurse needs to determine a client's strength before ambulating. Which of the following should the nurse do?

Ask the client to plantar flex the feet against resistance *It is necessary to assess the client for muscle strength (legs and upper arms) as immobile clients have decreased muscle strength, tone, and mass, which affects the ability to bear weight and raise the body.

A nurse is admitting a client in preparation for a surgical procedure. Under the Patient Self-Determination Act (PSDA), which of the following is the nurse's responsibility regarding the client's advance directives?

Ask the client whether she has created advance directives *The PSDA requires facilities to provide information to the client about the client's rights under state law to make decisions, including the right to refuse treatment and formulate advance directives. *Under the act, staff should ask the client if she has advance directives and document the client's response.

When admitting a client, the nurse records which information in the client's record first?

Assessment of the client *The nurse should document the findings of the client's assessment to provide information about the health status of the client on admission. *This is the first step of the nursing process and takes place prior to the subsequent steps. TEST-TAKING STRATEGY: With a priority-setting question where all the options appear correct, but various stages of the nursing process (assessment, intervention, evaluation) are reflected in the options, rely on the nursing process to help set priorities. Assessment comes first, followed by analysis, planning, intervention, and evaluation.

A nurse is caring for a 16-year-old client who has multiple injuries including a brain contusion as a result of a motor-vehicle crash. He has been combative and impulsive and has pushed the nurse away and climbed over the side rails. His parents tell the nurse, "This is not like our son at all." Which nursing intervention will best ensure the safety of this client?

Assign a staff member to sit with the client around the clock. *Restraints may only be used when all other methods to control a client's unsafe behavior are exhausted. *In this situation, these methods include moving the client to a safer location, reorienting the client, and arranging for a staff member to sit with the client at all times. *The nurse realizes that the action most likely to ensure the client's safety is to enlist a sitter. *A sitter can provide the continuity of care this client needs, including frequent reorientation of the client's behavior for unsafe actions.

A nurse is providing education for a client who has a new diagnosis of Crohn's disease. Which of the following activities are essential for assisting the client with managing the disorder and continuing to perform self-care activities? (Select all that apply.)

Establishing the client's learning needs *Prior to planning any teaching session, the nurse should perform a comprehensive assessment of the client's learning needs. *This assessment incorporates information from the client's history and physical assessment, current health problems, understanding of and compliance with the prescribed treatment plan, and support system. Determining the client's literacy level *Knowing the client's literacy level is an important factor in communicating with the client and in delivering audiovisual presentations and written materials. *If the client cannot understand the information the nurse presents, he will not learn. Evaluating the client's readiness for learning *The nurse should determine the client's physical readiness (pain control, for example), emotional readiness (acceptance of diagnosis, for example), and cognitive readiness (appropriate level of consciousness, for example). Identifying the client's learning style *The best way to learn varies from client to client. *Some people learn best by watching a demonstration, others thrive in a group setting, while others prefer to read information on their own. *In a group setting, the nurse should use a variety of styles to accommodate most learners. *For an individual client teaching session, the nurse should first identify how the client learns best.

A 3 year old child has had multiple tooth extractions while under general anesthesia. The client returns from the postanesthesia care crying, but awake, from the recovery room. Which approach is likely to be successful?

Examine the mouth last *It is always appropriate to leave the most distressing part of a physical examination of a toddler until the end. *Since the mouth is the area of discomfort, examining it is likely to cause more crying and uncooperative behavior for the remainder of the assessment

A nurse is verifying NG tube placement following insertion for a client. Which of the following actions should the nurse take? (Select all that apply.)

Examining aspirated secretions *Gastric secretions are usually cloudy and green, off-white, or tan, and are sometimes bloody, depending on the client's condition. *Intestinal secretions are stained with bile and usually appear golden yellow or brownish green. Measuring the pH of aspirate *Stomach contents are usually acidic, with a pH from 1 to 4, although it can be as high as 6 if the client is taking certain acid-reducing medications. *A pH above 6 is an indication the distal end of the tube could be in the respiratory tract or in the intestines. Obtaining an x-ray of the chest and abdomen *Radiological examination is the most reliable method of verifying the placement of an NG tube.

A nurse is providing teaching to a client who is experiencing constipation. Which of the following should the nurse discuss as causes of constipation? (Select all that apply.)

Excessive laxative use is correct. *Excessive laxative use should be discussed as a cause of constipation. *Chronic use of laxatives causes the large intestine to lose muscle tone and become less responsive to stimulation by laxatives. Ignoring the urge to defecate is correct. *Ignoring the urge to defecate should be discussed as a cause of constipation. *Anything that prevents the client from responding to the urge to defecate and disrupts regular habits can cause possible alterations in bowel habits, such as constipation. Inadequate fluid intake is correct. *Reduced fluid intake slows the passage of food through the intestine and can result in hardening of stool contents, and should be discussed as a cause of constipation. Increased fiber in the diet is incorrect. *Increased fiber promotes more efficient bowel emptying, and should not be discussed as a cause of constipation. Increased activity is incorrect. *Increased activity promotes bowel emptying, and should not be discussed as a cause of constipation.

A nurse is triaging clients following a mass casualty event. The nurse should place a client who has sustained fatal injuries in which of the following triage categories?

Expectant Category (Class IV) *Class IV (Expectant Category) is reserved for clients who are not expected to live and will be allowed to die naturally. *Comfort measures may be provided, but restorative care will not. *These clients are the lowest priority when a mass casualty has occurred.

A nurse is preparing to insert a nasogastric tube for a client admitted with a bowel obstruction. Which of the following should the nurse do first?

Explain the procedure to the client *Informing the client about the procedure reduces fear and is helps gain the client's cooperation, which is important for nasogastric tube insertion. *This is the first action the nurse should take.

A nurse is caring for a client who has a new diagnosis of type 1 diabetes mellitus. The client has voiced feelings of hopelessness about the knowledge and skills needed for self-care. Which of the following interventions should the nurse use next to encourage the client to begin learning?

Exploring the client's past coping mechanisms *The first action the nurse should take using the nursing process is to assess the client's successful ways of coping in the past and then reinforce them. *This will help encourage the client to begin to learn self-care.

A nurse is delegating client care tasks to a newly hired assistive personnel (AP). Which of the following tasks is the priority for the nurse to supervise?

Feeding a client who has dysphagia *Using the airway, breathing, circulation approach to client care, the priority action the nurse should take is to supervise the AP feeding the client who has a risk for aspiration. *Therefore, this is the priority task for the nurse to supervise.

A nurse is assessing a client who has narcolepsy. Which of the following is an expected finding? (Select all that apply).

Feeling extremely tired upon waking is incorrect. *Clients who have narcolepsy typically feel refreshed upon waking. Sudden attacks of sleep is correct. *Sudden attacks of sleep is an expected finding of narcolepsy. Sleep-wake cycle hallucinations is correct. *Sleep-wake cycle hallucinations, known as hypnagogic hallucinations, are an expected finding of narcolepsy. Sleep apnea is incorrect. *Sleep apnea is associated with breathing-related sleep disorder rather than narcolepsy. Urge to move legs when trying to sleep is incorrect. *The urge to move legs when trying to sleep is associated with restless legs syndrome rather than narcolepsy.

A nurse is caring for an older adult client who is confused and continually grabs at the nurses. Which of the following is a nursing action?

Firmly tell the client not to grab *Setting limits by telling the client not to grab people is an effective way of dealing with this behavior.

A nurse is documenting the intake for a client who is scheduled for an abdominal computed axial tomography (CT) scan. Prior to the scan, the client consumes 12 oz sodium diatrizoate and meglumine diatrizoate (Gastrografin). The client is NPO and has an IV of D5½ NS running at 75 mL/hr from 0700 until 1200. The IV runs at 30 mL/hr from 1200 to 1500. At 1500, the client is no longer NPO and has 6 oz juice. How many mL should the nurse document as the client's intake for the shift?

First, determine the amount of intake for each source Sodium diatrizoate and meglumine diatrizoate: 12 oz 1 oz = 30 mL 12 oz x 30= 360 mL D5½ NS IV: 75 mL/hr from 0700 until 1200: 75 mL/hr x 5 hr = 375 mL 30 mL/hr from 1200 until 1500: 30 mL/hr x 3hr = 90 mL Total IV intake = 90 mL + 375 mL = 465 mL Juice: 6 oz 1 oz = 30 mL 6 oz x 30 = 180 mL Total the amounts: 360 mL + 465 mL +180 mL = 1,005 mL The client's total intake is 1,005 mL.

A client is recovering from gallbladder surgery performed under general anesthesia. The nurse should encourage the client to use the incentive spirometer how many times per hour?

Four to five *This device is designed to motivate the client to take deep breaths and should be included in the postoperative plan of care. *Clients should use incentive spirometry four to five times every hour.

A nurse has just finished teaching a client with diverticulosis about appropriate dietary choices. Which selection by a client on the following day's menu indicates to the nurse that the client understands the teaching?

Fresh green beans instead of canned for lunch *A high-fiber diet can help relieve the symptoms. *A diet high in fiber produces a large, bulky fecal mass that requires a shorter transit time in the bowel and helps maintain intracolonic pressure within a normal range. *The diet should include raw fruits and vegetables instead of canned or cooked ones.

A nurse is assisting an older adult client to ambulate who sometimes loses her balance while walking. Which of the following devices should the nurse use in helping the client to ambulate?

Gait belt *The nurse should use a gait belt to help support the client during ambulation. *A wheeled walker will not support a client from falling if balance is lost *A cane will not support a client from falling if balance is lost

A nurse is caring for a client who has a terminal illness. The client requests a do-not-resuscitate (DNR) order, but the provider states there is not a need for one at this point. Which of the following actions by the nurse is the priority?

Gather information to support the need for a DNR order *The first action the nurse should take using the nursing process is to assess the situation by gathering information to support the client's request to have a DNR order.

A client is ambulating in the hallway in bare feet. What is the priority nursing action at this time?

Get the client's slippers and have him put them on *Making sure that the client wears slippers or shoes is the priority action since it addresses the client's immediate risk of slipping on the floor.

Which nursing action prevents injury to a client's eye during the administration of eye drops?

Holding the tip of the container above the conjunctival sac *The tip of the container can injure the client's eye and should not come in contact with the eye. *In addition, if the client has an eye infection, the nurse must be careful not to touch one eye with secretions from the other eye.

A nurse is caring for a client who is in the early stages of hypoxia and is receiving oxygen therapy. When assessing this client, the nurse should expect to find which of the following early indications of hypoxia?

Hypertension *During the early stages of hypoxia, blood pressure is usually elevated unless shock is the cause of the hypoxia. *In the late stages of hypoxia, clients are likely to develop hypotension. *In the early stages, vital-sign changes include increases in the heart and respiratory rates.

The mother of a toddler calls to the nurse, "Help! My baby is choking on his food." The nurse determines that the Heimlich maneuver is necessary based on which finding?

Inability of the toddler to cry or speak *When no sound can pass through the vocal cords, a complete obstruction is evident. *The Heimlich maneuver should be used to dislodge whatever is obstructing the trachea.

The parent of a two-year-old child reports feeling frustrated with the fact that her son is saying no to everything. The nurse should teach the parent that this behavior is a normal expression of the child's desire to accomplish which of the following?

Increase their independence *The drive for independence is expressed by the toddler opposing the desires of those in authority (tantrums) and attempting to do everything for themselves. *The Erickson developmental stage for this age is "Autonomy vs. Shame and Doubt."

Which nursing action demonstrates safe principles of administering a routine immunization to an infant?

Inject the vaccine into the vastus lateralis muscle *The vastus lateralis muscle is the preferred site for administering routine immunizations to infants because it is large enough to accommodate the volume of the medication.

A nurse is preparing information for a foot and nail care program for a group of clients who have peripheral neuropathy. Which of the following information should the nurse include in the program?

Inspect each foot daily using a mirror *The nurse should include in the program to inspect the top and bottom of each foot daily with a mirror to find a possible break in the skin, which can place the client at risk for an infection.

A nurse is caring for a client who is on bedrest. The client's plan of care states that the client should perform isometric exercises every 2 hr. Which of the following actions should the nurse take as directed by the plan of care?

Instruct the client to hold a muscle tight for approximately 5 seconds, then relax *Isometrics is a form of exercise involving static (no movement) contraction of a muscle without any movement of the joint. *Isometrics may help to prevent muscle atrophy in clients who are on complete bedrest.

A nurse is working to develop a therapeutic relationship with a client. The nurse understands that which of the following is an example of the working phase of a therapeutic relationship?

Instructing the client on methods to achieve goals. *Instructing the client on methods to achieve goals describes the working phase, when the nurse and client work together to solve problems and accomplish goals.

A school nurse is teaching a group of parents about measures to prevent firearm injuries in the home. The nurse should explain that the best way to reduce the risk of injuries from guns is to do which of the following?

Keep ammunition and guns in separate, locked locations *The greatest risk to this client is injury from a loaded firearm. *Keeping ammunition in a locked cabinet separate from the firearms is the best intervention for reducing the risk of injury. *Not only does it prevent access to the weapon, but it also prevents injury from accidental discharge because it does not contain ammunition.

A nurse is assessing an older adult client who has osteoporosis. Which of the following spinal deformities should the nurse expect to find in this client?

Kyphosis *Kyphosis, a forward "stooping" posture with a loss of height, is an angulation of the posterior curve of the thoracic spine, usually a result of osteoporosis. *It is most common in older adults and increases with aging and vertebral fractures.

The parents of an adolescent client ask the nurse why the meningiococcal conjugate vaccine is recommended before attending college. Which of the following statements best explains the reason why college-aged students should receive this vaccine?

Living in a dormitory increases the risk of exposure to the disease *Living in close quarters, like dormitories or barracks, greatly increases the risk of being exposed to meningococcal pneumonia. *Other risk factors include travel to a country where the disease is endemic, biologists who work with the organism and clients who have no spleen function (and consequently are immunosuppressed).

A nurse has inserted an indwelling urinary catheter for a male client. Where should the nurse tape the catheter to prevent pressure on the client's urethra at the penoscrotal junction?

Lower abdomen *The lower abdomen or the inner aspect of the thigh are the recommended sites to eliminate the penoscrotal angle and prevent the formation of a urethrocutaneous fistula.

A nurse is preparing to transfer a client from the bed to a stretcher. Which action increases the nurse's risk for injury?

Manually lifting the client's full weight *Lifting is a high risk activity that causes significant biochemical and postural stressors. *Manual lifting should only be performed as a last resort and only if it does not involve lifting most or all of a client's weight. *Use of client-handling equipment (i.e., friction reducing slide sheets) helps reduce the caregiver muscle strain during client handling.

How high should the solution bag for a cleansing enema be placed?

Maximum of 2 ft above the client *If the solution bag is placed higher than 2 feet, the solution may run in too fast, causing discomfort and spasms that make it more difficult for the client to retain the enema, and in turn, make the enema less effective in cleansing the bowel.

A nurse is caring for a client who is receiving total parenteral nutrition (TPN) via a peripherally inserted central catheter (PICC) line. When assessing the client, the nurse notes that the client's arm seems swollen above the PICC insertion site. Which of the following actions should the nurse take first?

Measure the circumference of both upper arms. *The first action to take if the client's arm appears to be swollen is to measure the arm and compare it to the circumference of the other arm. *If the arm is swollen, it is appropriate to notify the provider who inserted the PICC line. *Swelling could indicate formation of a clot above the site.

A nurse is delegating tasks and client care interventions to assistive personnel (AP). Which of the following is an appropriate action by the nurse?

Monitor the technique an AP uses when assisting a client with ambulation *When delegating client care activities, the delegating nurse is responsible for making sure that APs complete tasks according to the standard of care.

A client returns from surgery with two Penrose drains in place. Anticipating frequent dressing changes, what should the nurse use around the incision area?

Montgomery straps *Montgomery straps are adhesive strips applied to the skin on either side of the surgical wound. *The strips have holes for using gauze to tie the dressing securly. *When the dressing is changed, the ties are released, the dressing replaced, and the ties secured again without removing the adhesive strips. *This taping technique minimizes irritation to the skin around the wound edges.

A nurse receives a phone prescription to administer four milligrams of morphine diluted with five milliliters of sterile water intravenous each morning at nine o'clock before a client's dressing change. Which of the following indicates the nurse is appropriately transcribing the prescription?

Morphine 4 mg IV bolus daily at 0900 before dressing changes, dilute medication with 5 mL of sterile water *This transcription contains appropriate abbreviations and complete information from the provider.

A nurse is caring for an older adult client who was alert and oriented. After four days of hospitalization, the client seems to be increasingly restless and intermittently confused. What is the most appropriate nursing intervention to address the safety needs of the client?

Move the client to a room closer to the nurse's station *This option is the most appropriate intervention to address the safety needs of the client. *By moving the client to a room closer to the nurse's station, it will be easier for the staff to observe the client should the client behave in an unsafe or inappropriate manner.

A nurse is preparing to transfer a client who weighs 150 kg (330.7 lb) from a bed to a stretcher. Which of the following is an appropriate nursing action?

Move the client using an air-assisted transfer device *The nurse should ask for assistance to move a client weighing over 90.9 kg (200 lb) and should use an air-assisted transfer device under the client to prevent health care personnel injury.

Before administering a medication to a client, the nurse needs to identify the client. Which of the following methods of identification should the nurse perform?

Name and Date of Birth

A nurse is caring for an older adult client who comes to the clinic with dry, flaky skin on her upper back. Which of the following is an appropriate intervention?

Note dry, flaky skin as a normal finding is incorrect *Skin generally becomes drier with increasing age but no flaking, scaling, or cracking should be present Perform examination of the back before the general inspection of the skin is incorrect *It is important to inspect the client's general skin condition first, as this data can aid in assessing the skin lesions. Use a penlight to examine the back in greater detail is incorrect *Bright light from a penlight or flashlight can distort the characteristics of various skin lesions. *A room with exposure to daylight is preferred.

When a nurse makes an initial assessment of a client who is postoperative following a gastric resection, the client's nasogastric tube is not draining. The nurse's attempt to irrigate the tube with 10 mL of 0.9% sodium chloride is unsuccessful, so she determines that the tube is obstructed. Which of the following actions should the nurse take?

Notify the surgeon *It is the surgeon's responsibility to manage the tube obstruction. *Nurses should not insert, reposition, or withdraw a nasogastric tube after a client has had a gastric resection because the suture line could easily be interrupted and hemorrhage could result.

A nurse is caring for a client who requires rectal temperature monitoring. Available at the client's bedside is a thermometer is with a long, slender tip. Which of the following is the appropriate action for the nurse to take?

Obtain a thermometer with a short, blunt insertion end *The thermometer that is available is an axillary or oral thermometer. *It has a long, slender insertion end to provide more surface area contact with the tissues under the tongue or in the axilla. *Because the bulb end is long and narrow rather than blunt, it has a greater potential for injuring the client's rectal tissue. *Using this thermometer to obtain a rectal temperature is unsafe.

A nurse is caring for a client who has hypertension. Which approach is the priority when the nurse is measuring the client's blood pressure?

Obtain the blood pressure under the same conditions each time *The nurse should record the client's position in the chart so that the next reading may be done with the client in the same place and position.

A client is receiving chemotherapy and reports that the tubing has pulled apart and notices a puddle on the floor. Which of the following is the priority nursing action to take after ensuring the client is stable and appropriate tubing disposal?

Obtain the spill kit specifically designated for this type of spill and use it *The first thing the nurse needs to do after determining that the client is stable, is to arrange for the spill to be cleaned up with a specially designed clean up kit which should be on the unit where any chemotherapy is being given. *Whether the nurse does it or someone else does is not important - the spill is an environmental hazard, and chemotherapy is a carcinogen and teratogen to anyone who handles it in an unprotected manner.

A right handed client is admitted with a fractured right arm and contusions of the left wrist following a motor vehicle crash. Which intervention should the nurse use when assisting the client with feeding?

Offer small bites of food *Offering small bites of food helps keep the client from choking because of too much food in the mouth.

A nurse at an extended care facility is teaching a class of older adults about the expected physiologic changes of aging. Which of the following facts should the nurse include in the discussion? (Select all that apply.)

Older adults have more difficulty seeing in low light or glare is correct. *Difficulty focusing close up may begin in the 40s, and the ability to distinguish fine details may begin to decline in the 70s. *From 50 on, there is increased susceptibility to glare, greater difficulty in seeing at low levels of illumination, and more difficulty in detecting moving targets. Personality changes are common in older adults is incorrect. *With age, the brain loses some neurons and others become damaged. *However, the brain adapts by increasing the number of synapses (connections between cells) and by regrowth in the dendrites and axons that carry messages in the brain. *There is no concomitant change in personality associated with the changes in the brain. *Personality is quite stable, and sudden changes may suggest disease processes. Vital capacity of the lungs declines significantly between the ages of 20 and 70 is correct. *The maximum vital capacity of the lungs declines with age, approximately 10% each decade, probably due to both decreased elasticity and increased residual volumes. Cardiac output decreases with age due to decreased heart size is incorrect. *The heart will actually grow slightly larger with age. *Maximal oxygen consumption during exercise declines by about 10% with each decade of adult life. *However, cardiac output stays nearly the same because the heart pumps more efficiently. Bladder capacity decreases and the kidneys become less efficient with age is correct. *With age, the kidneys gradually become less efficient at extracting waste from the blood. *Bladder capacity declines; however, urinary incontinence, which may occur after tissue atrophy, is not universal in the older adult.

A nurse is caring for a client who has had a triple lumen catheter inserted into the left subclavian vein of a client who is septic. The nurse obtains vital signs and records T 101° F, BP 88/48, P 118 bpm, R 36 bpm and O2 Sat 88%. An order is written to begin IV fluids and initiate antibiotic therapy. Which of the following should the nurse do immediately?

Order a stat chest X-ray *According to the airway, breathing, circulation, (ABC) priority-setting framework, the nurse should first order a stat chest x-ray to ensure that the central line is in proper placement. *This is the priority intervention for the nurse to take.

The provider orders a cleansing enema for a client having bowel surgery. Which nursing intervention is appropriate during this procedure?

Position the client on his side *Positioning is an important aspects of administering an enema. *Having the client lie on his left side facilitates the flow of the enema solution into the sigmoid and descending colon.

A nurse is administering intermittent enteral feedings to a client. Which of the following actions should the nurse take when administering the feeding?

Pour the formula into the syringe, raising or lowering it to control the rate of flow *Gravity promotes movement of the feeding into the stomach; however, too-rapid administration can cause vomiting or cramps. *Typically, the nurse should position the syringe or bag 45 cm (18 in) above the client's stomach, but should lower it if the formula flows too quickly or the client reports nausea or cramping.

A nurse is preparing to call the provider about a change in a client's status. Which of the following information should the nurse include in the background portion of the communication tool ISBAR?

Previous laboratory tests *The nurse should include previous laboratory tests and treatments in the background portion of ISBAR, which stands for introduction, situation, background, assessment, and recommendation.

A nurse is educating a client who observes Kosher laws of food preparation. When planning menus with this client, which of the following would not be an appropriate food choice?

Rabbit *Of the "beasts of the earth" (which basically refers to land mammals with the exception of swarming rodents), clients observing Kosher laws may eat any animal that has cloven hooves and chews its cud. *Any land mammal that does not have both of these qualities is forbidden. *The Torah specifies that the camel, the rock badger, the hare and the pig are not kosher because each lacks one of these two qualifications. Cattle, sheep, goats, deer and bison are kosher.

A nurse is caring for a client who has pneumonia. The client's oxygen saturation is 85%. Which of the following should the nurse do first?

Raise the head of the bed *Elevating the head of the bed can reduce the client's workload and minimize fatigue. *Raising the head of the bed uses gravity to drop the abdominal organs away from the diaphragm, which provides increased expansion of the lungs.

A nurse is assisting a client to move up in bed. Which of the following actions demonstrates the correct procedure?

Raise the height of the bed *Raising the height of the bed brings the client closer to the nurse's center of gravity and keeps the nurse from having to bend forward to assist the client.

A nurse is positioning a client for a urinary catheterization. Which of the following nursing actions would be best in preventing musculoskeletal injuries during the procedure?

Raising the bed to a comfortable height. *Working with the bed at a comfortable height is more ergonomically appropriate to prevent back strain and possible injury, to prevent bending and/or twisting from the waist.

A client with pneumonia has an oxygen saturation of 85%, heart rate of 88, respiratory rate of 22, and blood pressure of 132/88. Which of the following is the priority nursing intervention?

Reassess pulse oximetry *When the other vital signs are within normal range, the immediate intervention would be to reassess the low oxygen saturation using another site before any other interventions are completed. *Causes of low readings include client movement, hypothermia, decreased peripheral blood flow, ambient light (sunlight, infrared lamps), decreased hemoglobin, edema, and fingernail polish.

A nurse is caring for a client diagnosed with an acute anxiety disorder. Which of the following is the priority nursing intervention?

Remain with the client during the crisis period *This action is priority. It is imperative that the nurse remain with the client and provide safety and comfort measures during the crisis period of the anxiety disorder. *This will increase the likelihood of anxiety relief and ensure client safety during the acute period.

A nurse caring for a client who requires contact precautions has just finished a care procedure. Which of the following actions should the nurse perform first?

Remove his gloves. *The gloves are the most contaminated item of personal protective equipment, so the nurse should remove them first. *The greatest risk to safety is pathogen transmission. *Failing to remove the most contaminated item first increases this risk. *Untie his gown at the waist. *Gown ties in the front may be contaminated, but untying them is not the first action he should take.

When the nurse takes morning medications to a client, the client states "I've never seen that one before." Which of the following is the most appropriate action for the nurse to take?

Return to the nurse's station and check all medications against provider orders *The best action would be to hold off on administering any of the medications until they are all verified against provider orders in the client record. *Once that is complete, the nurse can tell the client with certainty that the medications have all been verified with the provider order, and then answer any questions about the medications the client or family asks. *These actions prevent errors and build trust.

A nurse is orienting a newly licensed nurse to the operating room. Which of the following actions by the new nurse indicates a need for further education about surgical aseptic hand hygiene?

Rinsing hands and arms while keeping them lower than elbows *While rinsing removes transient bacteria from fingers, hands and forearms, keeping hands elevated above the elbows allows water to flow from least to most

What is sanguineous drainage and what does it indicate?

Sanguineous indicates fresh bleeding and is bright red.

A nurse is completing a preadmission interview with a client who reports a latex allergy and is scheduled for surgery. Which of the following interventions should be included when planning care for the client's surgery? (Select all that apply.)

Schedule the client as the last case of the day is incorrect. *A client who is allergic to latex should be the first case of the day in the surgical suite. *This allows overnight removal of latex dust from the previous day. Notify ancillary departments of the client's allergy is correct. *Notifying ancillary departments of the client's sensitivity to latex allows the staff to take appropriate measures to ensure medications and surgical items are not contaminated by latex. Label the surgical suite as latex-free is correct. *This helps keep personnel from bringing rubber products into the room. Provide powdered gloves for the staff's use is incorrect. *Powder from products containing latex can transmit allergens from the hands of personnel to the client. Make sure a latex allergy cart is available is correct. *A latex allergy cart should be kept in the operating room at all times. *All of the contents must be latex free.

What is scoliosis?

Scoliosis is a lateral curvature and rotation of the thoracic spine, most often occuring in adolescents.

A nurse is caring for a client who has a stage 3 pressure ulcer. The nurse recognizes that which of the following laboratory findings will impact wound healing?

Serum albumin 3.2 g/dL *A serum albumin level is a good indicator of the nutritional status of a client. *A value below 3.5 g/dL is an indicator of poor nutrition and can delay wound healing and lead to infection.

A nurse is reviewing a new prescription for continuous passive motion (CPM) for a client's right lower extremity following a total knee arthroplasty. Which of the following prescriptions should the nurse verify with the provider?

Set the CPM flexion at 90° *The nurse should verify with the provider about initially setting the CPM flexion at 90° following a total knee arthroplasty *Initial flexion should be set at 20° to 30° with a gradual increase to 90°

A nurse is planning care for a client with a nasogastric tube following abdominal surgery. Which of the following should the nurse include in the plan of care? (Select all that apply.)

Set the nasogastric tube on high suction is incorrect *High suction can traumatize the gastric lining. Gastric suction should be maintained at a low or intermittent setting to protect the gastric mucosa. Provide oral hygiene frequently is correct. *Frequent oral hygiene provides comfort for the client since mucous membranes easily become dry and uncomfortable when a client cannot drink fluids. Measure the drainage from the nasogastric tube every 8 hr is correct. *Measuring the drainage at least every 8 hr helps the provider calculate fluid losses and prescribe appropriate replacement therapy. Secure the nasogastric tube to the client's gown is correct. *An unsecured nasogastric tube can irritate the nares if the tube is pulled or caught on the bed or other equipment. The tube can also dislodge if not secured appropriately. Apply petroleum jelly to the client's nares is incorrect. T *The client could aspirate an oil-based lubricant like petroleum jelly into the lungs, possibly resulting in lipid pneumonia. A water-soluble lubricant should be applied to the nostrils to help prevent or relieve dry skin.

A nurse is implementing a bowel-training program for a client who has fecal incontinence. At which of the following times should the nurse offer the client a bedpan or assist the client to a commode?

Soon after breakfast *Eating activates the gastrocolic reflex that promotes stool elimination; therefore, it is best to encourage defecation about 30 min after a meal.

What is the usually pH of the stomach?

Stomach contents are normally acidic, usually with a pH from 1 to 4, although it can be as high as 6 if the client is receiving acid-reducing medications.

A nurse is performing tracheostomy care and suctioning a client who has copious secretions. Which of the following methods should the nurse use to remove secretions?

Suction two to three times with a 60-second pause between passes *Copious secretions may require several passes of the suction catheter. *An interval of 60 seconds should be allowed between passes to prevent a decrease in the client's blood oxygen levels.

A nurse is caring for a client who had spinal surgery 3 days ago and reports a pain level of 9 on a scale of 0 to 10. After administering the prescribed analgesic, which of the following should the nurse use to manage the client's pain while waiting for the analgesic to work?

Suggest the client listen to music *Listening to music creates a distraction from the pain. *Distraction works best for short, intense pain lasting for a few minutes, such as during an invasive procedure or while waiting for an analgesic to work. *It is important to let the client select the type of music preferred.

A nurse in an acute care facility is caring for a client who has an endotracheal tube and is receiving mechanical ventilation. Which of the following interventions should the nurse include to reduce the risk for ventilator-associated pneumonia?

Swab the client's mouth with chlorhexidine solution *The nurse should swab the client's mouth with chlorhexidine solution, which decreases bacterial growth in the mouth that can cause ventilator-associated pneumonia.

A client is transferred to the postanesthesia care unit after a colon resection for adenocarcinoma. Which manifestation would the nurse expect to see if the client were to develop internal abdominal bleeding postoperatively?

Tachycardia *Because of the decreased circulating blood volume due to internal bleeding, oxygen-carrying capacity of the blood is reduced. *The body attempts to relieve the hypoxia by increasing the heart rate and cardiac output along with increasing the respiratory rate.

A nurse is performing an abdominal assessment of an adult client. Identify the correct sequence of steps used for this assessment. (Move the sequence of steps into the box on the right, placing them in the selected order of performance. All steps must be used.)

The appropriate sequence for the nurse to perform the abdominal assessment is to: (1) inspect (2) auscultate (3) percuss (4) palpate *This sequence prevents altering the bowels sounds. *The appropriate sequence for any other assessment for an adult client is: (1) inspection, (2) palpation, (3) percussion, (4) auscultation

A nurse is caring for a client who is receiving an intravenous infusion (IV) that has infiltrated. Which of the following would be an unexpected finding when the nurse assesses the client's infusion line and insertion site?

The area around the injection site feels warm when touched *The area around the injection site would not feel warm when the IV is infiltrated. *Since the IV fluid is at room temperature, it is cooler than body temperature. *The area around the injection site will feel cool when the IV is infiltrated. If the area around the injection site feels warm, it may indicate infection or phlebitis. TEST-TAKING STRATEGY: Since this is a negative-format stem question, an INAPPROPRIATE finding is correct.

A nurse is working with a newly graduated nurse who is caring for a client receiving a continuous IV infusion. The newly graduated nurse identifies that her client's IV has infiltrated. Which of the following reported findings indicates a need for clarification?

The area surrounding the insertion site feels warm to the touch *The IV fluid is at room temperature, so the area around the injection site will feel cool, not warm, to the touch when the IV is infiltrated. *A warm area around the injection site indicates infection or phlebitis.

A nurse has administered the first DTaP (diphtheria toxoid, tetanus and pertussis) immunization to a two-month-old infant. For which of the following symptoms should the nurse teach the parents to seek immediate medical attention?

The baby is crying inconsolably for more than three hours *Inconsolable crying lasting more than three hours and/or seizures within 48 hours of vaccination is a sign of encephalopathy that must be treated immediately.

A nurse is caring for four clients who have drainage tubes. Which of the following clients should the nurse recognize is at risk for hypokalemia?

The client who has an NG tube to suction *Hypokalemia is a low serum potassium. *An NG tube is used to decompress the stomach. *When hooked to suction drainage, an NG tube will empty the stomach of gastric contents, which are high in electrolytes, and this loss will put the client at risk for hypokalemia.

A client admitted with abdominal pain tells the nurse that her father died recently, and she begins crying while talking about him. The nurse determines that the client's temperature is 39.2° C (102.6° F), her abdomen is soft without tenderness, and her menses is overdue by 2 days. To which observation should the nurse give priority attention?

The client's temperature *An elevated temperature may be a sign of an infection or disease. *A client with a temperature of 102.6° F is not well. *This can affect her behavior, which may or may not be related to the death of her father. TEST-TAKING STRATEGY: With a priority setting question where all four options appear plausible, rely on Maslow's hierarchy of needs to help set the priorities. Remember, clients with basic physiologic needs (sleep, food) come first, then clients with safety needs (security), love and belonging needs, self-esteem needs, and finally self-actualization needs. This client's physiologic need takes precedence over other needs.

A nurse is educating an older adult about food safety in the home. Which of the following instructions should the nurse include in teaching?

When preparing a meal raw and fresh foods should be handled separately *Raw and fresh foods should be handled separately to prevent cross contamination.

A nurse is assisting a client with bowel training. When should the nurse instruct the client to attempt defecation?

When the client has the urge to defecate *Failure to heed the call to defecate may lead to overdistention of the rectum with hardening of the stool and subsequent constipation. *Therefore, the best time to toilet a client to encourage bowel training is when the client has the urge to defecate.

A postoperative client has been diagnosed with paralytic ileus. When performing auscultation of the client's abdomen, the nurse expects the bowel sounds to be

absent *Paralytic ileus is an immobile bowel. *With this disorder, bowel sounds are absent

A nurse is in a public building when someone cries out, "Help! I think he's having a heart attack!" The nurse responds to the scene and finds an unconscious adult lying on the floor. Another bystander has obtained an automated external defibrillator (AED). The nurse's first action, after making certain someone has called for emergency medical services (EMS), should be to

administer cardiac compressions *Using the airway breathing circulation (ABC) approach to client care, the nurse determines the priority finding is to administer chest compressions for a client who has suffered an unwitnessed, out-of-hospital cardiac arrest. *It is recommended that the rescuer complete 5 cycles (or about 2 min) of CPR before attaching and using the AED. *This is the first action the nurse should take.

A client is 2 days postoperative following an appendectomy. While changing the linens on the client's bed, the nurse notes drainage from an infected wound has soiled the bed sheet. The appropriate nursing action is to

carefully place the soiled sheet in a moisture-resistant plastic laundry bag *Placing the sheet in a moisture-resistant plastic bag protects the laundry employees and others that may come in contact with the bag from exposure to organisms that may be present in the soiled linen.

A hospitalized client needs a chest x ray. The radiology department calls the nursing unit and says that they are sending a transporter for the client. When entering the client's room, the priority action is to

check the client's identification bracelet *Once the client's identity is determined, the nurse can then proceed with the other options. *This action is the priority action because it provides for the safety of the client. *It is a nursing responsibility to be certain that each client receives only what has been prescribed for that client.

A postoperative client has an indwelling urinary catheter in place to gravity drainage. The nurse notes that the client's urinary drainage bag has been empty for 2 hr. The first action the nurse should take is to

check to see if the tubing is kinked *A common reason a tube is not draining is that there is a kink in the tubing or that the client is lying on it. *The nurse should inspect the tubing carefully, straightening out any kinks and making certain that there are no dependent loops. TEST-TAKING STRATEGY: With a priority-setting question where all the options appear correct, but various stages of the nursing process (assessment, intervention, evaluation) are reflected in the options, rely on the nursing process to help set priorities. Assessment comes first, followed by analysis, planning, intervention, and evaluation.

When obtaining a urine specimen for a culture and sensitivity from an indwelling catheter, the nurse should

cleanse the entry port prior to withdrawing urine *Disinfecting the entry port removes or destroys any micro-organisms on the surface of the catheter, thereby avoiding contamination of the specimen and the catheter

While preparing a client for discharge, the nurse teaches the proper position for postural drainage. The nurse knows that to achieve success in this teaching program, the information about the client that is most important is the

client's goal concerning his ability to be self-sufficient *The client's motivation and goals are essential for success, and they are a primary concern in any teaching program. *Teaching/learning theory states that if the client is not motivated or goal-directed, the discharge teaching program is unlikely to be effective.

Following an emergency splenectomy, a 17-year-old client is admitted to the nursing unit from the postanesthesia care unit (PACU). The client reports severe abdominal pain, and the client's parents are asking to see their child. The nurse's first action should be to

complete a physical assessment including postoperative vital signs *Any client recovering from surgery may have altered vital signs, and the nurse's first priority is a full physical assessment. *In addition, a client who has had an emergency splenectomy is at risk for abdominal hemorrhage and has an increased risk for hypovolemia. *Therefore, vital signs are a priority. TEST-TAKING STRATEGY: With a priority-setting question where all the options appear correct, but various stages of the nursing process (assessment, intervention, evaluation) are reflected in the options, rely on the nursing process to help set priorities. Assessment comes first, followed by analysis, planning, intervention, and evaluation.

Before giving preoperative medication to a client being prepared for surgery, the nurse must make sure that the

consent form has been signed *For legal reasons, the nurse must always check that the consent form has been signed prior to administering preoperative medication. *Clients cannot give consent if medications that cause cognitive alterations have been administered.

When transcribing the orders for a client admitted with an exacerbation of systemic lupus erythematosus (SLE), a newly licensed nurse notes that the provider has prescribed a medication with which the nurse is unfamiliar. The nurse should

consult the medication reference book available on the unit *The nurse should become familiar with the medication by researching it in the latest medication reference available. *Another appropriate resource is the hospitals pharmacy staff.

A nurse is precepting a newly licensed nurse who is preparing to help a client perform tracheostomy care. The nurse should intervene if the equipment the preceptee gathered included

cotton balls *Cotton ball particles can enter the tracheostomy opening, causing aspiration. TEST TAKING STRATEGY: A negative-format question requires an INAPPROPRIATE option to be the CORRECT answer.

A nurse is caring for a client who has acute renal failure. The nurse knows that on a day-to-day basis, the most accurate measure of the client's fluid status is the

daily weight *Daily weight is the most accurate method used to measure fluid changes.

Before donning gloves to perform a procedure, proper hand hygiene is essential. The nurse understands that the most important aspect of hand hygiene is the amount of

friction *Alcohol-based hand rubs or sanitizers are now recommended by the Centers for Disease Control and Prevention (CDC) for hand hygiene between clients in situations the hands are not visibly soiled. *The hand rub is applied and the hands are rubbed briskly until dry. *If traditional soap and water are used, friction also is the most important component for removing micro-organisms.

While changing the linen on a client's bed, the nurse should

hold the linen away from his body and clothing *This is the appropriate method for handling the linen. *The nurse should hold the linen away from his clothing to prevent soiling or the transfer of micro-organisms. *Since he must go from client to client, any micro-organisms present on the nurse's clothing could be transferred from one client to another.

Two days postoperative following a small bowel resection, a client reports gas pains in the periumbilical area. The nurse notes abdominal distentionand revises the client's care plan based on the knowledge that postoperative gas pains develop as a result of

impaired peristalsis of the intestines *Normal bowel function is delayed up to several days following a bowel resection. *When peristalsis is absent or sluggish, intestinal gas builds up, producing pain and abdominal distention. *The client needs to get out of bed and ambulate.

A nurse caring for a client who is immobilized knows that, without interventions to prevent constipation and fecal impaction, this client is at risk for

intestinal obstruction *A fecal impaction is the presence of either hardened or putty-like feces in the rectum and sigmoid colon. *If the condition is not relieved, intestinal obstruction can occur.

A nurse is teaching a client who has cardiovascular disease how to reduce his intake of sodium and cholesterol. The nurse understands that the most significant factor in planning dietary changes for this client is the

involvement of the client in planning the change *A client who is actively involved in planning dietary changes and is more receptive to the changes and more likely to adhere to them.

A nurse is caring for a client who has a new prescription for tube feeding. The nurse understands that the provider prescribed tube feeding because the client

is unable to swallow foods by mouth *Tube feeding is commonly prescribed for clients who are unable to eat by mouth.

A client smoking in his bathroom has dropped a discarded cigarette butt into a wastepaper basket, which begins to smolder. The nurse recognizes that the priority action in case of fire is to

move any clients in the immediate vicinity *The nurse realizes that in case of fire, you must R-A-C-E. *R is for Rescue, the first action taken in case of fire. *Moving any clients in the immediate vicinity, therefore in imminent danger, is the priority action at this time.

To use the nursing process correctly, the nurse must first

obtain information about the client *The scientific application of nursing, the nursing process, is based on the scientific process. *The first step in the scientific process is the collection of data; therefore, the first step in the nursing process is assessment

A nurse takes an older adult client who has dysphagia following a cerebrovascular accident (CVA) to the dining room for dinner. When assisting the client at mealtime, the nurse should

offer the client tart or sour foods *Tart and sour foods stimulate saliva production, which helps with chewing and swallowing

A client is admitted to the hospital with generalized weakness. At dinner time, the nurse should

open the milk and juice containers for the client *Opening containers makes it easier for the client to eat.

A nurse has organized a discussion session for assistive personnel (AP) at an extended care facility about cultural and religious traditions and rituals at the time of death. The nurse determines that one of the participants has a misconception when the AP states that

organ donation is strictly forbidden by the Baptist Church *Some people may believe that donation conflicts with their faith. However, most major religions accept or encourage organ donation. *Although specific teachings and requirements related to donation vary, there is general agreement that donating organs or tissues to benefit others demonstrates love for other people. *The Baptist Church leaves the decision to the individual, but donation is supported as an act of charity. TEST TAKING STRATEGY: With a negative-format question like this one, the CORRECT answer is an INCORRECT belief.

When assessing a client's heart sounds, the nurse hears a scratching sound during both systole and diastole. These sounds become more distinct when the nurse has the client sit up and lean forward. The nurse should document the presence of a(n)

pericardial friction rub *A pericardial friction rub has a scratching, grating, or squeaking leathery quality. *It tends to be high in frequency and best heard with the diaphragm of the stethoscope and with the client leaning forward. *A pericardial friction rub is a sign of pericardial inflammation and may be heard with infective carditis with myocardial infarction, following cardiac surgery or trauma, and with some autoimmune problems, such as rheumatic fever.

To use proper body mechanics while making an occupied bed for a client on bed rest, the nurse should

place the bed in a high horizontal position *To use correct body mechanics, the nurse should raise the bed to a high horizontal position. *This helps the nurse avoid excessive bending and stretching

A nurse admits a client to a same-day surgery center for an exploratory laparotomy procedure this morning. The client's surgeon asks the nurse to witness the signing of the preoperative consent form. In signing the form as a witness, the nurse affirms that

the signature on the preoperative consent form is the client's *The nurse acts as a witness solely to attest that it is the client's signature on the preoperative consent form. *It is the responsibility of the surgeon who will perform the procedure to inform the client of the risks and benefits and obtain their consent.

A provider has prescribed restraints for a client who is agitated. When applying restraints, the nurse would put the client at risk by

tying the restraint with a knot that cannot be easily undone. -Restraints should be tied with knots that can be undone easily in case the client's well-being necessitates quickly removing the restraints. *To protect the client from releasing the restraints, the knot should be placed where the client cannot easily reach it. TEST-TAKING STRATEGY: With a negative-format question like this one, the CORRECT answer has to be an INCORRECT action.

A client is hospitalized for an infection of a surgical wound following abdominal surgery. To promote healing and fight wound infection the nurse plans to arrange to increase the client's intake of

vitamin C and zinc *The body's need for both vitamin C and zinc increases when fighting a wound infection. *The client should receive a multivitamin plus a mineral supplement of both. *In addition, vitamin E supplements have been shown to aid in skin and wound healing.

A nurse is preparing a client with a compression injury of the right leg for surgery. After administering the preoperative benzodiazepine, lorazepam (Ativan) as prescribed, the nurse determines that the medication was effective when the client states,

"I feel very sleepy." *Preoperative doses of benzodiazepines, such as lorazepam (Ativan) and midazolam (Versed), relieve anxiety and promote sedation.

What is a fleets enema?

*A Fleet enema, a commercial product that contains hypertonic fluid solution, is given to cleanse the bowel. *It is usually given after digital removal of the impaction

A nurse is working to develop a therapeutic relationship with a client. The nurse understands that which of the following is an example of the pre interaction phase of a therapeutic relationship?

Reviewing the client's demographic information *This option describes the preinteraction phase, which is done before meeting the client.

A nurse is assisting a client with a meal. The client suddenly grabs at her neck with both hands and appears frightened. The appropriate nursing action is to

ask the client if she is choking *The client may be demonstrating the universal choking gesture. *If she nods and cannot talk, severe airway obstruction is present. *As long there is good air exchange and she can cough and breathe spontaneously, the nurse should stay with the client and monitor her condition.

A nurse is caring for a client on strict bed rest. When entering the client's room, the nurse notices flames in the waste basket. The nurse's priority action is to

pull the client out into the hall in the bed *The client in the room with a fire is at high risk for injury. *The smoke from a fire can deprive a client of adequate oxygenation, and the fire poses a direct threat to the safety of this client. *Moving this client to safety is the first priority. *Because the client is on strict bed rest, the nurse removes the client from the room while still in the bed. *The acronym RACE: Remove, Alarm, Contain, and Extinguish.

A home health nurse is visiting an older adult client. Which of the following statements by the client should alert the nurse to suggest additional safety measures in the client's home?

"I use space heaters to keep warm in the winter." *A common environmental hazard in the home is the use of space heaters, which can increase the risk of fire.

A nurse is teaching a client to manage stress effectively by using progressive relaxation techniques. Which of the following statements indicates an understanding of the teaching?

"I'll compare the sensations I feel when I tense my muscles to what I feel when I relax them." *Progressive relaxation involves tensing and relaxing specific muscles, moving progressively through the body's muscle groups. *The key is to distinguish sensations during tension from those during relaxation.

A nurse is caring for a client who is receiving oxygen at 4 L/min via a nasal cannula. What oxygen concentration is the client receiving?

36% *A flow rate of 4 L/min delivers an oxygen concentration of approximately 36%.

What is an appropriate angle of insertion for a subcutaneous injection?

60°

A nurse is caring for a client who has been immobile for 3 days following a cerebrovascular accident. Which of the following actions should the nurse take to maintain the client's skin integrity?

Cleansing skin by using an alcohol-free cleanser *When cleansing the client's skin, the nurse should use a cleanser with nonionic surfactants that are gentle to the skin to prevent irritation and further skin breakdown.

A nurse is caring for a client with the following arterial blood gases: HCO3 of 18 mEq (22-26), CO2 of 28 mmHg (35-45). Which of the following pH values and acid base imbalances would accompany these values?

Decreased pH and metabolic acidosis *This client would have a decreased pH and be in metabolic acidosis.

A client is admitted to the hospital with decreased circulation in the left leg. During the admission assessment, which is the most important nursing action initially?

Evaluate the pedal pulses *Assessing the reason for the client's admission is essential and is the most important initial action. *It provides the nurse with an admission baseline for comparison during later assessments. *The nurse should check the pedal pulses in the feet of BOTH legs to compare the degree of decreased circulation in the "bad" leg with that in the "good" one.

A nurse is caring for a client with a new diagnosis of diabetes mellitus type 1. Which of the following is an appropriate teaching intervention that focuses on affective learning?

Explore the client's feelings about dietary modifications *This teaching intervention allows the client to express his acceptance of this change and focuses on affective learning.

A nurse applies restraints to a mental health client who is refusing to take his antipsychotic medication. The nurse may be charged with which of the following intentional torts?

False Imprisonment

A nurse is providing dietary education to a client with a new ileostomy. What foods should the nurse instruct the client to avoid in the first weeks after surgery?

Fresh vegetables *Fresh vegetables are high in fiber and therefore, should be avoided in the first weeks after surgery. *During the first weeks after surgery, many providers recommend low fiber diets, particularly for clients with ileostomies, because the small bowel requires time to adapt to the diversion. *As ostomies heal, clients are able to eat almost any food and high fiber foods are encouraged to help ensure a more solid stool to achieve success at irrigation, but high fiber foods should be avoided in the first weeks after surgery.

A nurse is completing a neurological assessment of an older adult client and notes that the client has become increasingly confused and agitated. Which of the following problems should the nurse consider first when planning care for the client?

Infection *Confusion and agitation indicate that this client is at greatest risk for injury from a bacterial or viral infection. *Therefore, the first action the nurse should take is to assess the client for an infection. *In an older adult client, delirium is a more common sign of infection than fever. *Delirium in older adults sometimes accompanies systemic infections and is often the initial manifestation of pneumonia or urinary tract infection.

A nurse is assessing a client who is postoperative following thoracic surgery. Which of the following manifestations should alert the nurse to the possibility of early hypovolemic shock?

Irritability *Hypovolemic shock results from a loss of circulatory volume, usually due to hemorrhage. *Early in hypovolemic shock, hyperactivity of the sympathetic nervous system with increased secretion of epinephrine makes the client feel anxious, nervous, and irritable.

A client develops a fecal impaction. Before digital removal of the mass, which type of enema should the nurse give to loosen the feces?

Oil retention *Before digital removal of the fecal mass, an oil retention enema is often given to soften the stool. *This makes the deimpaction less painful for the client

When a nurse percusses the abdomen, what could it reveal?

Percussion of the abdomen helps reveal the presence of air in the stomach and intestines and maps out underlying organs, bones, and masses.

A nurse is caring for an older adult client who comes to the clinic with dry, flaky skin on her upper back. Which of the following is an appropriate intervention?

Pinch up a fold of skin to check for turgor *Turgor is properly assessed by pinching an area of skin. *This observation is important when performing a skin examination.

A client has just returned to the surgical unit after an open cholestectomy. A nurse notes the abdominal dressing is saturated with sanguineous drainage. Which of the following is the most appropriate intervention?

Reinforce the dressing with additional gauze *The appropriate intervention for a dressing that becomes wet from drainage is to reinforce the dressing by adding more dressing material to the existing dressing. *The first dressing change is performed by the surgeon.

A nurse is caring for a client with a diagnosis of sepsis with a temperature of 40.8 C (105.5 F). The provider has ordered a cooling blanket. Which intervention is appropriate to delegate to an Unlicensed Assistive Personnel (UAP)?

Report shivering by the client *The unlicensed assistive personnel should be taught to observe for and report shivering during any form of external cooling. *Shivering may indicate that the client is being cooled too quickly.

A newly-licensed nurse is preparing the surgical suite for a client who has a latex allergy. Which action demonstrates a need for further education?

Scheduling the case late in the day *This action indicates a need for further education. *Clients with latex allergy should be scheduled as the first case in the morning. *This will allow latex dust (from the previous day) to be removed overnight.

What is serous drainage?

Serous drainage is clear to light yellow, watery plasma.

A nurse is receiving shift report about assigned clients. Which of the following activities should the nurse plan to attend to first?

Suction the tracheostomy of a client who has copious secretions *Using the airway, breathing, circulation approach to client care, the priority action is to suction the tracheostomy of a client who has copious secretions.

A home health care nurse is conducting a fall risk assessment for an older adult client who lives alone. The nurse should identify which of the following factors as creating a significant risk for falls?

The client's small dog *Although pets also provide many therapeutic benefits, small animals, especially if they are very active or follow closely behind older adults as they walk, can easily cause older clients to trip and fall.

A nurse is planning care for several medical clients. Which of the following clients should benefit most from the nurse acting as an advocate?

The elderly client with no family members who is uncertain about moving to assisted living *The nurse acts as an advocate by expressing and defending the needs and rights of another individual. *This example should benefit the client most.

A nurse correctly understands which of the following characteristics is a possible developmental delay for a 3-month-old client?

The infant does not raise his head when placed on his abdomen *When placed on the abdomen the 3 month old should attempt to raise his head. *Some sources refer to this as "tummy time" which provides the infant with the stimulation to strengthen upper body and neck muscles in preparation for good head control when sitting upright and the some of the muscles required for crawling.

A nurse is removing an isolation gown after caring for a client who requires contact precautions. Which of the following steps should the nurse take to properly remove the isolation gown that has ties in the front?

Untie front waist strings, remove gloves, and untie neck ties *When removing an isolation gown that has ties in the front, the nurse should untie the waist ties first while still wearing gloves as the front ties are considered to be dirty.

A nurse is caring for a client who is pulling at abdominal wound drains. After finding less restrictive prevention methods ineffective, a provider prescribes wrist restraints for the client. When applying the restraints, to which of the following parts of the bed should the nurse secure the straps?

Upper portion of the bed frame *Attaching the wrist restraints to the upper portion of the bed frame allows the head of the bed to be raised or lowered without causing injury to the client.

In planning care for a client with a surgical wound healing by secondary intention, the nurse can anticipate that the client will

be at an increased susceptibility for infection *The wound edges are left open in a wound healing by secondary intention. *Most wounds left to heal by secondary intention heal within 5 to 21 days by forming granulation tissue that fills in the wound edges, and then forms a scar. *Open wounds place the client at an increased risk for wound infection.

When replacing a client's surgical dressing, the nurse should

don clean gloves to remove the old dressing *Standard precautions require the nurse to don clean gloves whenever there is a possibility of coming into contact with secretions. *Removing a soiled dressing is a procedure that requires wearing clean (not sterile) gloves. *Sterile gloves are not necessary until the nurse applies the new sterile dressing.

How often should a continuously infusing IV bag be changed?

every 24 hr to minimize the risk of contamination and infection

A client who reports shortness of breath requests the nurse's help in changing positions. In addition to repositioning the client, the nurse's highest priority should be to

observe the rate, depth, and character of the client's respirations *Before initiating 15-min checks, calling the provider, or giving a back rub, the nurse should assess the client. *Following the assessment, one or more of the other actions may be appropriate. TEST-TAKING STRATEGY: With a priority-setting question where all the options appear correct, but various stages of the nursing process (assessment, intervention, evaluation) are reflected in the options, rely on the nursing process to help set priorities. Assessment comes first, followed by analysis, planning, intervention, and evaluation.

A client was admitted to the coronary care unit with a diagnosis of myocardial infarction (MI). After the client's condition is stabilized, the client says to the nurse, "All this equipment is making me nervous. Am I so sick that I need all of this?" Which of the following is an appropriate nursing response?

"All of this equipment can be frightening." *This statement is therapeutic because it demonstrates the nurse's empathy. *The client is feeling fearful, and this response shows the nurse understands those feelings, which will encourage the client to communicate more.

A nurse is providing teaching about bathtub safety for an older adult client who is being discharged home. Which of the following statements by the client indicates an understanding of the teaching?

"I will place a rubber mat in the tub." *The client should place a rubber mat in the tub prior to bathing. *This will prevent the client from slipping or injury during bathing.

A nurse is taking the health history of a school-age girl. Which statement by the client's mother indicates a need for further teaching regarding the client's nutritional status?

"We allow her to pick out a treat at the grocery store for good behavior." *This statement indicates a need for further teaching. *This client's mother should be educated about the importance of praising the client's abilities and skills rather than using food as a reward, which may lead to an increased risk for obesity.

A nurse is accepting a client who was transferred to ICU after an attempted medication overdose while on the medical floor. Upon seeing the nurse who admitted her initially, the client looks down at the floor and mumbles, "Hello." Which of the following is the best response by the nurse?

"Would you like to talk about what happened?" *Caring is conveyed through acknowledgment. *Asking the client if she would like to talk allows her the choice of whether to discuss the suicide attempt at this time.

What are crackles?

*Crackles are a series of explosive, high-pitched sounds audible just before the end of inspiration. *The sound is similar to that of rolling hair between the fingers just behind the ear.

A charge nurse is expecting four new admissions from the emergency department and must assign each to a room. Which of the following clients should the nurse admit to the room closest to the nurse's station?

A client who has a concussion and is having periods of confusion *A client who is confused is best placed in a room near the nurse's station so that the client can be closely observed for impulsive and inappropriate behavior that could put him at risk.

How often should a client who is immunocompromised wash their toothbrush?

Daily in the dishwasher or rinse it in a bleach solution to prevent bacterial growth

A nurse is preparing to insert an IV catheter to administer intermittent IV medications to a client who has an allergy to latex. Which of the following equipment places the client at risk for an allergic reaction to latex?

IV tubing with rubber injection ports *Because rubber ports are made of latex, they place the client at risk for reaction to latex. *Latex-free tubing should be used for this client.

A nurse is teaching a client about dietary modifications to help control blood pressure. Which of the following food choices by the client indicates an understanding of the teaching?

Grilled chicken salad with fresh salsa *Grilled chicken salad and fresh salsa are both made from fresh (preservative-free) materials and therefore are likely to be of lower sodium content than French onion soup, chips, chicken bouillon, or crackers.

A nurse is caring for an older adult client with delirium. Which intervention will most effectively reduce the client's risk for falls?

Hourly rounding by the nurse *In the health care environment, hourly rounding by nurses significantly reduces the occurrence of client falls, as well as reducing call light usage and increasing client satisfaction.

A client is transported to a post-anesthesia care unit (PACU) following a splenectomy. The abdominal dressing is dry and intact and IV fluids are infusing at 125 mL/hr. Which of the following is a priority nursing goal at this time?

Maintaining a patent airway *Following the ABC (airway, breathing, circulation) guideline, the highest priority goal is maintaining a patent airway.

What does palpation of each quadrant of the abdomen determine?

Palpation of each quadrant determines abdominal distension or tenderness.

The assessment findings for a client who suddenly becomes confused and drowsy include the following: pulse 100 bpm, respiratory rate 26, BP 132/76 mm Hg, and temperature 36.8º C (98.2º F). Which of the following is an appropriate intervention?

Perform a neurological check *Monitoring the client's neurological status is the appropriate intervention.

A nurse is providing discharge teaching for a client who will be on home oxygen therapy. Which of the following information should the nurse include in the instructions?

Store oxygen tanks in an upright position *The nurse should instruct the client to store oxygen tanks in an upright position in a holder to prevent injury to the client and the client's family.

A nurse is completing a dietary evaluation for a client diagnosed with acute glomerulonephritis. Which of the following statements made by the client demonstrates understanding of necessary restrictions?

"I should limit my sodium intake to 4 grams per day." *Excessively high protein and sodium diets put clients at risk for glomerulonephritis. *Clients with this condition should implement sodium and protein restriction.

A nurse is preparing a client for discharge after an anterior-posterior colporrhaphy. Which of the following statements made by the client indicates a need for further teaching?

"I will increase my fiber intake to stay regular." *A full liquid diet is provided immediately after surgery, followed by a low-residue diet to decrease bowel movements and allow time for the incision to heal. *Foods that are high in fiber should be avoided until it has been determined that normal bowel function has been regained. *Stool softeners should be administered as prescribed to facilitate bowel elimination and prevent stress on stitches.

A nurse is instructing a client newly diagnosed with Raynaud's disease about the prevention of the onset of symptoms. Which of the following client statements should indicate to the nurse the need for additional teaching?

"I will take my medications at the first sign of an attack." *Taking medications at the onset of an attack may help to reduce the severity of the attack, but it will not prevent the onset of vasoconstriction characteristic of Raynaud's disease.

A nurse is caring for a client just diagnosed with type 1 diabetes mellitus. The client is resistant to learning self injection of insulin and asks the nurse to administer all the injections. The nurse explains the importance of learning self care and appropriately adds which of the following statements?

"Tell me what I can do to help you overcome your fear of giving yourself injections." *This illustrates the therapeutic communication tool of clarifying and offering self. *It is important for the nurse to allow the client to express feelings and fears and to support the client in learning how to give the injections.

A nurse is caring for a client who is postoperative following a partial colectomy. The client has a nasogastric tube set to low continuous suction. The client tells the nurse that his throat is sore and asks the nurse when the nasogastric tube will be taken out. Which of the following responses by the nurse is appropriate at this time?

"When your gastrointestinal tract is working again, in about three to five days, the tube can be removed." *Bowel sounds and the passing of flatus through the rectum indicate the return of peristalsis. *It is then safe to remove the nasogastric tube and begin the client's progression from sips of clear liquids to a regular diet.

A nurse is providing preoperative teaching for a female client who is to have surgery with general anesthesia. Which of the following statements should the nurse include in the teaching?

"You should remove nail polish from your fingers." *The nurse should teach the client to remove nail polish for accurate pulse oximetry monitoring and for a clear view of the nail beds when assessing capillary refill.

A nurse is planning interventions for a group of clients who are obese. What can the nurse do to improve their commitment to a long term goal of weight loss?

Attempt to develop the clients' self-motivation *Long term commitment to lifestyle changes is based on intrinsic motivation. *Each individual must choose to take the actions necessary for health changes

A nurse is assessing a client who is postoperative following a cholecystectomy. Which of the following techniques should the nurse use to assess for peristalsis of the abdomen?

Auscultate for as long as 5 min *Although it usually takes only 5 to 20 seconds to hear bowel sounds, the nurse might have to listen in all four abdominal quadrants for at least 5 full min before determining that bowel sounds are absent.

A client who has type 1 diabetes is scheduled for an appendectomy. The client has been NPO since midnight. There are no preoperative orders for a daily insulin dose. Which intervention is appropriate?

Call the provider to request an insulin prescription *Surgery is stressful, and adjustments in the diabetes regimen can be planned to ensure glycemic control. *Typically, the client is given IV fluids and insulin immediately before, during, and after surgery when there is no oral intake. *In this situation, the nurse must contact the provider to clarify how to proceed.

A nurse is caring for a client who is incontinent of loose stool and is reporting a painful perineum. Which of the following is the priority nursing action?

Check the client's perineum *The first step of the nursing process is assessment. *In this situation, the nurse should collect more data before taking any other action.

A nurse enters a client's room and finds the client is in respiratory arrest. What is the first action the nurse should take?

Establish an open airway *Remember the ABCs of a client found in arrest: Airway, Breathing, and Circulation. *The first action the nurse should take is to establish an open airway using the head-tilt, chin-lift method. *When cervical injury is suspected, the nurse should open the airway using the jaw-thrust method.

A nurse manager is teaching a group of unit nurses about procedures within a nurse's scope of practice. Which of the following should the nurse include in the teaching?

Monitoring a continuous intraarterial infusion of a clot-dissolving agent *Monitoring the infusion of a clot-dissolving agent is within the nurse's scope of practice. *In addition, the nurse should inspect the IV line for a disconnection, check the infusion site for bleeding, and maintain site integrity.

Which of the following should the nurse do first when preparing to provide tracheostomy care?

Perform hand hygiene *A basic principle of medical and surgical asepsis is thorough hand hygiene before any contact with clients or equipment. *This reduces the risk of transmission of microbes from other areas of the facility to either the client or to equipment used for that client

A nurse is teaching a client with right-sided hemiparesis to ambulate with a quad cane. Which instructions are appropriate?

Place quad cane in left hand, extend left hand with quad cane, and right lower extremity followed by left leg *Place quad cane in left hand, extend left hand with quad cane and right lower extremity followed by left leg. *Holding the quad cane on the stronger side of the body and moving the cane in unison with the weaker leg gives support and helps to maintain stability for the client.

A nurse is caring for a toddler in contact isolation. Which of the following is an appropriate toy to offer the toddler?

Plastic building blocks *Plastic building blocks can be sterilized. *Therefore, they are an appropriate toy to bring into contact isolation.

A client is being discharged to home with oxygen therapy via a nasal cannula. Which instruction should the nurse give to the client and family?

Wear clothing to avoid static electricity *The use of cotton clothing will limit static electricity. *Oxygen is a highly combustible gas. *The use of oxygen in high concentrations has great combustion potential and readily fuels fire. *Although it will not spontaneously burn or cause an explosion, it can easily cause a fire in a client's room if it contacts a spark.

A nurse is instructing a client with a right fractured tibia on the correct technique for using a three-point gait with crutches. Which of the following should be included in teaching?

Weight is distributed on both crutches and then on the unaffected leg with the sequence being repeated *Three point gait requires the client to bear all of the weight on one foot. *The affected leg does not touch the ground.

A nurse is implementing a bowel training program for a client. For the program to be effective the client should be taken to the bathroom at which of the following times?

When the client has the urge to defecate *When on a bowel training program, the client should be taken to the bathroom when the urge to defecate is recognized. *Failure to heed the call to defecate may lead to overdistention of the rectum with hardening of the stool and constipation.

A nurse is planning range-of-motion exercises for a client. The nurse understands that active range of motion is performed before passive range of motion (PROM) because

active range of motion is used to determine limitation of movement *Active range of motion is performed before passive range of motion to determine limitation of movement. *This helps ensure that no injury will develop during passive range of motion. *Active range of motion requires muscle power and therefore, must be done first. *Passive range of motion is then used to assist with circulation, decrease pain, maintain joint and soft tissue flexibility, and keep the client aware of the area of treatment.

A nurse is caring for a client who has a lacerated spleen and has been on strict bedrest for several days. The nurse notes decreased breath sounds in the lower lobes of both lungs. The nurse should realize that this finding is most likely due to

atelectasis *Atelectasis is the collapse of part or all of a lung by blockage of the air passages (bronchus or bronchioles) or by very shallow breathing. *Anesthesia, prolonged bedrest with few changes in position, and underlying lung disease are risk factors for the development of atelectasis.

Following an accidental fall while playing volleyball, a client is sent home in a lower leg cast due to a hairline fracture of the tibia and must use crutches. When teaching the client the four-point gait, the nurse explains that the client should

be able to bear weight on both legs *With the four-point gait, the client brings the left crutch forward first, followed by the right foot; then the right crutch is brought forward, followed by the left foot. *Thus, both legs must be able to bear some weight. *Each leg is moved alternately with each opposing crutch so that three points of support are on the floor at all times.

A nurse is caring for a 5 year old child returning from the surgical suite following an exploratory laparotomy and removal of a ruptured appendix. When writing the child's nursing care plan, the nurse lists the priority intervention as

having the child turn, cough, and breathe deeply every 2 hr *Keeping in mind the nursing guideline of ABC (Airway-Breathing-Circulation), the nurse realizes that a child recovering from abdominal surgery is at increased risk of atelectasis and impaired breathing. *Coughing and deep breathing are a priority because the immediate risk for the client is atelectasis, and this presents the greatest risk to the client immediately following surgery.

A client's provider has ordered that a sputum specimen be collected for culture and sensitivity. The nurse plans to collect this specimen

in the morning, on arising *Generally, the deepest specimens are obtained in the early morning, and it's preferable to collect the specimen before breakfast. *The nurse instructs the client to rinse the mouth, take a deep breath, and cough prior to expectorating into the sterile container.

A nurse is to planning to insert a nasogastric (NG) tube. The nurse understands that an improper use of the NG tube would be for

maintaining NPO status *Maintaining NPO status is an inappropriate use of an NG tube. *Instillation of liquid nutritional supplements of feedings for clients unable to swallow fluid is an appropriate and common use of an NG tube.

A client is prescribed a hypothermia blanket. When caring for the client, the nurse

places a layer of cloth between the client and the blanket *A hypothermia blanket is used to cool a client with a high fever unresponsive to antipyretics. *To prevent tissue damage, the client's skin should never come in direct contact with any method used for cooling or heating purposes. *Placing a layer of cloth between the client and the cooling blanket will protect the client from injury.

A nurse is teaching a client with a new colostomy about how to irrigate the ostomy. The nurse realizes that the client needs further teaching when the client

positions the irrigating solution bag 30 inches above the stoma *The client needs further teaching. *The irrigating bag should be positioned a maximum of 20 inches above the height of the stoma, not 30 inches. *This height can cause too much pressure in the line and force the irrigating solution in too rapidly, causing abdominal cramping. TEST-TAKING STRATEGY: This question asks which action indicates that the client needs FURTHER teaching, thus the CORRECT answer is an INCORRECT action.

A nurse is caring for a client who is 3 days postoperative following a cholecystectomy. The nurse suspects a wound infection because the drainage on the dressing is yellow and thick. The nurse identifies this type of drainage as

purulent *Purulent describes thick yellow, green, or brown drainage. *Purulent drainage is often associated with wound sloughing or infection.

Cardiopulmonary resuscitation (CPR) has been initiated for a client in the emergency room. The nurse understands that a critical concept related to effective cardiac (chest) compressions is the need to

push hard and deep on the chest *Compressions should be hard and deep. *Shallow chest compressions may not produce adequate blood flow.

A nurse is planning to collect a liquid stool specimen from a client for ova and parasites. Inaccurate test results may result if the nurse

refrigerates the collected specimen *A liquid stool specimen for ova and parasites must be sent immediately to the laboratory and examined within 30 min to preserve the life of any ova. *If it cannot be examined within 30 min, then some of the specimen should be placed in a preservative, not in the refrigerator. TEST-TAKING STRATEGY: This question asks which action could falsely alter the test results, thus the CORRECT answer is an INCORRECT action.

Hot coffee spills and scalds a client's arm. The nurse's priority action is to

remove the clothing from the burned area and apply cold water *Removing the hot clothing and applying cold water helps stop the burning process. *This is the nurse's priority in this situation.

A client is admitted to the hospital in the terminal stage of cancer. The nurse enters the client's room to administer medications and finds the client crying. The appropriate nursing action is to

sit and hold the client's hand *With this action, the nurse uses the therapeutic communication tool of being silent, which conveys importance to the client. *Holding the client's hand is a nonverbal way for the nurse to express empathy

A nurse removes an indwelling urinary catheter that an older adult client has had in place for 2 days. The nurse should assess the client for the expected outcome of

temporary urinary retentions *Until the bladder regains full tone, it is common for clients to develop urinary retention. *If a client does not urinate for 6 to 8 hr after catheter removal, reinsertion might become necessary.

A client admitted to a long term care facility requires total care. In providing mouth care to the client, the appropriate nursing action is to

turn the client on his side before starting mouth care *Placing the client on his side allows excess fluids to run out of his mouth into a basin, thus reducing the risk of aspiration of fluids and secretions.

When ambulating a frail, older adult client, the nurse should

use a transfer belt if the client is unsteady *The use of a transfer belt helps hold the client steady while ambulating.

The nurse is caring for an adult client who has fluid volume excess. When weighing this client, the nurse should

weigh the client on arising *Accurate daily weights provide the easiest measurement of volume status. *An increase of 1 kg (2.2 lb) is equal to 1,000 mL (1 L) of retained fluid. *An accurate weight requires the client to be weighed at the same time every day (preferably on arising), wearing the same garments, and on the same carefully calibrated scale (balanced to zero before each use).

A nurse is preparing a client for surgery. She should begin preoperative teaching by exploring

what the client knows about the surgery *The first step in client instruction is to determine the client's learning needs. *The nurse does this by determining what the client needs to know, in this case, about the perioperative experience.

At the surgical scrub sink, a surgical nurse demonstrates the proper surgical handwashing technique by scrubbing

with her hands held higher than her elbows *Hands must be held higher than the elbows so that water and soapsuds can drain away from the clean area toward the dirty area.

A nurse tells a client that the provider has prescribed IV fluids. The client appears to be upset about the IV catheter insertion, but says nothing to the nurse. Which of the following is an appropriate nursing response?

"Is there something about this procedure that concerns you?" *With this response, the nurse uses the therapeutic communication tools of clarification and offering self. *The nurse inquires about the client's concerns (feelings), and offers self by suggesting that they talk about both the procedure and the client's feelings

What technique is used for assessing capillary refill?

Push on a fingernail bed until it blanches, release it, and observe how long it takes the skin to become pink

What is pernicious anemia?

*Pernicious anemia is caused by a lack of intrinsic factor, a substance needed to absorb vitamin B12 from the gastrointestinal tract. *Vitamin B12 is needed for the formation of red blood cells. *Hematuria, or hemoglobin present in the urine, is not a manifestation of pernicious anemia.

What are rhonchi?

*Rhonchi are continuous rumbling, snoring or rattling sounds

What is serosanguineous drainage?

*Serosanguineous indicates plasma mixed with light bloody drainage. *It is typically pale yellow to blood-tinged and watery drainage.

What is stridor?

*Stridor is a continuous musical sound of constant pitch

A nurse is teaching pursed-lip breathing to a client who has COPD. Which of the following information should the nurse include in the teaching?

Exhale slowly through the mouth *The client should exhale slowly through pursed lips to prolong exhalation and increase airway pressure, which decreases the amount of trapped air in the lungs.

Where is the mitral valve located?

Fifth intercostal space just medial to the midclavicular line

Where is the tricuspid valve located?

Fifth intercostal space to the left of the sternum

What is lordosis?

Lordosis or swayback is an exaggerated lumbar curve or anterior convexity of the lumbar spine that is common in pregnancy.

Where is the pulmonic valve located?

Second intercostal space to the left of the sternum

A client taking several medications to treat congestive heart failure and rheumatoid arthritis arrives at the clinic reporting fatigue, anorexia, and nausea. Which assessment question is the nurse's priority?

"Have you been taking your medication as prescribed?" *This is the nurse's priority because the client takes several medications and therefore is at increased risk for drug interactions and adverse reactions. *Fatigue, anorexia, and nausea are common symptoms of both drug interactions and toxicity. *Drug interactions and adverse reactions can have the potential to become life-threatening.

A nurse is completing a health assessment for an adult client. During the health history, the client expresses concern about a recent lack of sexual desire. Which of the following is an appropriate response by the nurse?

"How have you been feeling about yourself lately?" *This is an open-ended question that promotes therapeutic communication about self-concept issues, including identity, body image, role performance, and self-esteem, which can affect a client's sexuality. *Asking this question encourages the client to discuss overall thoughts, feelings, and concerns that might be affecting sexuality.

A nurse provided discharge teaching to new parents on how to care for their newborn following circumcision. Which of the following statements by the parents indicates the need for further clarification?

"I can give him a tub bath in two days." *The newborn should not be immersed in water until the circumcision has healed and the umbilical cord has detached. *The circumcision should heal within two weeks.

A nurse is teaching a client who has a new diagnosis of atopic dermatitis. Which of the following statements is appropriate for the nurse to include?

"Your provider may recommend a daily antihistamine to help control your symptoms." *Atopic dermatitis is commonly related to an allergic reaction and therefore it is appropriate to treat this condition with an antihistamine.

A nurse is caring for several clients who are receiving oxygen therapy. Which client should the nurse assess most frequently for manifestations of oxygen toxicity? The client receiving

100% oxygen via a partial rebreathing mask *100% oxygen via a partial rebreathing mask delivers concentrations of 60 with 90% inspired oxygen. *(Inspired oxygen concentrations with oxygen flow to the reservoir bag and with how much the bag collapses with inspiration.) *Oxygen toxicity is associated with oxygen concentrations above 50% for longer than 24 to 48 hr.

A nurse is calculating the client's intake and output. Based on the information below, which of the following values correctly represents the client's total output? --Sipped 8 oz. clear broth. --100 mL ice chips. --Voided 450 mL. --IV push pain medication 50 mL. --Drank 4 oz. juice and 6 oz. hot tea. --Vomited 120 mL and voided 600 mL. --Jackson Pratt drain emptied 40 mL.

1210 mL *1210 mL output is the correct value. *Input includes all liquids taken by mouth, including through nasogastric or jejunostomy feeding tubes, IV fluids, and blood or its components. *Output includes urine, diarrhea, vomitus, and drainage from tubes such as through gastric suction and drainage from postsurgical wounds or other tubes.

A nurse is caring for a client who is at risk for pressure ulcer formation due to immobility. Which of the following positions should the nurse plan to use to reduce pressure on the client's bony prominences?

30° lateral position *The 30° lateral position, along with positioning devices, should prevent pressure directly over bony prominences.

A nurse is caring for a client who is receiving oxygen at 5 L/min or above via a simple face mask. What oxygen concentration is the client receiving?

50% *Simple face masks deliver oxygen concentrations of 40%-60% with flow rates of 5 L/min and above

A nurse is caring for a client who is receiving oxygen at a minimum of 10 L/min via a non rebreather mask with a reservoir bag

70% *A nonrebreather mask with a reservoir bag with a minimum flow rate of 10 L/min can deliver oxygen concentrations of 60% to 90%.

A nurse is preparing to administer an intramuscular injection to a client. At which of the following angles should the nurse insert the needle?

90° *This is an appropriate angle of insertion for an intramuscular injection. *The intramuscular route promotes quicker medication absorption into the muscle than the other routes of medication administration.

A client recovering from an appendectomy for a ruptured appendix has a surgical wound healing by secondary intention. When changing the client's dressing, which observation should the nurse report to the client's surgeon?

A halo of erythema on the surrounding skin *A ring of erythema (redness) on the surrounding skin may indicate underlying infection. *This and any other sign of infection, such as purulent drainage, swelling, warmth, or a strong odor, should be reported. TEST-TAKING STRATEGY: This question requires sorting out postoperative wound observations that are EXPECTED versus UNEXPECTED.

What is an ejection click?

A high-pitched sound heard shortly after S1 *It is associated with a dilated pulmonary artery or septal defects.

A nurse in a long-term care facility is caring for an older adult client who wears dentures. The client reports mouth pain and sores. Which of the following actions should the nurse take?

Advise the client to remove his dentures when not eating *The nurse should advise the client to remove his dentures and replace them only for meals to promote healing of oral mucosa and gums.

A client scheduled for a hysterectomy has not yet signed the operative consent form. When the nurse approaches the client and asks that she review and sign the form, the client says she no longer wants to have the surgery. At this time, which action should the nurse take?

Ask the client why she has changed her mind *The nurse has to find out the reasons for the client's decision to forego the surgery. *It may be a simple misunderstanding on the client's part, or she may still have unanswered questions about the procedure. TEST-TAKING STRATEGY: With a question where various stages of the nursing process (assessment, intervention, evaluation) are reflected in the options, rely on the nursing process to determine what to do. Assessment comes first, followed by analysis, planning, intervention, and evaluation.

A nurse is caring for a client who is receiving intermittent tube feedings. What intervention reduces the risk of aspiration?

Assessing gastric residual volume immediately before administering the feeding *Measuring the gastric residual volume (GRV) every 4 to 6 hours in clients who are receiving continuous feedings and immediately before the feeding in clients receiving intermittent feedings is an effective way to reduce the risk of aspiration. *Nursing measures to reduce the risk of aspiration, such as keeping the head of bed elevated and routine assessment for aspiration, should be implemented for clients who are receiving tube feedings. *Feedings should be withheld if the GRV is greater than 200 mL in two successive measurements.

A nurse is caring for a client with a spinal cord injury who has an indwelling catheter. Which of the following is the highest priority when providing perineal care for this client?

Avoid inadvertently advancing the catheter into the bladder *Accidental advancement of the catheter into the bladder during cleansing increases the risk of introducing bacteria into the bladder. *Therefore, avoiding inadvertent advancement of the catheter into the bladder is the priority intervention.

A nurse is caring for a client who is in the early stages of hypoxia and is receiving oxygen therapy. When assessing this client, the nurse should expect to find which of the following late indications of hypoxia?

Bradypnea *A declining respiratory rate is a common finding in the late stages of hypoxia. Cyanosis *Cyanosis, a bluish discoloration of the skin and mucous membranes, is a common finding in the late stages of hypoxia.

A nurse is planning care for a client who has IV fluids infusing. Which of the following interventions should the nurse implement to maintain asepsis?

Change the primary IV infusion set every 72 hr *The nurse should change the primary IV administration set every 72 hr to minimize the risk of contamination and infection.

A nurse is collecting a diet history for a client with chronic renal failure. Which food choice indicates the client would benefit from further education?

Cheddar cheese *Client's with renal failure need to restrict protein and phosphorus which is present in cheese and many milk products.

A graduate nurse is performing ostomy care for a client with a new colostomy. Which intervention performed by the nurse indicates the need for more education?

Cleansing the peristomal skin with alcohol *This intervention is not appropriate. *The peristomal skin should not be cleansed with alcohol.

A nurse is caring for a client who has an ankle sprain and a prescription for an aquathermia pad. Which of the following actions should the nurse take?

Cover the pad with a pillow case before application *A thin towel or pillow case should be placed over the aquathermia pad before it is used, as applying the pad directly to the skin could cause a burn injury.

A nurse is educating the parents of an infant about symptoms that should be reported to the provider. What finding should be immediately reported?

Decreased urine output *Decreased urine output indicates dehydration and should be reported immediately to the provider. *Listlessness, sunken eyes, decreased tears, and dry mucous membranes are other symptoms of dehydration that should be immediately reported.

A nurse in an emergency department is caring for a client who collapsed after playing football on a hot, sunny day. After reviewing the admission laboratory values below, the nurse should recognize that these results are consistent with which of the following? Serum Electrolyte Panel Sodium 152 mEq/L Glucose 102 mg/dL Potassium 3.0 mEq/L BUN 25 mg/dL Chloride 15 mEq/L Creatinine 0.5 mg/dL Carbon Dioxide 24 mEq/L

Dehydration *Hypernatremic (hypertonic) dehydration occurs when lost fluid contains less sodium than the blood. *The nurse should note that the client's sodium and BUN levels are elevated while the potassium is decreased and creatinine is within normal limits. *The client's history, collapsing after activity on a hot, sunny day, and the findings, an elevated BUN and sodium, are consistent with dehydration.

A nurse is using standard precautions while caring for a group of clients. Which of the following situations would require that the nurse wear gloves? (Select all that apply.)

Emptying urine from an indwelling urine collection bag is correct. *The nurse following standard precautions should wear gloves when in direct contact with bodily fluids. Providing oral care is correct. *The nurse following standard precautions should wear gloves when in direct contact with bodily fluids. Changing an ostomy pouch is correct. *The nurse following standard precautions should wear gloves when in direct contact with bodily fluids. Delivering a food tray to a client who has AIDS is incorrect. *Delivering a food tray to a client who has AIDS, would not require the nurse to wear gloves. Placing oral medication tablets into a client's hand is incorrect. *Placing oral medication ito a client's hand would not require the nurse to wear gloves.

An older adult client has been hospitalized on bed rest for 1 week. The client reports elbow pain. Which of the following is an appropriate initial action for the nurse caring for this client to take?

Examine the elbow *Assessing the elbow is appropriate because the nurse does not know enough about the client's elbow pain or its probable cause. *The nurse should assess the elbow for redness, swelling, and joint pain. *Then, after assessing the problem, the nurse can analyze the situation and develop a plan of care and implement the appropriate nursing interventions. TEST-TAKING STRATEGY: With a priority-setting question where all the options appear correct, but various stages of the nursing process (assessment, intervention, evaluation) are reflected in the options, rely on the nursing process to help set priorities. Assessment comes first, followed by analysis, planning, intervention, and evaluation.

A nurse is caring for a client when the IV infusion pump malfunctions and delivers 1 Liter of IV fluid over 2 hours. Which intervention is the priority?

Fill out an incident report

A nurse is caring for a client admitted to the hospital with a high fever, chills, and dehydration. The nurse knows that which laboratory test will not help the provider confirm infection?

Glucose *Blood glucose would not be part of the screening procedure for infection. *This test is primarily used for clients who have diabetes mellitus. TEST-TAKING STRATEGY: With a negative-format question like this one, the CORRECT answer has to be an INCORRECT laboratory test.

An older adult client just diagnosed with colon cancer asks the nurse what the primary care provider is going to do. The provider will be making rounds within the hour. Which of the following nursing actions is appropriate?

Help the client write down the questions to ask the provider, so that the client doesn't forget *Forgetfulness is often a part of the aging process. *Since the provider will be making rounds soon, this action addresses the client's needs.

A nurse is caring for a male client who has hematuria. The client also has an Hct of 34% and an Hgb of 11.4 g/dL. The nurse should be aware that the presence of hemoglobin in the urine is consistent with which of the following types of anemia?

Hemolytic *Hematuria, or hemoglobin present in the urine, may indicate hemolysis and is a manifestation of hemolytic anemia. *Hemolytic anemia involves erythrocyte destruction and may be medication-induced or caused by sickle cell disease, transfusion reaction, or kidney disease.

A nurse is assessing a client who is receiving intermittent catheter irrigation following a transurethral resection of the prostate (TURP). Which of the following findings should the nurse report to the provider?

Increase in bladder spasms *An increase in bladder spasms following a TURP can indicate an occlusion of the catheter, such as a blood clot. *The nurse should notify the provider of this finding.

A client had a hiatal hernia repair 3 days ago. During this morning's assessment, the client tells the nurse, "My abdomen feels swollen, I'm nauseated, and I have even more abdominal discomfort." What should be the nurse's initial action?

Listen for bowel sounds *Paralytic ileus is a complication of after intestinal or abdominal surgery. *It's characterized by the absence of bowel sounds, abdominal discomfort, and distention. *The nurse should complete an abdominal assessment before taking any other action. TEST-TAKING STRATEGY: With a priority-setting question where all the options appear correct, but various stages of the nursing process (assessment, intervention, evaluation) are reflected in the options, rely on the nursing process to help set priorities. Assessment comes first, followed by analysis, planning, intervention, and evaluation.

What technique is used for determining a client's body fat percentage?

Measure the skin fold thickness at the upper arm using a pair of calibrated skin fold calipers

A nurse is admitting a client that reports flu-like symptoms with hyperactive reflexes along a new onset of confusion. The nurse realizes that the client is experiencing which of the following imbalances?

Metabolic Alkalosis

A nurse is teaching a client how to replace fentanyl (Duragesic) transdermal patches. Which of the following instructions should the nurse include in the teaching?

Monitor the need for a short-acting analgesic after applying the new patch *The nurse should tell the client that the concentration of fentanyl increases slowly and a supplementary analgesic might be necessary if break-through pain occurs during the first 12 to 24 hr.

A nurse receives transfer report on a client who is recovering from surgery. The client is receiving a clear liquid diet. Based on the information in the client's medical record, which of the following actions should the nurse implement first? (Click on the "Exhibit" button below for additional client information. There are three tabs that contain separate categories of data.)

Obtain a new prescription for IV fluids *The greatest risk to this client is injury from dehydration. *Therefore, the first action is to contact the provider for a prescription to reinitiate IV fluid infusion. *The client has assessment findings that indicate fluid volume deficit and dehydration. *The client has increased urine specific gravity, decreased blood pressure, an increased temperature, and a weak pulse. *The client also has increased output with decreased intake, along with concentrated urine. *The fastest way to prevent worsening dehydration is to administer IV fluid.

A community health nurse is a member of a case management team at a home health facility. Which of the following roles is appropriate for the nurse to take to provide optimal care for a client who is recovering from a spinal cord injury?

Participate in proactive planning with a collaborative approach *As part of an interprofessional team, each member should take an active role and work together to achieve the goals of the team.

What is a sign of chronic hypoxia?

Peripheral edema *Peripheral edema is a sign of chronic hypoxia, such as patients with long-standing COPD develop.

While eating, a client suddenly coughs a few times then attempts to cough and makes a whistling sound on inhalation. The nurse recognizes that the client is choking. When performing the Heimlich maneuver on a conscious client, which nursing action is effective?

Place both arms around the client, and position a fist in between the bottom of the sternum and the navel *This is the required emergency intervention. *The client needs immediate assistance to dislodge the object that is obstructing her airway, as demonstrated by her inability to cough and the whistling sound on inspiration. *This is the correct placement for the fist in the Heimlich maneuver: above the navel and below the end of the sternum.

A nurse is providing dietary teaching to a client diagnosed with ulcerative colitis. Which of the following foods should the nurse instruct the client to avoid?

Pork chop and brown rice *Pork chops and brown rice are high in roughage content which will stimulate peristalsis and makes the symptoms of ulcerative colitis worse. *Other foods to be avoided include whole grains, nuts, raw fruits and vegetables, caffeine, alcohol, tough meats, pork and highly spiced meats.

A nurse is caring for a client following a right below the knee amputation. Which of the following should the nurse include in the plan of care to prevent infection?

Position the affected limb in a dependent position *Positioning the extremity in a dependent position will promote blood flow and oxygenation which will decrease the risk of infection.

A nurse is assessing a client who has an NG tube for continuous enteral feedings and auscultates coarse crackles in the client's lungs. After discontinuing the feeding, which of the following actions should the nurse take next?

Position the client on her side *The greatest risk to this client is aspiration from possible dislodgment of the NG tube. *Therefore, the priority nursing action to decrease exacerbation of the condition is to position the client on his side

What technique is used for determining how much pitting edema a client has?

Press the skin in above the ankle for 5 sec, release it, and note the depth of the impression

While starting an intravenous infusion (IV) for a client, the nurse notices that her gloved hands get spotted with blood. The client has not been diagnosed with any infection transmitted via the bloodstream. Which of the following should the nurse do as soon as the task is completed?

Remove the gloves carefully and follow with hand hygiene *Standard precautions require the use of gloves and hand hygiene in the care of all clients

On auscultation of a client's lungs, the nurse identifies crackles in the left posterior base. Which of the following is the appropriate nursing intervention?

Repeat auscultation after asking the client to breathe deeply and cough *Although crackles often indicate fluid in the alveoli, they can also develop from hypoventilation. *They sometimes clear after a deep breath or a cough.

A nurse is preparing to administer ophthalmic drops to a client. Which of the following actions should the nurse take?

Rest a hand on the client's forehead while instilling the drops *This action stabilizes the nurse's hand and ensures that the hand will move with the client if he moves suddenly. *This simple precaution reduces the risk of striking the client's eye with the dropper and injuring it.

At a mobile screening clinic, a nurse is assessing a client who reports a history of a heart murmur due to aortic stenosis. To auscultate the aortic valve, the nurse should place the stethoscope at which location?

Second intercostal space to the right of the sternum *The aortic valve is located in the second intercostal space to the right of the sternum. *Aortic stenosis produces a midsystolic ejection murmur that can be heard clearly at the aortic area with the client leaning forward.

A nurse is providing staff development. The nurse understands that which of the following may impede learning?

Self-confidence *Self-confidence is not an asset for learning. *Self-confidence is considered an obstacle to learning.

While assessing a client's coping skills, a nurse should distinguish the client's internal stressors from the client's external stressors. Which of the following stressors should the nurse identify as internal?

Sense of anxiety *Anxiety is an internal stressor that originates within the client. Internal stressors often force clients to deal with conflicting inner values and interactions.

A nurse is caring for a client who has a diagnosis of hyperreflexia. Which of the following interventions should the nurse use to assess for this condition?

Using a reflex hammer *A reflex hammer assesses for hyperreflexia. *The reflex hammer causes the muscle to immediately contract due to a two-neuron reflex arc involving the spinal or brainstem segment that innervates the muscle.

A nurse is teaching a group of nurses about vancomycin-resistant enterococci (VRE) infections. Which of the following information should the nurse include in the teaching?

VRE can survive for weeks on environmental surfaces *VRE can survive for days or weeks on environmental surfaces. *Therefore, cross contamination can occur if surfaces are not adequately clean. *It is imperative for nurses to wear gloves prior to touching any items in the client's room and to practice hand hygiene with antimicrobial soap to help reduce the risk of transmitting the organism from client to client.

A nurse is performing an eye irrigation for a client who has been exposed to smoke and ash. Which of the following nursing actions should receive the highest priority during the irrigation?

Wearing gloves during the procedure *The nurse must wear gloves during an eye irrigation to maintain standard precautions. *They protect the nurse from direct contact with body secretions. *Wearing gloves also helps protect the client's eyes from introduction of a foreign body or micro-organisms from the nurse's hands.

A nurse is caring for a client diagnosed with a terminal illness. The client asks several questions about the nurse's religious beliefs related to death and dying. An appropriate nursing response is to

encourage the client to express his thoughts about death and dying *The nurse must recognize the client's need to talk about impending death, and encourage the client to discuss his thoughts on the subject. *Depending on the situation, the nurse may also want to share some thoughts on this topic. *Self-disclosure is a communication skill that can help open lines of communication when appropriate. *If the nurse does not want to share personal beliefs, the communication skill of offering self and listening to the client's thoughts is appropriate.

A client is admitted for evaluation and control of hypertension. Several hours after the client's admission, the nurse discovers the client supine on the floor, unresponsive to verbal or painful stimuli. The nurse's first action at this time should be to

establish an airway *This is an emergency situation. *For an unresponsive client, the nurse's immediate priority is to establish and maintain an airway. TEST-TAKING STRATEGY: When answering a priority-setting question where all four options appear plausible, think of the ABCs: airway, breathing, circulation. Nursing actions should follow that order, so if there is a respiratory action listed that is appropriate for the client, it is likely to be the correct answer.

How often should the secondary IV infusion set be changed?

every 24 hr if it is not attached to the primary IV infusion set

How often should the extension tubing attached to the primary IV infusion set be changed?

every 72 hr to minimize the risk of contamination and infection

When communicating with a client who is hearing impaired the nurse should

face the client and speak slowly *Nurses should always face clients who are hearing impaired and accentuate their words. *Many clients who are hearing impaired combine lip reading with their residual hearing when communicating.

A client comes to the emergency department reporting that he has had diarrhea for 4 days and is urinating less than usual. When assessing the client's skin turgor, the nurse should

grasp a fold of skin on the chest under the clavicle, release it, and note if it springs back *This is the correct technique for assessing skin turgor. *If the client has good turgor and is properly hydrated, the grasped fold of skin will immediately return to normal; with dehydration, the skin will remain tented

A nurse is caring for a female client who has an indwelling urinary catheter. The nurse determines that the assistive personnel (AP) performing hygiene care for the client requires further education about the care of indwelling catheters when she observes the AP

hanging the collection bag at the level of the bladder *The collection bag must be kept below the level of the bladder to prevent backflow of urine into the bladder. TEST-TAKING STRATEGY: With a negative-format question, the CORRECT answer will be an INCORRECT action.

An assistive personnel (AP) tells the nurse, "I am unable to find a large blood pressure cuff for a client who is obese. Can I just use the regular cuff if I can get it to stay on?" The nurse replies that taking the blood pressure of a morbidly obese client with a regular blood pressure cuff will result in a reading that is

high *Blood pressure cuffs come in various sizes, and the nurse realizes that the correct size cuff is necessary to obtain a reliable measurement. *Blood pressure readings may be falsely high if the cuff is too small for the client

A nurse prepares to admit a client who is immediately postoperative to the unit following abdominal surgery. When transferring the client from the gurney to the bed, the nurse should

lock the wheels on the bed and stretcher *Locking the wheels prevents the client from falling to the floor by not allowing the cart or bed to move apart or away from the client. *This is the priority action for transferring a client

During the termination phase of a therapeutic nurse client relationship, the nurse should initiate discussion about the concept of

loss *At the close of a relationship, even one that is planned, a person will feel loss. *The nurse should recognize the client's feelings of imminent loss and help her deal with these feelings. *This is the essential part of the termination phase.

A client who is postoperative following a laparotomy is reporting pain and a dry mouth. The client has morphine sulfate ordered to control the pain. Before administering the morphine sulfate prescribed for the client the nurse should first

measure the client's vital signs *The nurse should measure the client's vital signs before administering morphine to provide a baseline for measuring respiratory depression, an adverse effect of opioid analgesics.

A nurse caring for a preoperative client administers atropine as prescribed to

minimize oral and respiratory secretions *Anticholinergic medications, such as atropine, are given to dry the oral and respiratory mucous membranes.

A nurse in a coronary unit is admitting a client who has been successfully resuscitated using cardiopulmonary resuscitation following cardiac arrest. The client is receiving a lidocaine (Xylocaine) drip at 2 mg/min. The nurse should recognize that the purpose of the lidocaine drip is to

prevent dysrhythmias *Lidocaine is an antiarrhythmic medication that is commonly used to restore a regular heartbeat in a client who has arrhythmia. *This effect is produced by delaying abnormal nerve pulses to the heart and reducing irritability of the heart tissue.

A nurse is demonstrating postoperative deep breathing and coughing exercises to a client about to undergo emergency abdominal surgery for appendicitis. The nurse realizes the client may be unprepared to learn if the client

reports severe pain *A client who is experiencing severe pain is not able to concentrate and therefore is not ready to learn a new activity. TEST-TAKING STRATEGY: With a negative-response question, the CORRECT answer will be an INCORRECT client response.

A nurse is collecting a urine specimen for a client to test via urine dipstick the urine's specific gravity. The nurse knows the result will indicate the amount of

solutes in the urine *The specific gravity of any liquid reflects the quantity of solutes dissolved in it. *The specific gravity of urine is a measurement of the ability of the kidneys to concentrate and excrete urine and will vary with the client's hydration status and renal function.

A nurse is caring for a female client who comes to the provider's office for treatment of acne vulgaris on her cheeks. Which of the following should the nurse include in her teaching plan for this client?

use a new cosmetic pad each time she applies makeup *Use a new cosmetic pad each time makeup is applied will decrease the risk of reinfection. Use friction when washing the face is incorrect *The use of friction should be avoided due to the risk of worsening acne. Adhere to strict dietary reduction of foods prepared with oil is incorrect *Unless a food allergy is identified or an association is made between exacerbations and diet, dietary changes have not been proven to be effective in the treatment of acne vulgaris. Express the larger comedones periodically is incorrect *This intervention increases the risk for scarring and an increased number of comedones.