CMS B

A nurse is planning care for a client who is disoriented and at risk for falls. Which of the following interventions should the nurse include? (SAP) 1. Ensure that the client is wearing nonskid slippers. 2. Move the bedside table away from the bedside. 3. Place the client in a room near the nurses' station. 4. Keep the bed's full side rails in the up position. 5. Reinforce teaching about how to use the call bell.

1, 3, 5 Nonskid slippers provide better traction and can help prevent slipping and falling. Keeping the client close to the nurses' station allows for more frequent observation to help identify actions that increase the risk for falls.Even if the client is confused, it is important to reinforce the use of the call bell for assistance to help prevent the client from attempting actions that could increase the risk for falls. The nurse should keep the bedside table within the client's reach to facilitate access to items they need. Reaching for objects increases the risk for falling out of bed. Because the client might attempt to climb over the bed's full side rails and fall, the nurse should keep half side rails up and only when necessary.

A nurse is preparing to administer a medication to a preschooler and must convert the child's weight from pounds to kilograms. The child weighs 30 lb. How many kilograms does the child weigh?

13.6 kg

AA nurse is calculating the intake and output for a client over the last 8 hr. The client is receiving a continuous IV infusion at 150 mL/hr and had 4 oz of juice and 0.5 L of water. How many mL of fluid should the nurse document as the client's intake for the last 8 hr?

1820 mL Continuous IV infusion: 150 mL × 8 hr = 1,200 mL Juice: 1 oz = 30 mL4 oz × 30 mL = 120 mL of juice Water: 1 L = 1,000 mL 0.5 L × 1,000 mL = 500 mL of water Then, add all three together to find the total fluid intake: IV infusion + Juice + Water = Total fluid intake 1,200 + 120 + 500 = 1,820 mL

A nurse is caring for a group of clients in a long-term care facility. Which of the following actions should the nurse take to pevent health care-associated infections for these clients? (SAP) 1. Place immunocompromised clients in the same room. 2. Wash hands after removing gloves. 3. Use antimicrobial hand gel after refilling a client's water pitcher. 4. Clean the stethoscope with an antimicrobial wipe after obtaining vital signs. 5. Administer a prophylactic dose of antibiotics prior to discharge.

2, 3, 4

A nurse is caring for a client who is postoperative and is experiencing nausea and vomiting. The nurse should identify which of the following findings as indications that the client has fluid volume deficit? (SAP) 1. Full bounding pulse 2. Cool extremities 3. Moist crackles in the lungs 4. Orthostatic hypotension 5. Flat neck veins

2, 4, 5 Cool extremities can indicate fluid volume deficit. Orthostatic hypotension indicates fluid volume deficit. Flat neck veins indicate fluid volume deficit. A full bounding pulse indicates fluid volume excess. The nurse should expect a weak peripheral pulse in a client who has fluid volume deficit. Moist crackles in the lungs indicate fluid volume excess. The nurse should expect clear lungs in a client who has fluid volume deficit.

A charge nurse smells smoke, enters the visitor restroom, and sees flames in the trash can. What is the sequence of actions that the nurse should take? 1. Close the fire doors on the unit 2. Use a fire extinguisher to put out the fir 3. Evacuate clients from the area 4. Pull the lever on the fire alarm box

3, 4, 1, 2 The first action the nurse should take when using the RACE protocol is to "rescue" or evacuate the clients from the area to prevent harm. For the next step, "alarm," the nurse should activate the facility fire alarm and call to report the fire to the facility emergency extension. For the third step, "confine," the nurse should close the unit fire doors to prevent the fire from spreading. For the final step, "extinguish," the nurse should use a fire extinguisher to put out the fire by aiming the nozzle at the base of the fire and using a sweeping motion.

A nurse is caring for a client who is scheduled for surgery the following day. During the night, the client is unable to sleep and is restless. Which of the following statements should the nurse make? A. it must be difficult facing this type of surgery B. other clients who have had this surgery have done just fine C. this facility is known for providing excellent care for people who need this type of surgery D. i can request a sleeping pill, if you think that will help

A. Stating that it must be difficult to be in this position is an open-ended and nonjudgmental statement that allows the client to talk about their fears. This statement provides false reassurance rather than exploring the concern. This statement provides false reassurance rather than exploring the concern. Offering the client a sleeping pill avoids the opportunity to discuss the client's concerns.

A nurse is preparing a client for a Romberg test. Which of the following statements should the nurse make? A. "Stand with your feet together and your arms at your sides." B. "After I place the tuning fork, tell me when you no longer hear the sound." C. "I'm going to stroke the lateral side of the bottom of your foot." D. "Touch each fingertip as quickly as possible with your thumb."

A. The Romberg test measures stability with and without the eyes closed. The nurse should instruct the client to stand with their feet together and their arms at their sides. The nurse should instruct the client to indicate when they no longer hear the sound of the tuning fork for a Rinne test. The nurse should stroke the lateral side of the bottom of the client's foot to test for the presence of a Babinski reflex. The nurse should instruct the client to touch their thumb to each fingertip as quickly as possible to evaluate their fine motor skills.

A nurse is caring for a postoperative client who is at risk for thrombus formation. Which of the following interventions should the nurse delegate to an assistive personnel (AP)? A. Apply thromboembolic stockings. B. Monitor the circulation in all four extremities. C. Record the condition of the client's skin. D. Reinforce teaching about performing range-of-motion exercises.

A. The application of thromboembolic stockings is within the range of function of an AP and does not require further data collection by the nurse. This type of data collection is not within the range of function of an AP because it requires the knowledge and skills of the nurse. Collecting and recording data about skin condition is outside the range of function of an AP because it requires the knowledge and skills of the nurse. Reinforcing teaching is not within the range of function of an AP because it requires the knowledge and skills of the nurse.

A nurse is reinforcing teaching about advance directives with a client who has an end-stage renal disease. Which of the following client statements indicates an understanding of the teaching? A. "I know that I can change my advance directives if I need to in the future." B. "My health care surrogate will make my health care decisions as soon as I have signed the power of attorney." C. "My family can overrule the decisions made by my health care surrogate." D. "Advance directives from one state are valid in any other state."

A. The client can change their advance directives at their discretion. The client's health care surrogate will only make health care decisions when the client is unable to do so. The individual named as health care surrogate for a client has the legal authority to make decisions on the client's behalf and cannot be overruled by the client's family. The nurse should inform the client that laws regarding advance directives vary among different states. The nurse should be familiar with the laws regarding advance directives in the state of practice.

A nurse is planning to perform intermittent urinary catheterization for a client who is unable to urinate. Which of the following actions should the nurse take first? A. Perform a bladder scan. B. Cleanse the meatus. C. Provide perineal care. D. Lubricate the catheter.

A. The first action the nurse should take when using the nursing process is to collect data from the client. Therefore, the nurse should evaluate the bladder contents before performing an invasive procedure. A bladder scan determines the amount of urine in the bladder and helps the nurse avoid unnecessary catheterizations. The nurse should cleanse the urinary meatus to reduce the risk of contamination; however, there is another action the nurse should take first. The nurse should provide perineal care to decrease the number of micro-organisms and to observe the urinary meatus; however, there is another action the nurse should take first. The nurse should lubricate the catheter to facilitate insertion; however, there is another action the nurse should take first.

A nurse is performing oral hygiene for a client who is unconscious. Which of the following actions should the nurse take first? A. Turn the client's head to the side. B. Suction secretions from the client's mouth. C. Insert an oral airway. D. Apply a water-soluble lubricant to the client's lips.

A. The greatest risk to this client is injury from aspiration of irrigating and cleansing fluids, such as water and mouthwash. Therefore, the priority intervention is to turn the client's head to the side so that fluid and secretions will pool and drain safely during the procedure. The nurse should remove secretions and fluid that collect while performing oral hygiene to prevent aspiration; however another action is the priority. The nurse should insert an oral airway to keep the client's teeth apart, thus allowing easy access to the client's mouth and preventing injury from the client biting down on the nurse's fingers; however another action is the priority. After brushing the client's teeth and tongue, the nurse should apply a water-soluble lubricant to the client's lips to prevent cracking and drying, which could lead to infection; however another action is the priority.

A nurse is reinforcing teaching with a client about living wills. Which of the following client statements indicates an understanding of the teaching? A. "The living will directs my medical care when I am unable to make decisions." B. "I should have a nurse cosign my living will." C. "After signing the living will, I will not be able to make any changes." D. "I am required by Medicare to have a living will when I am admitted to the hospital."

A. The living will provides specific directions for a client's medical treatment when the client is unable to make decisions due to their health status. It is the nurse's responsibility to reinforce teaching regarding living wills and to support the client in the decision-making process. However, the nurse does not cosign a client's living will. The nurse should inform the client that they can make changes to their living will at any time, as long as they have the mental capability and are deemed competent to do so. Medicare requires health care facilities to inform clients about advance directives and about their right to make their own choices regarding living wills.

A nurse is assisting with the plan of care for a client who has a bacterial infection and a persistent oral temperature of 38.9 C (102 F). Which of the following interventions should the nurse include in the plan of care to treat the fever? A. Administer acetaminophen. B. Apply ice packs to the client's axillae. C. Maintain the room temperature at 18.3° C (64.9° F). D. Assist the client to ambulate four times a day.

A. The nurse should administer acetaminophen or an NSAID such as ibuprofen to the client to reduce the body's temperature. Acetaminophen inhibits the synthesis of prostaglandins, resulting in a reduced fever. The nurse should not apply ice packs to the client's axillae or groin because this measure can lead to shivering, which increases the client's body temperature. The nurse should maintain the room temperature between 21.1° to 26.7° C (70° to 80° F). A room temperature that is too low can lead to shivering, which increases the client's body temperature. The nurse should limit the client's physical activity to decrease body heat production.

A nurse is planning to perform wound irrigation for a client who has a large abdominal wound. Which of the following actions should the nurse plan to take? A. Administer an analgesic 30 min before starting the procedure. B. Hold the syringe 5 cm (2 in) above the upper end of the wound. C. Place the irrigation solution in a basin of cool water. D. Perform the wound irrigation with a 10-mL syringe with an angiocatheter.

A. The nurse should administer an analgesic to promote pain control, which allows the client to move more easily and be positioned to facilitate the irrigation procedure. The nurse should hold the syringe 2.5 cm (1 in) above the upper end of the wound and over the area they are cleaning to prevent syringe contamination and unsafe pressure of flowing solution. The nurse should place the irrigation solution in a basin of hot water to warm the solution to body temperature. This action will reduce vasoconstriction of the tissues. The nurse should use a 35-mL syringe with a 19-gauge needle or an angiocatheter to ensure an irrigation pressure within the correct range.

A nurse is checking a client for a pulse deficit after detecting an irregular heart rate. Which of the following actions should the nurse take? A. Count the client's radial and apical pulses simultaneously with another nurse. B. Calculate the client's pulse for 30 seconds and multiply by 2. C. Assist the client to a side-lying position. D. Auscultate the area of the client's chest over the Erb's point.

A. The nurse should have another nurse count the radial pulse as they count the apical pulse. A pulse deficit occurs when there are differences between the radial and apical pulse rates. The nurse should count the pulse for 60 seconds to determine whether there is a discrepancy between the apical and radial pulse rates when checking for a pulse deficit. The nurse should place the client in a supine or sitting position for an accurate measurement when checking for a pulse deficit. The nurse should auscultate the area of the client's chest over the apex of the heart when checking for a pulse deficit. Erb's point is auscultated at the third intercostal angle.

A nurse is providing wound care for a group of clients. Which of the following wounds should the nurse identify as healing by secondary intention? A. A stage 3 pressure injury on the coccyx B. A contaminated wound that is closed after 72 hr C. A puncture wound that is sutured D. An abdominal surgical wound with intact staples

A. The nurse should identify a pressure injury and other wounds with edges that are not approximated as healing by secondary intention. The nurse should identify a contaminated wound that is left open for monitoring and then closed after several days as healing by tertiary intention. The nurse should identify a wound that is sutured as healing by primary intention. The nurse should identify a surgical wound that has intact staples as healing by primary intention.

A nurse is caring for a client who has metastatic cancer and practices Catholicism. The client asks the nurse to discuss the afterlife with them. Which of the following statements by the nurse assists in meeting the client's spiritual needs? A. "Tell me what the afterlife means to you." B. "You should discuss the afterlife with your priest." C. "Keep praying. A miracle could happen." D. "Maybe your condition will lead you closer to God."

A. This statement respects the client's spiritual needs by using open-ended therapeutic communication to assist the client to talk about their concerns. This statement avoids the client's concerns and is a nontherapeutic form of communication. This statement uses unwarranted reassurance, which is a nontherapeutic form of communication. This statement uses stereotyping, which is a nontherapeutic form of communication.

A nurse is caring for a client who has dyspnea caused bya respiratory infection. The nurse should assist the client into which of the following positions? A. orthopneic B. dorsal recumbent C. sims D. prone

A. The nurse should assist the client into the orthopneic position by having the client sit upright either in bed or in a chair and lean forward. This position allows maximal chest expansion and facilitates breathing. When dorsal recumbent, the client is supine or back-lying. This position makes breathing especially difficult for clients who have respiratory problems. In the Sims' position, the client is side-lying and partially on the abdomen, with flexion of the upper hip, knee, elbow, and shoulder. This position is useful for clients who are unconscious, as secretions can drain from the mouth. However, the Sims' position does not relieve dyspnea. In the prone position, the client is lying on the abdomen. This position is useful for clients who are unconscious, as secretions can drain from the mouth. It also prevents flexion contractures of the knees and hips. However, the prone position does not relieve dyspnea.

A nurse is preparing to administer an enteral feeding to a client who has an NG tube in place. Which of the following methods should the nurse use to verify correct placement of the NG tube? A. Check the pH of the gastric aspirate. B. Observe the color of the gastric aspirate after adding blue dye to the formula. C. Auscultate over the epigastrium. D. Measure the length of the inserted NG tube.

A. The nurse should check the pH of the gastric contents to verify tube placement. A pH greater than 6 is an indication that the nurse has aspirated respiratory contents or that the tube is in the intestine, and that the nurse should withhold the feeding. The nurse should not add blue dye to the formula as a way of checking for tube placement because blue dye can cause adverse reactions. The nurse should not auscultate over the epigastrium because this is not a reliable indication that the tube is in place. The nurse should measure the length of the inserted NG tube immediately after insertion of the tube. However, measuring the length of the tube at this point is not a reliable indication that the tube is in place.

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take? A. Clean the perineal area at least once a day. B. Empty the drainage bag when it is three-fourths full. C. Flush the catheter with sterile water daily. D. Disconnect the drainage bag when emptying and measuring urine.

A. The nurse should clean the perineal area at least once a day to reduce the risk for infection. The nurse should empty the drainage bag when it is one-half full to reduce the risk for infection. The nurse should avoid flushing the catheter routinely because this can increase the risk for infection. The nurse should avoid flushing the catheter routinely because this can increase the risk for infection.

A nurse is caring for a client who reports difficulty sleeping at home. Which of the following recommendations should the nurse provide to promote a restful home sleep environment? A. "Perform muscle relaxation before bedtime." B. "Exercise vigorously 1 hour prior to going to bed." C. "Drink a cup of hot chocolate at bedtime." D. "Change the time you go to sleep each day."

A. The nurse should encourage the client to perform muscle relaxation to reduce anxiety and induce sleep. Vigorous exercise immediately before bedtime is a stimulant and can cause difficulty falling asleep. Caffeine and nicotine are stimulants and can cause difficulty falling asleep. Maintaining a consistent bedtime can help to induce sleep.

A nurse is caring for a client who has a seizure disorder. Which of the following supplies or equipment should the nurse ensure is available at the client's bedside at all times? A. Wrist restraints B. Oral suction equipment C. Padded tongue blade D. Sterile gloves

B. A client who has a seizure disorder is at risk for injury from aspiration of secretions or emesis. Therefore, the nurse should have oral suction equipment available at all times to clear the client's mouth of secretions or emesis after a seizure. If the client has a seizure, the nurse should not restrain the client, because this increases the risk for client injury. If the client has a seizure, the nurse should not attempt to insert anything into the client's mouth, because this increases the risk for client injury. The nurse should have clean gloves available due to the potential need for respiratory care and intervention; however, sterile gloves are not necessary.

A nurse is caring for a client who has been vomiting and has diarrhea. Which of the following findings should the nurse identify as an indication of fluid volume deficit? A. BUN 18mg/dL B. a thready pulse C. hemoglobin 15 g/dL D. prominent neck veins

B. A client who has fluid volume deficit will have thready peripheral pulses. A BUN above 20 mg/dL indicates an extracellular fluid volume deficit. This finding is within the expected reference range of 10 to 20 mg/dL. The nurse should identify that a hemoglobin level of 15 g/dL is within the expected reference range of 14 to 18 g/dL for males and 12 to 16 g/dL for females. An increased hemoglobin level indicates that the client can be experiencing dehydration, congenital heart disease, or COPD, while decreased levels can indicate anemia, cirrhosis, or hemorrhage. With a fluid volume deficit, the client's neck veins are flat. With a fluid volume excess, they are full and visible when the client is in a sitting position.

A nurse is demonstrating the use of a transparent film dressing over a client's superficial wound. Which of the following information about a transparent film dressing should the nurse include? A. "This dressing keeps the wound bed dry." B. "This dressing allows the wound bed to breathe." C. "This dressing requires a secondary dressing." D."This dressing requires paper tape to secure."

B. A transparent dressing is applied to allow oxygen to pass through the dressing. This is referred to as "breathing" and promotes healing of the wound. A transparent dressing will promote a moist environment that should increase epithelial cell growth and promote healing of the wound. A transparent dressing does not require a secondary dressing because it adheres to undamaged skin and all secretions are contained, creating a moist environment that promotes healing of the wound. A transparent dressing is self-adhesive when applied over a small wound and it should adhere easily to undamaged skin, creating a moist environment that promotes healing of the wound.

A nurse is collecting data on four clients. Which of the following findings should the nurse report to the provider? A. Heart rate 62/min B. Urine output of 200 mL over 8 hr C. Pulse oximetry 95% on room air D. BP 112/76 mm Hg

B. A urinary output of less than 30 mL/hr can indicate low blood volume or kidney malfunction. The nurse should report an output that averages 25 mL/hr to the provider. A heart rate of 62/min is within the expected reference range of 60 to 100/min and does not need to be reported. A pulse oximetry of 95% on room air is within the expected reference range of greater than or equal to 95% and does not need to be reported. A BP of 112/76 mm Hg is within the expected reference range of less than 120 mm Hg systolic and less than 80 mm Hg diastolic.

A nurse is assisting in the plan of care for a client who has a chest tube. Which of the following recommendations should the nurse include in the plan of care? A. Elevate the head of bed 10° while lying supine. B. Immerse a disconnected chest tube in a glass of sterile water. C. Clamp the chest tube while ambulating. D. Loop the chest tube several times on the bed.

B. The nurse should immerse the open end of a disconnected chest tube in a glass of water to temporally reestablish a water seal until the client's tube can be reconnected. The nurse should position the client in semi-Fowler's position to high-Fowler's position depending on the medical condition of the client. These positions allow the maximum fluid or air to drain out through the chest tubes. The nurse should clamp the client's chest tube when replacing the chest tube drainage system. Clamping when ambulating or transporting a client can cause air pressure build up in the pleural space and cause the lung to collapse. The nurse should straighten the tubing of the client's chest tube on the bed to prevent kinking that can occur when the tubing is looped.

A nurse is contributing to the plan of care for four clients. For which of the following clients should the nurse initiate airborne precautions? A. A client who has pneumonia B. A client who has measles C. A client who has pertussis D. A client who has methicillin-resistant Staphylococcus aureus (MRSA)

B. The nurse should initiate airborne precautions for a client who has measles. The nurse should initiate droplet precautions for a client who has pneumonia. The nurse should initiate droplet precautions for a client who has pertussis. The nurse should initiate contact precautions for a client who has MRSA.

A nurse is reinforcing teaching with the partner of a client who is immobile. Which of the following instructions should the nurse give the partner about turning the client in bed? A. "Keep your feet close together." B. "Tighten your stomach muscles." C. "Straighten your knees." D. "Bend at your waist."

B. The nurse should instruct the client's partner to tighten the abdominal and gluteal muscles to help protect their back. The nurse should instruct the client's partner to keep a wide stance to create a broad base of support and increase stability. The nurse should instruct the client's partner to keep their knees bent to maintain their center of gravity. The nurse should instruct the client's partner to avoid bending at the waist, which can cause stress on their back muscles.

A nurse is contributing to a plan of care for a client who has a new prescription for a wrist restraint. Which of the following actions should the nurse include in the plan? A. Check that the restraint is tied to a fixed frame of the bed. B. Pad bony prominences on the wrist. C. Remove the restraint every 4 hr to allow movement. D. Tie the restraint with a knot that will tighten when pulled.

B. The nurse should pad bony prominences on the wrist to prevent skin breakdown caused by the restraint rubbing against the client's skin. The nurse should tie the restraint to the part of the bedframe that moves when raising or lowering the head of the bed. The restraint should not be tied to the siderails or the immovable part of the bedframe. The nurse should remove the restraint every 2 hr. A knot that tightens when pulled could injure the client. The nurse should use a quick-release knot or buckle to secure the restraint.

A nurse is caring for a client who is postoperative and requires the use of a sequential compression device (SCD). Which of the following actions should the nurse take? A. Assist the client into a side-lying position. B. Place an SCD sleeve under each leg with the opening at the knee. C. Ensure that one finger can fit under each SCD sleeve. D. Make sure that the ankle pressure is between 60 and 70 mm Hg.

B. The nurse should place an SCD sleeve under each leg, with the opening at the level of the knee, and then wrap the sleeve around the leg so that it is secure. The nurse should assist the client into a supine or semi-Fowler's position to facilitate application of the SCD sleeves. The nurse should ensure that two fingers fit under each SCD sleeve. Less space between the sleeve and the leg could compromise circulation to the leg when the sleeve inflates. The nurse should make sure that the ankle pressure on the device is between 35 and 55 mg Hg to prevent circulatory impairment and damage to the client's skin. The average ankle pressure is 40 mm Hg.

A client who has advanced cancer tells the nurse that they have a difficult time talking to anyone about the illness. which of the following actions should the nurse take to encourage therapeutic communication? A. Keep the conversation moving by asking about the client's family. B. Let the client know that, as their nurse, they are available and willing to listen. C. Ask if the client understands what to expect in the advanced stages of the illness. D. Ask the client's visitors not to say anything about the advanced disease.

B. Active listening conveys the nurse's respect and acceptance for the client's feelings and gives the client an opportunity to express their thoughts and needs. Changing the subject reflects a lack of empathy for the client's feelings and a disregard for the client's needs. Asking the client for an explanation about their illness can reflect lack of empathy for the client's feelings. The client's words indicate that they need help in coping with this situation. Interfering with a visitor's relationship with the client in this way suggests that the nurse is controlling the situation and blocking the client's ability to communicate their feelings and needs to their family and friends.

A nurse is collecting data from a client during a physical examination. Which of the following findings should the nurse report t the provider as an indication of an underlying systemic disorder? A. Dark tinted macules B. Clubbing C. Bronchovesicular lung sounds D. Red tinted angiomas

B. Clubbing is an abnormal nail shape, where the angle the nail forms beyond the expected angle of 160°. Early clubbing occurs at an angle of 180°; late clubbing exceeds an angle of 180°. It is an indication of long-term inadequate oxygenation. The nurse should report this finding to the provider because it is an indication of pulmonary or cardiovascular disease.

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take to prevent urinary tract infections? A. Empty the urine drainage bag every 12 hr. B. Drain urine from the tubing before ambulation. C. Use clean technique for urine specimen collection. D. Hang the urine drainage bag at the level of the bladder.

B. Draining urine from the tubing before ambulation will prevent backflow of urine into the bladder. The nurse should empty the drainage bag whenever it is half full. The nurse should use sterile technique to collect specimens from the drainage system to prevent contamination. The nurse should hang the drainage bag below the level of the client's bladder to prevent backflow of urine into the bladder.

A nurse is caring for a client who is experiencing pain. The nurse administers pain medication and informs the client, "I will return in 30 minutes to check on you." Which of the following ethical principles is the nurse demonstrating upon returning within 30 min to check on the client? A. Veracity B. Fidelity C. Justice D. Nonmaleficence

B. Fidelity is the fulfillment of promises. The nurse follows through by returning within 30 min to check on the client. Veracity is telling the client the truth. Justice is fairness in the delivery of care to multiple clients. Nonmaleficence is a commitment to do the client no harm.

A nurse is preparing to measure a client's blood pressure. Which of the following actions should the nurse take? A. Use a cuff with a bladder that encircles 60% of the client's upper arm. B. Position the client's arm at the level of the client's heart. C. Wrap the cuff loosely around the client's arm. D. Ensure the lower edge of the cuff is 1.3 cm (0.5 in) above the antecubital space.

B. If the client's arm is above heart level, the blood pressure reading will be falsely low. If the client's arm is below heart level, the blood pressure reading will be falsely high. The nurse should ensure the cuff's bladder encircles 80% of the client's upper arm. The nurse should wrap the cuff snugly around the client's arm. If the cuff is loose, the blood pressure reading will be falsely high. The nurse should ensure the lower edge of the cuff is 2.5 cm (1 in) above the antecubital space to allow room for the stethoscope's diaphragm.

A nurse is contributing to the plan of care for a client who has a prescription for elastic bandages to the lower extremities. Which of the following actions should the nurse recommend for the plan of care? A. Check for capillary refill proximally to the elastic bandages every 12 hr. B. Compare the client's pedal pulses bilaterally every 4 hr. C. Place the client's legs in a dependent position for 30 min before applying the elastic bandages. D. Remove the elastic bandages every other day to inspect the skin.

B. The nurse should compare the pedal pulses bilaterally every 4 hr to check for adequate circulation for a client who has elastic bandages on their lower extremities. The nurse should check capillary refill distally every 4 hr for a client who has elastic bandages on their lower extremities. The nurse should elevate the client's legs for at least 20 min before applying the elastic bandages. The nurse should remove the elastic bandages daily to inspect for skin breakdown.

A nurse is caring for a client who reports itching 30min after receiving a newly prescribed medication. Which of the following data should the nurse document in the client's medical record? A. Client is itching from medication. B. Client states, "I started to itch after taking that medication." C. It appears that the client has a rash from the medication. D. Rash from medication noted.

B. The nurse should document information using an objective description, putting the client's exact words in quotation marks. This documentation offers the nurse's interpretation about the cause of the itching. The nurse should document factual information so that it is accurate and complete. The term "appears" is vague and suggests the nurse's interpretation about the cause of the itching. This documentation offers the nurse's interpretation about the cause of the itching and does not offer an accurate or factual depiction of the data.

A nurse is preparing to palpate a client's pulse. The nurse should recognize that which of the following pulses is located on the top of the client's foot? A. Posterior tibial B. Dorsalis pedis C. Popliteal D. Brachial

B. The nurse should document palpating the dorsalis pedis pulse on the top of the foot. The posterior tibial pulses are located on the inner side of the ankle below the medial malleolus. The popliteal pulses are located behind the knees. The brachial pulses are located at the inner aspect of the biceps muscles.

A nurse is planning care for a group of clients. The nurse should expect to witness an informed consent for a client who will undergo which of the following procedures? A. administration of an enema B. performance of a paracentesis C. insertion of an indwelling urinary catheter D. placement of an NG tube

B. The nurse should expect to witness the informed consent for a client prior to an invasive diagnostic procedure, such as a paracentesis. The general consent form that a client signs upon admission to a facility covers procedures that are noninvasive routine treatments, such as administration of an enema or various medications. The general consent form that a client signs upon admission to a facility covers procedures that are noninvasive routine treatments, such as insertion of an indwelling urinary catheter or suctioning a client's airway. The general consent form that a client signs upon admission to a facility covers procedures that are noninvasive routine treatments, such as insertion of an NG tube or irrigation of a wound.

A nurse is evaluating the crutch-walking technique of a client who is required to keep weight off their right leg. Which of the following is the proper crutch gait for this client? A. Four-point B. Three-point C. Two-point D. Swing-through

B. The nurse should identify that the client needs to be able to bear weight on the unaffected leg; therefore, a three-point gait provides at least two points of support at all times. A four-point gait provides three points of support at all times. A client needs to be able to bear weight on both legs to use this technique. A two-point gait provides two points of support at all times and requires more balance than the other gaits. A client needs to use partial weight bearing on each leg. A swing-through gait requires strength, skill, and coordination. A client needs to lift their body weight with their arms and swing through and beyond the crutches. A swing-through gait does not provide enough support for a client who is required to keep weight off the affected leg.

A nurse is reinforcing teaching to a client about guaiac fecal occult blood testing. Which of the following statements should the nurse include? A. "Avoid eating red meat for 7 days before performing the test." B. "Perform three separate tests using three separate stool specimens." C. "A false positive result can occur if vitamin C supplements or citrus products are consumed before the test." D. "Plan to take ibuprofen if there is a need to treat any type of pain."

B. The nurse should reinforce and provide the client with three separate test cards to obtain three separate stool specimens. Each of the test cards are sent to a laboratory for the provider to determine the presence of blood. The client should avoid eating red meat for 3 days before collecting a stool specimen. Red meat can cause a false-positive reading. The client should not consume vitamin C or citrus products for 3 days before collecting a stool specimen. Vitamin C supplements or citrus products can cause a false-negative result. The client can take acetaminophen, but should avoid taking any type of NSAIDs such as aspirin, ibuprofen, and naproxen for 7 days before collecting a stool specimen. NSAIDs can cause a false-positive result.

A nurse is reinforcing teaching about an ostomy pouch with a client who has a colostomy. Which of the following information should the nurse include in the teaching? A. Change the ostomy pouch every 10 days. B. Empty the ostomy pouch when one-third full. C. Cut the wafer opening for the pouch larger than the stoma. D. Moisten the edges of the peristomal skin before applying the wafer for the pouch.

B. The nurse should reinforce with the client to empty the ostomy pouch when it is at least one-third to one-half full of fecal matter to prevent the pouch from becoming too heavy and pulling away from the skin. The nurse should reinforce with the client to change the ostomy pouch every 3 to 7 days to decrease odor and maintain cleanliness. The nurse should reinforce with the client to cut the wafer opening for the pouch according to the diameter of the stoma with no peristomal skin visible. The peristomal skin can blister and ulcerate if stool meets the skin. The nurse should reinforce with the client to ensure that the peristomal skin is dry prior to applying the wafer for the pouch. This allows for better adhesion.

A nurse is caring for a client who has been prescribed wrist restraints.Which of the following actions should the nurse take? A. Check that three fingers fit under the restraint. B. Remove the restraints at least every 2 hr. C. Tie a double knot with the restraint straps. D. Attach the restraints' straps to the side rails.

B. The nurse should remove the restraints at least every 2 hr to reposition the client, provide fluids and nutrients, assist with range-of-motion exercises, and evaluate the client's status. The nurse should ensure that two fingers fit under the restraint. A space of three fingers might indicate the restraint is too loose; a space of one finger might indicate that the restraint is too tight. The nurse should attach the restraint with a quick-release buckle or a knot that will not tighten when the client pulls on it, not a double knot. The nurse should attach the restraints' straps to a part of the bed frame that moves with raising and lowering the bed, not to the side rails.

A nurse is preparing to transfer a client from an acute care facility to a long-term care facility. Which of the following information should the nurse plan to include in the transfer report? A. Discontinued medications B. Resolved health conditions C. Frequency of vital sign collection D. Completed nursing interventions

B. The nurse should report both unresolved and resolved health conditions to promote continuity of care. The nurse should report current medications that the client is prescribed, rather than discontinued medications. It is not necessary to report routine care, such as the frequency of vital sign collection, in the transfer report. The nurse should report ongoing interventions, rather than completed interventions.

A nurse is contributing to the plan of care for a client who is at risk for developing foot drop due to immobility. Which of the following interventions should the nurse recommend to include in the plan? A. Flex the client's feet using pillows. B. Support the client's feet with foot boots. C. Place a hand roll under the client's heels. D. Remove ankle-foot orthotic devices at bed time.

B. The nurse should support the feet in dorsiflexion with foot boots to prevent foot drop. The nurse should flex the client's feet. However, pillows will not provide enough pressure to prevent foot drop. The nurse should place a hand roll in the palm of the client's immobile hand to maintain a functional position and prevent contractures. The nurse should have the client alternate wearing the ankle-foot orthotic devices for 2 hr and removing them for 2 hr.

A nurse is reinforcing teaching with a client who is scheduled for a bladder scan. Which of the following instructions should the nurse include in the teaching? A. "You will need to sign a consent form before we begin the procedure." B. "I will place a gel pad directly above your pubic area before I place the probe." C. "You will need to hold your urine for 1 hour prior to the procedure." D. "You will receive a contrast dye through an IV catheter prior to the scan."

B. The nurse should use a gel pad, which promotes ultrasound transmission and accurate measurement. The correct placement of the ultrasound device is just above the symphysis pubis. The nurse should inform the client that they do not need to sign a separate consent form for a bladder scan, which is a noninvasive diagnostic procedure that the nurse can perform at the client's bedside. The nurse should inform the client that a bladder scan will detect the amount of urine remaining in the bladder after the client has voided. The nurse should inform the client that a bladder scan is a noninvasive procedure and does not require the use of contrast dye.

A nurse is reinforcing preoperative teaching with a client about how to turn, cough, and deep breathe. Which of the following statements by the client indicates an understanding of the teaching? A. "This can help prevent nausea." B. "This can help prevent pneumonia." C. "I should do this every 4 hours." D. "I should do this to keep my heart from beating too fast."

B. The purpose of turning, coughing, and breathing deeply is to reduce the risk of respiratory complications such as atelectasis, which can lead to pneumonia. This helps to maximize lung expansion and assist with the removal of pulmonary secretions. Turning, coughing, and deep breathing can reduce the risk of developing a pulmonary embolus, rather than prevent nausea. The nurse should instruct the client to turn, cough, and deep breathe every 1 to 2 hr to promote lung expansion. Turning, coughing, and deep breathing can reduce the risk of developing a thrombus formation, rather than tachycardia.

A nurse is removing gloves and a gown after caring for a client who requires contact precautions. Which of the following actions should the nurse take? A. Grasp the inside of the cuff of one glove with the other gloved hand. B. Pull the glove off and into the hand that is still wearing a glove. C. Remove the gown before removing the gloves. D. Dispose of the first glove before removing the second glove.

B. This action removes the first glove without contaminating the skin of the hand that was wearing it. The nurse should grasp the outside of the cuff of one glove with the other gloved hand to prevent or reduce the contamination of the hand beneath the glove. The nurse can also remove the first glove by grasping the palm of it with the other gloved hand. The nurse should remove the gloves first, because they are the most soiled. Removing the gown first increases the risk for contamination. This action would be inefficient. The nurse should pull off the second glove while that gloved hand holds the first glove, thus encasing the contaminated surfaces of both gloves inside the second glove. Then the nurse should dispose of both gloves together.

A nurse is providing care to four clients in an acute care setting. The nurse should identify that which of the following client statements presents an ethical dilemma A. i might file a lawsuit because of how my surgery went B. please don't tell my doctor, but I am taking my partner's oxycodone C. please don't get me out of bed this morning. It hurts too much D. I don't want to take my medicine. It makes me sick to my stomach

B. This situation poses an ethical dilemma for the nurse because there is a conflict between what the client is asking of the nurse and the nurse's responsibility to protect the client from harm during hospitalization. This situation is not an ethical dilemma because the client can make a decision without input from the nurse. This situation is not an ethical dilemma because there is a clear solution to the problem. The nurse should medicate the client for pain in order to increase comfort when moving. This situation is not an ethical dilemma because the nurse can use the nursing process to resolve the client's issue.

A nurse is caring for a client who reports difficulty sleeping and is interested in trying an herbal supplement. Which of the following herbal supplements should the nurse recommend to promote sleep? A. Ginger B. Valerian C. Echinacea D. Feverfew

B. Valerian is an herbal supplement that can help control restlessness, mild anxiety, and sleep disorders. It can also help lower blood pressure and ease the discomfort of menstrual cramps. Ginger is an herbal supplement that can help relieve nausea, vomiting, and dizziness. Echinacea is an herbal supplement that can help stimulate the immune system and help provide some relief from upper respiratory infections. It can also help with wound healing. Feverfew is an herbal supplement that has anti-inflammatory effects and can help with wound healing, arthritis, and migraine headaches.

A nurse is reinforcing teaching with a client about the use of crutches. Which of the following actions by the client indicates an understanding of the teaching? A. The client leans on the crutches for support while standing still. B. The client advances the unaffected leg first while climbing stairs. C. The client stands 5 cm (2 in) from the front of a chair before sitting. D. The client bears weight on their axilla while standing in the tripod position.

B. When ascending stairs, the client should first advance the unaffected leg. The nurse should reinforce with the client that it is unsafe to lean on the crutches to support their body weight. The nurse should reinforce with the client that they should stand with the back of their legs placed against the chair for support during the procedure of sitting. The nurse should reinforce with the client that their axilla should not bear any weight while in the tripod position because this can cause pressure injury formation. The client should bear their weight with their arms and hands.

A nurse is using Maslow's hierarchy of needs in assisting with discharge planning for a client. Which of the following activities should the nurse recommend as the priority for this client? A. Volunteer at the local food pantry. Attend an exercise program. Find an enjoyable hobby. Support environmental conservation.

B. When using Maslow's hierarchy of needs, the nurse should determine that the priority activity is to fulfill the client's physiological needs for activity. Therefore, the nurse should recommend exercise and help the client select a suitable exercise program. According to Maslow's hierarchy of needs, volunteering at the local food pantry helps fulfill the client's self-esteem needs. Therefore, another activity is the priority. According to Maslow's hierarchy of needs, finding an enjoyable hobby helps fulfill the client's self-esteem needs. Therefore, another activity is the priority. According to Maslow's hierarchy of needs, supporting environmental conservation helps fulfill the client's self-actualization needs. Therefore, another activity is the priority.

A nurse is assisting a client who experienced a seizure for the first time and is starting to arouse. Which of the following is the priority action for the nurse to take? A. Pad the rails of the client's bed. B. Reorient and explain to the client what happened. C. Assist the client with oral hygiene. D. Document the events of the client's seizure.

B. When using the urgent vs nonurgent approach to client care, the nurse should determine that the priority action is to reorient and explain what happened to the client. The nurse should reassure the client and answer any questions the client has expressed. Pad the rails of the bed is nonurgent currently because the seizure is over and the client is arousing; therefore, there is another action that is the nurse's priority. Assisting the client with oral hygiene is nonurgent at this time for a client who has had a seizure; therefore, there is another action that is the nurse's priority. Documenting the events of the client's seizure is nonurgent currently; therefore, there is another action that is the nurse's priority.

A nurse manager is reinforcing teaching with a group of newly licensed nurses about the disclosure of client health information. A nurse can disclose health information without the client's written permission to which of the following entities? A. an insurance agency offering a life insurance policy B. a family member who requests the client's diagnosis C. a physical therapist who is involved in the client's care D. an employer completing a pre-employment screening

C. According to HIPAA guidelines, a nurse is allowed to disclose personal health information to members of the health care team involved in the client's care. HIPAA guidelines require written authorization from the client to disclose personal health information to an insurance agency. HIPAA guidelines require written authorization from the client to disclose personal health information to others, including family members. HIPAA guidelines require written authorization from the client to disclose personal health information to an employer.

A nurse is collecting data from an older adult client. Which of the following findings should the nurse report to the provider? A. The client has smooth, brown, irregular lesions on the back of each hand. B. The client has glossy, white circles around the periphery of the corneas. C. The client reports urinary incontinence. D. The client reports a decreased sense of taste.

C. Aging is a risk factor for urinary incontinence as older adult males can experience hypertrophy of the prostate gland, and older adult females can experience stress incontinence with laughing, sneezing, or coughing. Urinary incontinence is an abnormal condition that can impact the quality of life for older adults. Urinary incontinence should be investigated; therefore, the nurse should report this finding to the provider. Interventions can be reinforced to the client to promote improved urinary function. Smooth, brown, irregular lesions on the backs of the hands of an older adult are an expected age-related physical change. Glossy, white circles around the periphery of the corneas, known as arcus senilis, are an expected age-related physical change. A decreased sense of taste is an expected age-related physical change.

A nurse is reinforcing teaching about hospice care measures with the family of a client who is dying. Which of the following statements by a member of the client's family indicates an understanding of the teaching? A. "We will make sure she eats three meals a day." B. "We will decrease her pain medication if she gets too drowsy." C. "We will keep her room cool to help her breathe better." D. "We will make sure to provide oral care twice a day."

C. Clients who are dying will have thick secretions and decreased muscle tone, which can make breathing more difficult. Keeping the air in the room cool will ease the work of breathing. Clients who are dying might have decreased appetites due to the disease process and medication side effects. Clients should not be forced to eat. Clients who are dying should be provided enough pain medication to promote comfort. Moderate increases in the client's pain medication will not hasten death. Clients who are dying will require oral care at least every 2 to 4 hr to keep the oral mucosa moisturized and prevent lesions.

A nurse is caring for a client who has an NG tube in place. Which of the following actions should the nurse take to verify the placement of the client's NG tube? A. Test the glucose level of the gastric aspirate. B. Instill air through the tube and auscultate the stomach for bubbling sounds. C. Test the pH of gastric aspirate. D. Instill air through the tube and ask the client to speak.

C. Prior to administering an enteral feeding, the nurse should aspirate 5 mL of gastric contents through the tube and then test the aspirate's pH. A pH between 0 and 4 indicates gastric placement. A pH higher than 6 indicates that the distal end of the tube is in the intestines or in the pulmonary system. The glucose content of pulmonary secretions varies; therefore, this is an inaccurate method of determining the placement of an NG tube. This method is unreliable because it does not detect if the tube is placed in the pulmonary system, and it does not differentiate between stomach and intestinal placement. This method is unreliable because some clients can speak with the distal end of an NG tube in their lungs.

A nurse is contributing to the plan of care for a client who practices Islam. Which of the following questions should the nurse ask the client to clarify the client's religious preferences? A. "Do you receive Holy Communion?" B. "Do you follow a kosher diet?" C. "Do you consume pork products?" D. "Do you oppose receiving a blood transfusion if it is needed?"

C. Some clients who practice Islam do not consume pork or alcohol. Some clients who practice Christianity receive Holy Communion. Some clients who practice Judaism require kosher food, which is food prepared according to Jewish law. Some clients who practice the Jehovah's Witness faith will refuse blood transfusions.

A nurse is removing soiled linens from the room of a client who is in contact isolation. Which of the following actions should the nurse take? A. Soak the linens in bleach before placing them in a bag. B. Dispose of the linens in a laundry bag. C. Place the linens in a nonporous bag and seal it. D. Transport the linens for sterilization.

C. The CDC recommends enclosing any articles contaminated with infectious material in a single bag that is strong, leakproof, and impervious to pathogens. The nurse should avoid contaminating the outside of the bag when tying the bag to seal it. The nurse should handle contaminated materials as little as possible to prevent contaminants from becoming airborne. Adding this step would require additional handling procedures. The nurse should not dispose of the linens because they can be cleaned and reused. Linens do not need to be sterilized before reuse. Only reusable glass and metal equipment should be sterilized.

A nurse is planning to remove sutures from a client's incision. Which of the following actions should the nurse take? A. Clip the suture 0.64 cm (0.25 in) from the skin. B. Clip and pull the visible suture through the underlying tissue. C. Clip the suture on one side and pull out on the other side. D. Clip both sides of the suture and remove.

C. The nurse should clip the suture on one side of the incision and pull out the suture on the other side of the incision. This technique prevents microorganism and debris from contaminating the underlying tissue. The nurse should clip the suture as close to the client's skin a possible before pulling the invisible suture through the tissue. The nurse should clip and then pull the visible suture without pulling through the underlying tissue to prevent microorganism and debris contaminating the incision. The nurse should clip only one side of the suture prior to removal to decrease the risk of losing the suture in the underlying skin tissue.

A nurse is preparing to document information bout a client's lower legs, which are swollen with 6mm edema. Which of the following information should the nurse document? A. 1+ pitting edema B. 2+ pitting edema C. 3+ pitting edema D. 4+ pitting edema

C. The nurse should document 3+ pitting edema when there is deep indentation of the tissue, which is about 6 mm. The nurse should document 1+ pitting edema when there a slight indentation of the tissue, which is about 2 mm. The nurse should document 2+ pitting edema when there is a slight indentation of about 4 mm to the tissue. The nurse should document 4+ pitting edema when there is very deep indentation of the tissue, which is about 8 mm.

A nurse in an acute care setting is documenting postmortem care in a client'ed medical record. Which of the following information should the nurse include in the documentation? A. completion of an incident report B. name of the nurse certifying the client's death C. release of personal belongings form D. one client identifier at the client's time of death

C. The nurse should document the release of the client's personal belongings form and the articles the nurse gave to the family. The nurse should not document the completion of an incident report in the client's medical record. The nurse should document the name of the provider who certified the death of the client. The nurse should document the identification of the client using two identifiers at the time of death and compare these with the identifiers in the client's medical record.

A nurse at a long-term care facility is caring for a client who is alert. Which of the following actions should the nurse take to protect the client's privacy? A. Place the client's medication record on the bedside table while ambulating the client. B. Give report about the client's status while standing at the nurses' station. C. Speak with the client about their condition after visitors have left. D. Place a message board in the client's room to post dietary information.

C. The nurse should ensure a private environment before discussing the client's condition with them. Placing the client's medication record on the bedside table and leaving it unattended can violate the client's privacy by allowing the opportunity for visitors or staff members who are not caring for the client to view this information. Giving report about the client in a location where others might overhear can violate the client's privacy. Posting the client's health care information in the client's room can violate the client's privacy by allowing anyone who enters the room to view this information.

A nurse is reinforcing teaching with a client about self-administration of ophthalmic drops. Which of the following instructions should the nurse include? A. you will need to look to the side when you put the drops in your eye B. you should put the drops directly in the center of your eyeball C. you should cleanse your eye from the inner tot he outer edge prior to putting in the drops D. you should avoid pressing on your tear duct after putting the drops in your eye

C. The nurse should instruct the client to cleanse the eye from the inner to the outer canthus to prevent contamination of the lacrimal duct. The nurse should instruct the client to look up during instillation of the medication to help protect the cornea and to reduce blinking. The nurse should instruct the client to place the drops on the lower conjunctival sac to protect the cornea. The nurse should instruct the client to press on the nasolacrimal duct for 30 seconds after instillation to prevent systemic absorption of the medication.

A nurse in an orthopedic clinic is reinforcing teaching with a client who has a back injury from loading a desk onto a truck. Which of the following instructions about lifting objects should the nurse include? A. "Relax your stomach muscles when lifting an object." B. "Stand with your feet close together when lifting an object." C. "Hold the object close to your body as you lift it." D. "Twist at the waist when you move an object to the side."

C. The nurse should instruct the client to keep the object as close to their body as possible, which keeps it close to the client's center of gravity. This should help to maintain balance and prevent further injury. The nurse should instruct the client to tighten their abdomen and pelvis muscles when lifting an object. This should help to maintain balance and protect the client's back from further injury. The nurse should instruct the client to stand with their feet shoulder-width apart to create a wide base of support and maintain stability. The nurse should instruct the client to pivot to place the object to the side. Twisting increases the client's risk for further injuring their back.

A nurse is preparing to administer oxygen to a client who has heart failure and is having severe difficulty breathing. Which of the following oxygen delivery equipment should the nurse select to provide the higher concentration of oxygen to the client? A. Nasal cannula B. Simple face mask C. Venturi mask D. Nonrebreather mask

D. A nonrebreather mask provides the highest percentage of oxygen concentration without intubation and mechanical ventilation. A nasal cannula provides a low oxygen concentration. A simple face mask can be adjusted for short-term delivery of low to medium oxygen concentration. A Venturi mask can be adjusted to provide a consistent lower oxygen concentration.

A nurse is performing point-of-care fecal occult blood testing for a client. Which of the following actions should the nurse take? A. Swipe the guaiac paper over the surface of the stool. B. Wait 15 min before applying the developing solution. C. Apply five drops of solution to each box. D. Report a blue color as positive result.

D. After applying the developing solution to the boxes on the back of the card, the nurse should interpret a color change to blue as an indication of blood in the client's stool. The nurse should use a wooden applicator to spread the stool thinly over the guaiac paper within the confines of the boxes on the slide. The nurse should wait 3 to 5 min after the stool is on the paper to apply the developing solution. The nurse should apply two drops of developing solution to each box on the reverse side of the slide.

A nurse is contributing to the plan of care for a client who has urinary and fecal incontinence. Which of the following interventions should the nurse implement to help maintain the client's skin integrity? A. Use soap and hot water to cleanse the skin. B. Use a cloth incontinence brief to contain urine and feces. C. Keep the head of the bed elevated to 45°. D. Apply a moisture barrier ointment after each incontinence episode.

D. After cleansing the skin of urine and feces, the nurse should apply a barrier ointment to help protect the skin from the damaging effects of excessive moisture and bacteria, especially if the client has diarrhea. Soap can have a drying effect on the skin, especially if the nurse does not rinse it off thoroughly. The nurse should use a no-rinse perineal cleanser or one with nonionic surfactants to remove urine and feces from the client's skin. The nurse should only use incontinence products that draw moisture away from the skin. The nurse should keep the head of the client's bed elevated to 30° with the client in a slight lateral position to minimize pressure on bony prominences.

A nurse is preparing to obtain a client's vital signs. Which of the following actions should the nurse take when washing their hands? A. Rinse their forearms with running water before applying soap. B. Hold their hands above elbow level while washing and rinsing. C. Generate a lather by rubbing their hands together vigorously for 5 seconds. D. Turn off the faucet with a clean paper towel after drying hands.

D. If the nurse's hands are wet or the paper towel is wet when they turn off the faucet, they increase the risk of transferring micro-organisms from the faucet back to their hands. For routine care procedures, the nurse does not have to rinse their forearms, just their hands and wrists. In health care, the hands of staff members are a major source of transmission of infection and are more contaminated than forearms are. The nurse should keep their hands and forearms below elbow level while washing and rinsing them to allow water to wash micro-organisms away without recontaminating clean areas. The nurse should wash their hands using ample lather and friction for at least 15 seconds to allow for sufficient removal of dirt and pathogens.

A nurse is assisting a provider with an outpatient surgical procedure for a client. Which of the following actions should the nurse take to maintain surgical asepsis? A. Prepare the sterile field at least 30 min before use. B. Cover the sterile tray with a sterile drape before leaving the room. C. Hold their hands below their elbows after a surgical hand wash. D. Avoid talking or reaching over the sterile field.

D. Micro-organisms from the nurse's clothing or arms, or droplets from the nurse's mouth, can contaminate the sterile field. The nurse should minimize talking and never cough, sneeze, or reach over the sterile field. Prolonged exposure to air contaminates a sterile field. The nurse should prepare the sterile field immediately before use. Leaving the room after preparing a sterile field makes the sterility of the field questionable. The nurse should consider a field contaminated if it is not within view at all times. The nurse should hold their hands above their elbows after a surgical hand wash to prevent micro-organisms on their forearms from contaminating their hands.

A nurse is reinforcing teaching with a client about the prevention of stress injuries. Which of the following instructions should the nurse include? A. "Keep your knees in a locked position when standing for prolonged periods." B. "Bend at the waist when lifting a heavy object." C. "Keep your feet close together when lifting a heavy object." D. "When lifting a heavy object, keep it close to your body."

D. The nurse should instruct the client to keep the object as close to their body as possible to increase stability and decrease back strain when lifting a heavy object. The nurse should instruct the client to avoid standing for a long period of time. If the client cannot avoid it, they should place one foot on a stool to minimize stress on the back. The nurse should instruct the client to keep their back straight and bend at the knees when lifting a heavy object. The nurse should instruct the client to maintain a wide base of support by keeping their feet far apart when lifting a heavy object.

A client who is scheduled to undergo surgery tells the nurse that they do not understand the procedure and are reconsidering their decision to have it. Which of the following actions should the nurse take? A. Offer information about alternative therapies to the procedure. B. Contact a family member to convince the client to change their mind. C. Tell the client the benefits of the surgery. D. Notify the charge nurse of the client's concerns.

D. The nurse should notify the charge nurse of the client's concerns. The charge nurse can then inform the provider that the client requires further explanation of the procedure. The nurse should not offer information about alternative therapies because this is not within the nurse's scope of practice. The nurse should not contact a family member to convince the client to change their mind because this is a violation of client confidentiality. The nurse should ensure that the client has given consent before discussing the client's treatment with family members. The nurse should not explain the benefits of the surgery to the client because this is not within the nurse's scope of practice.

A nurse is repositioning a client who has quadriplegia and is in the supine position. Which of the following actions should the nurse take to prevent client musculoskeletal injury? A. Support the client's head with a pillow that maintains cervical flexion. B. Position the client's shoulders off the pillow for internal rotation. C. Place the client's arms at their sides to keep their elbows extended. D. Internally rotate the client's hips by using a trochanter roll.

D. The nurse should place trochanter rolls at the proximal end of each of the client's legs to maintain a neutral or internal rotation of the client's hips and to prevent external rotation of the hips, which can cause injury when the client is supine. The nurse should position the client's head on a pillow that does not cause cervical flexion when the client is supine. The nurse should support the client's shoulders with a pillow or blanket to prevent internal rotation of the shoulders when the client is supine. The nurse should position the client's elbows in a flexed position on pillows when the client is supine.

A nurse is reinforcing preoperative teaching with a client who speaks a different language than the nurse. Which of the following actions should the nurse take? A. Ask a family member who speaks the client's primary language to interpret. B> Plan a long teaching session initially to introduce the necessary material. C. Provide the least important information first. D. Provide handouts written in the client's primary language.

D. The nurse should provide handouts that are easy to read in the client's primary language to promote learning. The nurse should request a certified interpreter to deliver the instructions to the client. The nurse should not ask the client's family members to interpret because they are not trained in medical terminology. The nurse should plan teaching sessions that are short in length to promote learning. The nurse should provide the most important information first while the client is receptive to learning.

A nurse is assisting with the admission of an older adult client to an acute care facility. The client states that they are afraid to go to sleep, fearing they will not wake up. Which of the following is a therapeutic response the nurse should make? A. I will have the nursing staff check on you frequently during the night B. you are right to be afraid. This is a new place for you C. i will give you your prescribed sleeping medication to help you fall asleep D. describe your concerns about sleeping to me.

D. This statement is open-ended and allows for further communication. This addresses the client's concerns and builds trust. This response is dismissive and does not address the client's immediate concerns. This is a nontherapeutic response that does not address the client's immediate concerns. This is a nontherapeutic response that does not address the client's immediate concerns.

A nurse is collecting data from a client who has an NG tube set to low intermittent suction. Which of the following findings indicates hypomagnesemia? A. Bone pain B. Drowsiness C. Bowel hypomotility D. Positive Chvostek's sign

D. To elicit Chvostek's sign, the nurse should tap the client's facial nerve near the ear. If the client's facial muscles contract, the sign is positive, indicating low serum magnesium or calcium levels. The nurse should identify bone pain as a finding associated with hypercalcemia. The nurse should identify drowsiness as a finding associated with hypermagnesemia. The nurse should identify decreased bowel motility as a finding associated with hypokalemia.

A nurse is caring for a client and is concerned that the client might have a fecal impaction. Which of the following is the most important question for the nurse to ask? A. "What types of foods have you been eating?" B. "Are you using stool softeners or laxatives?" C. "Have you been passing gas?" D. "Have you had small liquid stools?"

D. Using the nursing process, the first action the nurse should take is to collect data from the client to determine if the client has any findings consistent with a fecal impaction. Therefore, the first question for the nurse to ask is if the client has had any small liquid stools, which can indicate that there is seepage of liquid feces around the impacted mass. The nurse should know what foods the client is eating to determine if they need to modify their diet; however, there is another question the nurse should ask first. The nurse should know what treatments the client might be using at home; however, there is another question the nurse should ask first. Flatus can be present even if the client has an impaction; however, there is another question the nurse should ask first.

A nurse is preparing to administer a topical medication to a client. Which of the following actions should the nurse take? A. Show the assistive personnel where to apply the medication. B. Ask the client when the previous nurse last applied the medication. C. Identify the client by comparing the medication administration record with the client's room number. D. Compare the label of the medication container with the medication administration record three times.

D. When preparing medication from a bottle or container, the nurse should compare the label of the medication container with the medication administration record three times to ensure it is the correct medication. The nurse should not delegate any part of the medication administration process to an assistive personnel because this action requires the use of nursing judgment. The nurse should check the medication administration record to determine when the last dose was administered. The client's room number is not an acceptable identifier when administering medications.

A nurse is collecting data from a client who is 1 day postoperative following abdominal surgery. Which of the following findings is the priority for the nurse to report to the provider? A. The client reports incisional pain as 7 on a scale of 0 to 10. B. The client reports increased nausea and chills. C. The client has an oral temperature of 38.5° C (101.3° F). D. The client has tenderness and warmth in their calf.

D. When using the airway, breathing, circulation approach to client care, the nurse should determine that the priority finding to report is tenderness and warmth in the client's calf, which can indicate the presence of a thrombus. If it moves from the vein to the heart, brain, or lungs, it can cause life-threatening complications. The nurse should take measures to relieve the client's pain; however, another finding is the priority to report. The nurse should take measures to relieve the client's discomfort; however, another finding is the priority to report. The nurse should treat the temperature with an antipyretic medication; however, another finding is the priority to report.

A nurse is caring for a client who has chronic kidney disease. The nurse should identify that which of the following findings is the priority to report to the provider? A. Client reports voiding three times during the night. B. Client reports burning and discomfort with urination. C. The client's WBC count is 11,000/mm3. D. The client's output was 60 mL for the past 3 hr.

D. When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding to report to the provider is a urinary output of 60 mL over 3 hr. This finding represents oliguria and can indicate a decrease in kidney perfusion or function. The nurse should identify this as nocturia and should report this finding to the provider; however, there is another finding that is the nurse's priority. The nurse should identify this as dysuria and should report this finding to the provider; however, there is another finding that is the nurse's priority. The nurse should identify this as an increased WBC count and an indication of infection, which should be reported to the provider; however, there is another finding that is the nurse's priority.

A nurse in a long-term care facility is serving as a preceptor to a newly hired nurse. The nurse asks the preceptor, "what should I do for my client who has dyspnea with oxygen saturation of 92%?" Which of the following interventions should the preceptor recommend? A. Apply oxygen using a nonrebreather face mask. B. Encourage the client to cough and deep breathe every 4 hr. C. Initiate nasotracheal suctioning. D. Position the client at a 45° angle in bed.

D. The preceptor should recommend for the nurse to position the client at a 45° angle in bed to promote greater lung expansion and decrease pressure from the abdomen onto the diaphragm. The preceptor should recommend for the nurse to apply oxygen at 2 L/min per nasal cannula for an oxygen saturation of 92%. Oxygen using a nonrebreather face mask is limited to severe respiratory distress. The preceptor should recommend for the nurse to encourage the client to cough and deep breathe at least every 1 to 2 hr to increase air in the lower lobes of the lungs and prevent atelectasis. The preceptor should recommend for the nurse to initiate nasotracheal suctioning if the client is unable to clear the airway of thick pulmonary secretions.

A nurse is caring for a client who is grieving following the death of a family member. Which of the following actions should the nurse take? A. Refer the client for psychological care if they are not eating or sleeping well. B. Avoid discussion of the facts surrounding the death. C. Discourage the client from reminiscing about past experiences with the family member. D. Offer personal presence and silence.

D. This approach encourages the client to express their feelings and to assure them that the nurse will take the time to understand how they feel. Difficulty eating and sleeping are expected responses to a loss and are not an indication of an emotional disorder under these circumstances. Talking about how the death happened and how the client found out about it, for example, helps the client accept that the loss is real and gain perspective about it. The nurse should encourage the client to reminisce and assure the client that is expected for these memories to evoke feelings of sadness.

A nurse is reviewing the vital signs of four adult clients. Which of the following findings requires further data collection by the nurse? A. A client who has a respiratory rate of 12/min B. A client who has a blood pressure of 110/74 mm Hg C. A client who has a temperature of 37.3° C (99.2° F) D. A client who has a pulse rate of 110/min

D. This client's heart rate is above the expected reference range of 60 to 100/min. Therefore, the nurse should collect further data to determine the cause of the tachycardia. This client's respiratory rate is within the expected reference range of 12 to 20/min. Therefore, the nurse does not need to collect further data. This client's blood pressure is within the expected reference range of less than 120 mm Hg systolic and less than 80 mm Hg diastolic. Therefore, the nurse does not need to collect further data. This client's temperature is within the expected reference range of 36° to 38° C (96.8° to 100.4° F). Therefore, the nurse does not need to collect further data.

A nurse is providing oral hygiene for a client who is unconscious. Identify the sequence of the steps the nurse should take 1. assess the client's gag reflex 2. place a towel under the client's head with an emesis basin under their chin 3. position the client on their side with their head turned to the side 4. separate the clients upper and lower teeth with an oral airway device 5. cleanse the client's mouth using a toothbrush

1, 3, 2, 4, 5

A nurse is contributing to the plan of care for a client who is dying. Which of the following interventions should the nurse recommend to include the client's family in the plan of care? (SAP) 1. keep the family updated about the client's status 2. suggest that family members return home at night to allow the client to rest 3. encourage the family to comb the client's hair 4. tell the client's family what to expect as the client's death nears 5. ask the family to encourage the client to eat

1, 3, 4

A nurse is preparing to assist a provider with a sterile procedure on a client's surgical wound. Which of the following actions should the nurse take? A. Prepare a container of sterile solution before putting on sterile gloves. B. Place the cap of a bottle of sterile solution on the sterile field with the cap's interior surface facing downward. C. Open the outside packaging of a sterile instrument and drop it onto the edge of the sterile field. D. Open the sterile pack by first unfolding the flap closest to their body.

A. A bottle of sterile solution is sterile inside and contaminated on the outside. Handling the bottle with sterile gloves contaminates the gloves. The nurse should pour the sterile solution into a sterile receptacle on the field before donning sterile gloves. Although the inside surface of the bottle cap is sterile, the outer edge of the cap is not. The nurse should place the bottle cap, inner surface up, on a clean surface. When the nurse opens the outside packaging, they should drop the sterile instrument in the center of the field to avoid having it contact the contaminated outer 2.5 cm (1 in) of the field. The nurse should open the sterile pack by first unfolding the flap farthest from their body, then the two side flaps, then the flap closest to their body. If the nurse opened the closest flap first, they would have to reach over the sterile field to open the farthest flap, thus contaminating the field.

A nurse is reinforcing teaching with a client about smoking cessation. Which of the following should the nurse identify as the first stage of health behavior change? A. Precontemplation B. Preparation C. Maintenance D. Action

A. According to evidence-based practice, the nurse should identify that precontemplation is the first stage the client will experience when using the stages of health behavior change. In this stage, the client avoids discussing the behavior and does not intend to make a change in behavior. The stages of health behavior change are precontemplation, contemplation, preparation, action and the maintenance stage. The nurse should identify that preparation is the third stage the client will experience when using the stages of health behavior change. In this stage, the client plans to make minor changes to behavior. However, according to evidence-based practice, another stage occurs prior to the preparation stage. The nurse should identify that maintenance is the last stage the client will experience when using the stages of health behavior change. In this stage, the client sustains changes to behavior. However, according to evidence-based practice, another stage occurs prior to the maintenance stage. The nurse should identify that action is the fourth stage the client will experience when using the stages of health behavior change. In this stage, the client actively changes behavior. However, according to evidence-based practice, another stage occurs prior to the action stage.

A nurse is caring for a client who has pneumonia and has a prescription to collect a sputum specimen. Which of the following actions should the nurse plan to take? A. Collect the sputum specimen in the morning. B. Offer the client mouthwash prior to the sputum collection. C. Have the client drink 120 mL of water before the sputum collection. D. Instruct the client to keep coughing up sputum until there is a sample volume of 15 to 20 mL.

A. Collecting the specimen in the morning before the client eats or drinks anything facilitates the collection of secretions that have accumulated during the night and produces a more concentrated specimen for analysis. The client should not use any mouthwash before the sputum collection because it can alter the laboratory results by killing some of the micro-organisms in the sputum. The nurse should offer the client mouthwash after the collection to minimize any unpleasant taste. The nurse should instruct the client not to eat or drink prior to the collection to ensure accurate results. The nurse should offer the client some water to use to rinse their mouth before the sputum collection to avoid contamination of the sputum with any micro-organisms or other particles in the mouth. A sputum specimen for laboratory analysis requires a volume of 4 to 10 mL.

A nurse is preparing to remove a client's peripheral IV catheter. After performing hand hygiene and applying clean gloves, which of the following actions should the nurse take first? A. Clamp the infusion tubing. B. Remove the dressing. C. Withdraw the catheter from the vein. D. Ensure the catheter is intact.

A. Evidence-based practice indicates that the nurse should first clamp the infusion tubing after applying clean gloves. This action stops the flow of the IV fluid and prevents it from leaking out during the IV removal. The nurse should remove the dressing while applying countertraction to the skin to prevent discomfort. However, evidence-based practice indicates the nurse should take a different action first. The nurse should withdraw the catheter from the vein by slowly pulling it along the line of the vein. However, evidence-based practice indicates the nurse should take a different action first. The nurse should ensure the catheter is intact because a broken catheter poses harm to the client and warrants notification of the provider. However, evidence-based practice indicates the nurse should take a different action first.

A nurse is caring for a client who has a terminal illness and a family member asks why the client's mouth is continually open. Which of the following responses should the nurse make? A. "The reduced muscle tone has relaxed the jaw muscles." B. "That happens when a person gets close to death." C. "I can apply a chin strap to help hold the mouth closed." D. "You shouldn't worry about that at this time."

A. Prior to death, decreased muscle tone causes jaw muscles to relax, resulting in an open mouth. This automatic response is nontherapeutic and does not address the family member's question. Applying a chin strap is a postmortem action that the nurse can take to keep the mouth closed. This response by the nurse is dismissive and does not address the family member's question.

a nurse is caring for a client who is immobile. To help prevent hip flexion contractures, the nurse should periodically assist the client into which of the following positions? A. Prone B. Supine C. Lateral D. High-Fowler's

A. Prone position is the only bed position in which the client has full extension of the hip and knee joints. The nurse should use this position to help prevent flexion contractures of the hip and knee joints while the client is immobile. The nurse should ensure that the client's back is correctly aligned when the client is placed in this position. The supine position provides comfort and healing after some types of surgery, but it does not help to prevent hip flexion contractures. The lateral position provides stability and balance, but it involves flexion of one hip and, therefore, does not help to prevent hip flexion contractures. The high-Fowler's position facilitates breathing for clients who have pulmonary and cardiovascular problems. However, because this position involves hip flexion, it does not help to prevent hip flexion contractures.

A nurse working in a community clinic is talking with an older client who states that their life has no purpose. The nurse should identify that the client is in which of the following stages of Erikson's Theory of Psychosocial Development? A. ego integrity vs. despair B. generativity vs. self-absorption C. identity vs. role confusion D. intimacy vs. isolation

A. The nurse should identify that this client is experiencing the ego integrity vs. despair stage of Erikson's Theory of Psychosocial Development, which occurs in the older adult population. The nurse should assist the client to reflect on past accomplishments and find pleasure in life rather than focusing on health problems and limitations. Supporting the client's ego integrity will help the client cope with the challenges of aging. The nurse should identify that middle adults are in the generativity vs. self-absorption and stagnation stage of Erikson's Theory of Psychosocial Development. In this stage, the client works to contribute to the welfare of future generations through activities such as parenthood, teaching, mentoring, and work within the community. The nurse should identify that adolescents are in the identity vs. role confusion stage of Erikson's Theory of Psychosocial Development. In this stage, the client works to establish a sense of identity that includes devotion and fidelity to others along with developing and maintaining a sense of personal values. The nurse should identify that young adults are in the intimacy vs. isolation stage of Erikson's Theory of Psychosocial Development. In this stage, the client works to establish and maintain meaningful relationships with others through companionship and intimacy.

A nurse is reinforcing teaching about health promotion with a group of young adults clients. Which of the following information should the nurse include? A. Young adults should receive a dental assessment every 6 months. B. Young adult males should have a testicular examination every 5 years. C. Young adult females should have a routine physical examination every 4 years. D. Young adults should receive a tuberculosis skin test every 3 years.

A. The nurse should include the recommendation for young adults to receive a dental assessment twice per year. Young adult males should have a testicular examination annually. Young adult females should have a routine physical examination every 1 to 3 years. Young adults who have an increased risk of exposure should receive a tuberculosis skin test every 2 years.

A nurse is reinforcing teaching about the use of crutches with a client who has a fractured right tibia and fibula. Which of the following statements by the client indicates an understanding of the teaching? A. "I will be sure to keep the crutch tips dry." B. "I will hold a crutch in each hand when sitting down." C. "I will place my weight on my underarms." D. "I will lead with my right leg when going up stairs."

A. The nurse should instruct the client to inspect the crutch tips frequently and keep them dry at all times to decrease the risk for slipping. The nurse should instruct the client to hold both crutches in one hand and use the other hand for balance when sitting down. The nurse should instruct the client to place their weight on the handgrips. Weight should never be borne on the axillae as this can damage the brachial plexus nerve bundle. The nurse should instruct the client to lead with the unaffected leg when going up stairs.

A nurse is preparing to collect data from a client for a health assessment. Which of the following actions should the nurse take? A. Provide privacy for the client. B. Keep the lights at a dim level. C. Expose half of the body at a time. D. Encourage the client's friend to remain in the room.

A. The nurse should promote a therapeutic environment by providing privacy while data is being collected for a health assessment. To promote a therapeutic environment, the room should be well lit. To promote a therapeutic environment, the nurse should expose only the area of the body from which data is being collected. To promote a therapeutic environment, the nurse should allow only the people requested by the client to remain in the room.

A nurse is preparing to perform a wound irrigation for a client who has stage 3 pressure injury. Which of the following supplies should the nurse plan to use? A. a piston syringe B. barrier ointment C. chilled irrigation solution D. sterile cotton balls

A. The nurse should use an irrigation or piston syringe with an angiocatheter attached to irrigate wounds because it provides a gentle flow of solution to flush exudate and debris from the wound. A barrier ointment is useful for protecting the skin of clients who have urinary incontinence. The nurse should not use a barrier ointment on an exudative wound, because it is a lubricant that could block the effects of the irrigating solution. The nurse should plan to use an irrigation solution that is warmed to body temperature. The nurse should not use sterile cotton balls, because fibers from the cotton can shed onto the wound's surface and adhere to its tissue. The nurse should use gauze to dry the edges of the wound after the irrigation procedure.

A nurse is caring for a client who has limited mobility. Which of the following actions should the nurse take to maintain the Client's skin integrity? A. Use warm water when bathing the client. B. Place a donut-shaped cushion in the client's chair. C. Massage reddened areas over bony prominences. D. Maintain the client in high-Fowler's position.

A. The nurse should use warm water to bathe the client because hot water can dry and damage the skin. The nurse should use a gel, foam, or air cushion to redistribute weight away from the ischial areas. Rigid and donut-shaped cushions are contraindicated because they reduce blood supply to the area. The nurse should not massage bony prominences because it can lead to tissue trauma. The nurse should keep the head of the client's bed at 30° or less to prevent pressure injuries from forming.

A nurse is collecting data from a client who is 2 days postoperative following a colostomy placement. Which of the following findings should the nurse report to the provider? A. a purple-colored stoma B. protrusion of the stoma C. a small amount of bleeding from the stoma D. intestinal gas in the pouch

A. The stoma should be reddish-pink and moist. A purple-colored stoma is an indication of poor circulation, and the nurse should report this finding to the provider immediately. A budded stoma protrudes from the skin level and is an expected finding for the client. A small amount of bleeding around the stoma is an expected finding. Intestinal gas in the pouch is an expected finding.

A nurse is reinforcing teaching about range-of-motion exercises for a client who is postoperative and has a history of thrombophlebitis. Which of the following instructions should the nurse include? A. "You should alternate pointing your toes upward and downward." B. "You should move your leg out to the side and then bring it back to the center." C. "You should spread your toes apart and then bring them back together." D. "You should lift your entire leg upward and then back down."

A. To help prevent thrombophlebitis, the client should perform antiembolic exercises, including ankle pumps, foot circles, and knee flexion. For ankle pumps, the nurse should instruct the client to alternate plantar flexion and dorsiflexion. This range-of-motion exercise can help strengthen the thigh muscles, but it is unlikely to have a direct effect on preventing thrombophlebitis. This range-of-motion exercise can help strengthen and stretch some muscles in the feet; however, adducting and abducting the toes is unlikely to have a direct effect on preventing thrombophlebitis. "You should lift your entire leg upward and then back down." This range-of-motion exercise can help strengthen the muscles surrounding the hips, but it is unlikely to have a direct effect on preventing thrombophlebitis.

a nurse is reinforcing teaching about bladder retraining with a client who has urinary inctontinence. Which of the following instructions should the nurse include? A. Try to suppress the urge to urinate until the scheduled time. B. Drink carbonated beverages to help with urinary retention. C. Awaken every 2 hr during the night to urinate. D. Restrict fluid intake to no more than 1 L during waking hours.

A. When clients follow a schedule of voiding intervals and feel the urge to urinate before the next time, they should try slow, deep breathing to help diminish the urge. Clients can also try performing five or six strong and quick pelvic muscle exercises. Carbonated beverages can irritate the bladder, making incontinence episodes more likely. The client should try to awaken every 4 hr during the night to urinate, which, for most clients, would be once during sleeping hours. Although clients who have urinary incontinence should reduce fluid intake during the 4 hr before bedtime, they should drink plenty of fluids during the rest of their waking hours. However, clients should avoid drinking large amounts at once. The recommendation for fluid intake for most clients is between 2.2 and 3 L per day.

A nurse is attempting to extinguish a small fire in a client's bathroom with a fire extinguisher. Which of the following actions should the nurse take? A. Pull the pin out of the extinguisher. B. Rotate the handles a quarter turn until they click into place. C. Point the hose at the top of the fire. D. Hold the hose in one position while dousing the central part of the fire.

A. When the pin is in place, it locks the handles; therefore, the nurse should remove it before using the extinguisher. The nurse should squeeze the handles together or press the handle to release the extinguishing material onto the fire. The nurse should point the hose at the base of the fire. The nurse should sweep the hose from side to side, pointing at the base of the fire, while attempting to extinguish the fire.

A nurse is caring for a client who is receiving intermittent enteral feedings. Which of the following is the first action the nurse should take? A. Measure the client's gastric residual before each feeding. B. Change the bag and tubing every 24 hr. C. Document intake and output. D. Flush the tubing with 30 mL of water after each feeding.

A. When using the nursing process, the first action the nurse should take is assessment. Therefore, obtaining gastric residual volume is the priority action for the nurse to take. Changing the bag and tube feeding every 24 hr is important to prevent infection; however, another action is the priority. Documenting intake and output is important for monitoring adequate fluid and electrolyte balance; however, another action is the priority. Flushing the tube with 30 mL of water after each feeding is important to maintain patency of the tube; however, another action is the priority.

A nurse is assisting with the care of a client who has a prescription for IV therapy. The client tells the nurse that they have numerous allergies. Which of the following allergies should the nurse bring to the attention of the charge nurse prior to the inititiation of the therapy? A. Eggs B. Latex C. Seafood D. Bee stings

B. Nurses use products containing latex, including gloves, tourniquets, and IV tubing, to deliver IV therapy. Clients who have an allergic reaction to latex can have a wide range of manifestations, such as itching and hives, or a more serious reaction, such as dyspnea or laryngospasm. Some food allergies place the client at risk for latex allergy due to cross-sensitivity; however, eggs are not one of the foods for which there is a cross-sensitivity. Examples of foods that have a cross-sensitivity to latex are wheat, tomatoes, strawberries, and kiwi fruit. Some food allergies place the client at risk for latex allergy due to cross-sensitivity; however, seafood is not one of the foods for which there is a cross-sensitivity. Examples of foods that have a cross-sensitivity to latex are nectarines, avocados, potatoes, and bananas. An allergy to bee stings does not place the client at risk for a reaction to IV therapy equipment and supplies. There is no bee venom in any of these products, and bee venom has no cross-sensitivity to latex.

A nurse is assisting with a presentation to a group of older adults at a community center about hypothermia and hyperthermia. Which of the following information should the nurse include about age-related changes? A. Body regulation of heat and cold increases with age. B. Circulation becomes less efficient with age. C. Increased metabolic rate occurs with age, increasing body temperature. D. Sweat gland activity is increased with age.

B. Older adults have an increased sensitivity to temperature extremes due to decreased cardiac output. Poor cardiac output leads to less efficient circulation of blood to the tissues. Older adults have a decreased ability to regulate body temperature due to poor control of vasoconstriction and vasodilation. Older adults also have a reduced ability to shiver to increase body temperature. Older adults have a decreased body temperature due to a decrease in metabolic rate. Older adults will have a decrease in sweat gland activity, which affects body temperature regulation.

A nurse is moving a client up in bed with the assistance of a second nurse. Which of the following actions should the nurse take? A. Stand facing the center of the bed at the client's side. B. Place feet apart with the foot nearest the head of the client's bed in front of the other foot. C. Keep knees and hips straight while bending at the waist toward the client. D. Encourage the client to keep their legs straight and remain still.

B. Placing the feet apart provides a wide base of support, which improves balance. Additionally, a forward-backward stance enables the nurse to shift their weight as the client moves up in bed. The nurse should face the head of the bed. Facing the direction of movement prevents twisting of the nurse's body while moving the client. The nurse should flex their knees and hips, bringing their forearms close to the level of the bed. This position brings the nurse's center of gravity closer to the client and enables the nurse to use their thigh muscles instead of their back muscles to move the client. The nurse should encourage the client to flex their knees with their feet flat on the bed, which assists with moving up in bed and reduces the workload for the nurse.

A nurse is contributing to the plan of care for a client who has a positive throat culture for streptococci. Which of the following interventions should the nurse recommend to be included in the plan of care? A. Place the client in a room with another client who has pharyngitis. B. Ensure that the client wears a surgical mask during transportation throughout the facility. C. Limit the client's visitors to visitations of 30 min. D. Provide the client a room with negative-pressure airflow of six air exchanges per hour.

B. Streptococcal pharyngitis requires droplet precautions. The nurse should instruct the client to wear a surgical mask when outside of the room to prevent the spread of infection. Staff should make every attempt to limit the client's movement outside of the room. Many organisms can cause pharyngitis; therefore, the nurse should only place the client in a room with another client who has a positive throat culture for streptococci to prevent bacterial transmission. There are no restrictions on the time visitors may spend with a client who has a positive throat culture for streptococci. The nurse should provide a room with negative-pressure airflow for clients who require airborne precautions.

A nurse is caring for a client who has a clostridium difficile infection. Which of the following solutions should the nurse use to perform hand hygiene while caring for this client? A. Isopropyl alcohol B. Mild soap C. Chlorhexidine D. Triclosan

B. The CDC recommends using soap and water for handwashing when caring for clients who have a C. difficile infection. C. difficile is a spore-forming bacterium that is difficult to kill with disinfectants. Isopropyl alcohol is an active ingredient in the alcohol-based cleansing solutions nurses use to perform hand hygiene when in contact with bacteria, fungi, and viruses. However, alcohol does not kill C. difficile. Chlorhexidine solution is effective against bacteria and viruses. However, this solution does not kill the spores of C. difficile. Triclosan is effective against some bacteria. However, this solution does not kill the spores of C. difficile.

A nurse and an assistive personnel (AP) are providing postmortem care for a deceased client prior to visitation by the family. Which of the following actions by the AP requires intervention by the nurse? A. Gathering the client's personal belongings B. Removing the client's dentures C. Placing absorbent pads under the client's buttocks D. Closing the client's eyes

B. The client's dentures should remain in place in order to give the face a natural appearance. The nurse should determine what items need to remain with the client's body. All other belongings should be gathered and given to the client's family. Absorbent pads are placed under the buttocks to absorb feces and urine released because of relaxation of the sphincter muscles. The deceased client's eyes should be closed by holding them gently shut for a few seconds.

A nurse is about to give a bed bath to a client who requires a bed rest. Which of the following actions should the nurse take first? A. Provide as much privacy as possible. B. Determine the client's ability to assist with the bath. C. Expose only one area of the client's body at a time. D. Offer the client a bedpan before beginning the bath.

B. The first action the nurse should take using the nursing process is to collect data from the client. Instead of performing every step of hygiene for the client, the nurse should encourage the client's independence by first determining what actions the client is able to perform. The nurse should close the curtains around the client's bed and close the door to the client's room to respect the client's privacy and to ensure that hygiene care is as private as possible; however, there is another action the nurse should take first. To help keep the client warm, the nurse should use draping with bath blankets or towels to cover areas below the neck that the nurse is not bathing at that moment; however, there is another action the nurse should take first. Warm water can trigger the need to urinate. Rather than interrupt the bath for toileting, the nurse should anticipate the client's needs and offer the use of a bedpan; however, there is another action the nurse should take first.

A nurse is reinforcing teaching about carbohydrate counting with a client who has a new diagnosis of diabetes mellitus. Which of the following actions should the nurse take first? A. Use pictures of different food groups to help the client plan a daily menu. B. Ask the client what they already know about meal planning. C. Give the client a brochure with sample menus for all meals. D. Involve the family in the discussion of the client's meal plan.

B. The first action the nurse should take using the nursing process is to collect data to determine the client's current level of knowledge. Then, the nurse can plan education to meet the client's needs. Using visual aids will assist with reinforcing the teaching, but it is not the first action the nurse should take. Using sample menus will assist with reinforcing the teaching, but it is not the first action the nurse should take. Involving the client's family will assist with reinforcing the teaching, but it is not the first action the nurse should take.

A nurse is reinforcing teaching with a client who has a partial hearing loss about how to modify the home environment. Which of the following is a priority modification that the nurse should include? A. Alarm clock that shakes the bed B. Flashing smoke alarm C. Low-pitched buzzer doorbell D. Telephone with an amplified receiver

B. The greatest risk to the client's safety is injury from a fire. Therefore, the priority modification is to install flashing smoke alarms because this allows the client to see when the alarm is activated rather than having to hear it. An alarm clock that shakes the bed is an effective waking tool for a client who has hearing loss because they can feel the vibrations rather than having to hear the alarm. However, another modification is the priority. A doorbell with a low-pitched buzzer is an effective tool for a client who has a partial hearing loss because, with sensorineural hearing loss, low-pitched sounds are easier to hear than high-pitched sounds. However, another modification is the priority. A telephone with an amplified receiver is an effective tool for a client who has a partial hearing loss because it can help them hear during a telephone conversation. However, another modification is the priority.

A nurse working in a hospital overhears the following conversation between two other nurses on the elevator. Which of the following actions should the nurse take? A. Inform the nurses that the neighbor's dog did not cause the wound. B. Tell the nurses to change the topic of conversation. C. Complete an incident report upon returning to the unit. d. Report the nurses' conversation to the client's provider.

B. The nurse has the responsibility to protect the client's right to confidentiality and should intervene on the client's behalf. A breach of client confidentiality can result in liability for those involved. Accurate information is important. However, the nurse should only share client information in a private location with staff members who are directly involved in the client's care and have a need to know. The nurse is not required to complete a facility incident report for this behavior. The nurse should report the nurses' behavior to the charge nurse, but it is not necessary to report the conversation to the provider.

A nurse is caring for a client who has prescription for potassium supplement. The client tells the nurse that the pill is too large to swallow and refuses to take it. The nurse offers to break the pill into two smaller pieces. The nurse is demonstrating which of the following ethical principles? A. Autonomy B. Beneficence C. Justice D. Nonmaleficence

B. The nurse is demonstrating beneficence by acting in the client's best interest to make it possible for the client to swallow the medication. The nurse is not demonstrating autonomy. The nurse is attempting to compromise, rather than simply accepting the client's refusal of the medication. Justice refers to fairness in client care. A nurse demonstrates fairness by dividing their time among assigned clients to ensure all clients have their needs met. Nonmaleficence means to avoid harm or injury to the client. This situation does not involve a choice among potentially painful interventions.

A nurse is assisting with the admission of a client who has active tuberculosis. Which of the following actions should the nurse plan to take? A. Restrict the client's visitors to the immediate family. B. Assign the client to a negative-pressure airflow room. C. Discard personal protective equipment outside the client's room. D. Have the client wear a HEPA mask during transportation throughout the facility.

B. The nurse should assign the client to a negative-pressure airflow room to ensure that the air from the client's room is not circulated throughout the facility. The nurse does not need to restrict visitors, but should ensure that they follow airborne precaution guidelines. The nurse should remove personal protective equipment before leaving the client's room to prevent the spread of bacteria outside the room. The nurse should have the client wear a surgical mask whenever they leave their room to prevent transmitting bacteria to others.

A nurse is caring for four clients who are required to provide informed consent for treatment. The nurse should identify that which of the following clients is able to provide informed consent? A. A client who is receiving opioid medications via a PCA pump B. A client who has moderate Alzheimer's disease C. An 18-year-old client who has acute appendicitis D. A 16-year-old client who has a fractured tibia

C. A competent 18-year-old client who has acute appendicitis is able to provide informed consent for treatment. Opioid medications have a sedative effect, which might impair the client's understanding of a procedure. Therefore, this client is not able to provide informed consent. A client who has moderate Alzheimer's disease will have impaired judgment that will interfere with their ability to make decisions. Therefore, this client is not able to provide informed consent. This client is considered a minor and is not old enough to provide informed consent. Therefore, this client is not able to provide informed consent. A parent or legal guardian should provide informed consent for this client.

A nurse is assisting with the care of a recently deceased client. Which of the following actions should the nurse complete prior to the family viewing the body? A. Remove dentures. B. Apply a shroud around the body with a visible identification tag. C. Clean soiled areas of the body. D. Place the client's head in a dependent position.

C. A complete bath is not necessary because the body will be washed by the mortician. The nurse should cleanse any soiled areas prior to the family viewing the body, make sure dentures are in place if applicable, and comb the client's hair. The nurse should ensure that dentures are in place to maintain facial shape to promote a sense of normalcy for the family. After the body has been viewed by the family, the nurse can wrap the body in a shroud or sheet, as per agency protocol, and place the identifying tags on the body. As soon as possible following death, the nurse should elevate the client's head on a pillow to prevent facial discoloration.

A nurse is assisting with the admission of a client who has brought their medications to the facility. Which of the following actions should the nurse take? A. Allow the client to continue taking the medications as they did at home. B. Take the medications from the client and discard them. C. Compare the medications the provider has prescribed with the client's medications from home. D. Place the medications in the medication cart and administer them as the client took them at home.

C. During admission, the nurse should compare the medications that the provider has prescribed with the medications that the client is taking at home to decrease the risk of medication error. The nurse should include this information in the client's medical record as a resource for other health care personnel. Allowing the client to self-administer their medications as they did at home poses a risk for overdose and interactions when taken with medications that the provider prescribes during hospitalization. During changes in the level of care, the provider often changes prescriptions, and the client needs to follow the most recent plan of care. Each facility has policies and procedures for handling the client's possessions, including medications. Discarding the medications the client purchased shows a lack of respect for the client's personal property. Administering the medications as the client took them at home might cause harm to the client because the provider often updates the treatment plan at admission to an acute facility. The nurse should not dispense medications from the client's home supply because the nurse cannot validate that the medication and dose are correct as labeled.

A nurse is caring for a client who has just died and practiced the Islamic faith. Which of the following cultural practices should the nurse expect? A. The client's body should be placed on the floor. B. The client's oldest child will bathe the body. C. The client's face should be turned toward Mecca. D. The client's body will be adorned with amulets.

C. Following death, it can be a practice of the Islamic faith to turn the face of a deceased person toward Mecca. It can be a practice of the Hindu faith to place the body of a deceased person on the floor. It can be a Chinese cultural practice for the oldest child to bathe the body of a deceased person under the direction of an older relative or priest. It can be a Hispanic and Latino cultural practice to adorn the body of a deceased person with amulets or rosary beads.

A nurse is providing handoff report for a client who has a chest tube in place. Which of the following information should the nurse include in the report? A. The client's visits from family and friends B. The client's family history of cardiovascular disease C. The amount and characteristics of drainage D. The need to check vital signs at 1600 and 2000

C. For a client who has a chest tube, the amount and characteristics of the drainage provide important information about the client's current respiratory and immune status and are an essential component of change-of-shift report. Unless there is a specific issue or concern about the client's visitors, the nurse should not report visitation. During change-of-shift report, the nurse should not include details about the client's family history. The nurse should not include routine care procedures in change-of-shift report, such as the standard timing for measuring vital signs on the unit.

A nurse is caring for a client who has chronic pain. The nurse recommends that the client concentrate on a memory of a pleasurable experience. Which of the following complementary therapies is the nurse suggesting? A. art therapy B. tai chi C. guided imagery D. biofeedback

C. Guided imagery is a technique that can produce physical changes in the body, such as decreasing pain levels, by concentrating on a visualization of a pleasurable memory. Art therapy involves using creative activities to cope with acute or chronic conditions. Tai chi uses breathing, movement, and meditation to balance the client's internal and external environment. Biofeedback involves using an instrument to control a physiologic change in the body, such as blood pressure or heart rate.

A nurse in a long-term facility is assisting with the admission of a client who had a stroke. The nurse should report which of the following findings as a possible manifestation of dysphagia? A. Rapid speech B. Dry mouth C. Pocketing food D. Hiccups

C. Incomplete oral clearance, or retaining food in the cheeks, under the tongue, or on the hard palate, is a common manifestation of dysphagia. Clients who have dysphagia tend to speak slowly, weakly, and imprecisely. Their vocal tone often changes after they swallow, and they commonly experience hoarseness. Drooling and copious oral secretions, rather than dry mouth, are possible indications of dysphagia due to an impaired ability of fluids to pass through the pharynx to the esophagus. Hiccups are not a manifestation of dysphagia. Clients who have dysphagia are more likely to have heartburn, vomiting, choking, belching, and coughing due to an impaired ability for the food to move from the esophagus into the stomach.

A nurse is reinforcing teaching about using crutches with a client who has a fractured left ankle. Which of the following client statements indicates an understanding of the instructions? A. "I'll place my weight on the crutch pads at my armpits." B. "I'll wear my leather-sole shoes when I am using my crutches." C. "I'll bend my elbows to about 25 degrees when I walk with my crutches." D. "When I go down stairs, I will put my crutches and my right leg on the lower step first."

C. The client should have 20° to 30° of flexion at the elbows when using their crutches. The nurse should verify that the client understands the correct amount of elbow flexion to have when using crutches. The client should use their arms, not their axillae, to bear their body weight. Pressure on the axillae can damage the radial nerve and cause weakness and partial paralysis below the elbows. The client should wear rubber-sole shoes to reduce the risk for slipping or skidding. The client should shift their weight to their right leg and then advance the crutches and their left leg down to the next step. Then, they should transfer their weight to the crutches and move their right leg down to the step that their left leg and the crutches are on.

A nurse is collecting data from a postoperative client and notes that the client's oxygen saturation has decreased from 95% to 88%. Which of the following actions should the nurse take first? A. Cover the sensor with a towel. B. Elevate the head of the client's bed. C. Observe the client for cyanosis and restlessness. D. Move the sensor to another location with optimal blood flow.

C. The first action the nurse should take when using the nursing process is to collect data from the client. If the client's pulse oximeter is generating a measurement that is significantly different from the client's baseline, the nurse should collect data to determine the client's respiratory status. The nurse should check for tachycardia, anxiety, cyanosis, and restlessness. The nurse should cover the sensor with a towel or sheet to determine whether light sources in the room have lowered the pulse oximeter's reading; however, there is another action the nurse should take first. The nurse should assist the client to a semi- or high-Fowler's position to ensure maximal lung expansion and oxygenation; however, there is another action the nurse should take first. The nurse should move the sensor to another location that has optimal circulation to see if the pulse oximeter's reading will increase; however, there is another action the nurse should take first.

A nurse in a provider's office is providing care for a client who has minimal exposure to sunlight. Which of the following interventions should the nurse recommend? A. Reduce intake of calcium-rich foods. B. Use sunscreen with skin protection factor (SPF) of 8. C. Take vitamin D supplements. D. Use a tanning bed 2 hr weekly.

C. The human body requires sunlight exposure to synthesize vitamin D. Therefore, the nurse should recommend that a client who has minimal sunlight exposure take supplemental vitamin D. The nurse should recommend for the client to consume an increased amount of calcium-rich foods. A client who has minimal exposure to sunlight might need a vitamin D supplement to increase calcium absorption. The nurse should recommend for the client to use sunscreen with SPF of at least 15 when exposed to direct sunlight to prevent sunburn and reduce the risk for developing skin cancer. The nurse should recommend for the client to avoid the use of tanning beds, which can increase the risk for developing skin cancer.

A nurse is caring for a client who has an infiltrated IV. Which of the following actions should the nurse take? A. Decrease the rate of the IV infusion. B. Obtain a culture specimen for the IV site of the infiltration. C. Insert a new IV in the other extremity. D. Keep the arm with the IV infiltration below the level of the heart.

C. The nurse insert a new IV in the other extremity. This will allow the affected extremity to heal. The nurse should discontinue the IV infusion when the IV is infiltrated to prevent further damage to the tissue. The nurse should obtain a culture specimen if suspecting an infection at the IV insertion site. The nurse should elevate the affected arm and apply moist warm compresses to decrease the edema from the IV infiltration.

A nurse is caring for a client who is refusing medical treatment. Which of the following actions should the nurse take? A. Explain the negative consequences of the refusal. B. Discuss with the client's partner why the treatment is necessary. C. Document the client's refusal of the treatment. D. Try to convince the client that the treatment is needed.

C. The nurse is responsible for notifying the provider when a client refuses a treatment or procedure and documenting the client's decision. The provider is responsible for explaining the negative consequences of the client's refusal. Consulting with the client's partner can be a violation of the client's privacy. The nurse should ensure that the client has been fully informed. However, the client has the right to refuse treatment.

A nurse is caring for a client who states, "I believe that my teenager is using drugs." Which of the following responses should the nurse make? A. "If I were you, I'd ask your child directly if they are using drugs." B. "I think you're right. Substance use would explain the changes in your child's behavior." C. "You suspect that your child's behavior changes could indicate substance use." D. "Why do you think your child would want to use drugs?"

C. The nurse is using the therapeutic communication technique of paraphrasing by restating the client's message in the nurse's own words. This lets the client know that the nurse is interested in understanding their concerns and hearing more about them. The nurse is using nontherapeutic communication of giving personal opinion. This takes the decision-making away from the client and impedes further communication. The nurse is using nontherapeutic communication of agreeing, which conveys that the client is right and that it is acceptable for the nurse to judge this. This impedes the client's opportunity to explore the situation further with the nurse. The nurse is using nontherapeutic communication of probing. Asking "why" questions can make the client react defensively.

A nurse is caring for a client who has hypokalemia. Which of the following findings should the nurse expect? A. Diarrhea B. Tetany C. Decreased bowel sounds D. Decreased level of consciousness

C. The nurse should auscultate the abdomen and expect decreased bowel sounds due to decreased smooth muscle contractility when the client has a decreased serum potassium level. The nurse should expect the client to have constipation, not diarrhea, due to decreased smooth muscle contractility when the client has a decreased serum potassium. Tetany is involuntary muscle spasms caused by calcium deficits. It is a finding that is associated with hypocalcemia. A decreased level of consciousness is a finding associated with hypercalcemia.

A nurse is caring for a client who is receiving continuous NG tube feedings. The nurse listens to the client's bowel sounds. Which of the following actions should the nurse take? A. Replace the NG tube. B. Place the client in Sims' position. C. Decrease the rate of the feeding. D. Check the client's blood glucose.

C. The nurse should expect to hear bowel sounds every 5 to 35 seconds. This audio clip indicates hypermotility because there are greater than 40 bowel sounds/min. Hypermotility leads to diarrhea and is an indication of intolerance to the enteral feeding. Therefore, the nurse should slow the rate of the feeding to promote the client's tolerance of the feeding. The nurse should replace the NG tube if the client demonstrates indications of tube displacement, such as coughing and vomiting. The findings for this client do not indicate tube displacement. The nurse should maintain a client who is receiving continuous NG tube feedings in a position with the head of the bed elevated 30° to 45° to prevent aspiration of the formula. The nurse should check the blood glucose if the client demonstrates indications of hyperglycemia such as headache and confusion. The client can develop hyperglycemia when receiving continuous NG tube feedings. The findings for this client do not indicate the presence of hyperglycemia.

A nurse is collecting data from a client following a lumbar puncture. The nurse should identify which of the following findings as a potential adverse effect of this procedure? A. Fluid overload B. Diarrhea C. Headache D. Difficulty voiding

C. The nurse should identify that a headache can be an adverse effect following a lumbar puncture. To minimize the client's discomfort, the nurse should administer analgesics, offer fluids, and maintain the client in a dorsal recumbent position for the length of time prescribed by the provider. Fluid overload is not an expected adverse effect of a lumber puncture. The nurse should offer the client fluids following a lumbar puncture to restore volume lost during the procedure. Diarrhea is not an expected adverse effect of a lumbar puncture. Difficulty voiding is not an expected adverse effect of a lumbar puncture.

A nurse is assisting with the admission of a client to a medical-surgical unit. Which of the following findings should the nurse identify as an indication that the client is malnourished? A. Heart rate 89/min B. Pink mucous membranes C. Pallor with scaly skin D. Body mass index 23

C. The nurse should identify that pallor along with scaly skin can indicate malnutrition. The skin should be smooth and have the same hue as other areas of sun-exposed skin in clients who are well-nourished. A heart rate of 89/min is within the expected reference range of 60 to 100/min for an adult client. This finding does not indicate malnutrition. Red, swollen, and inflamed gums are an indication of malnutrition. Pink mucous membranes are an expected finding in well-nourished clients. This is an expected finding. A body mass index below 18.5 indicates malnutrition.

A nurse is documenting client care in a client's electronic health record. Which of the following entries should the nurse include in the documentation? A. complained about having incisional pain B. voided adequate amounts through the shift C. became short of breath when ambulating D. appeared to be sleeping while in bed

C. The nurse should include objective and significant information about the client when documenting client data in the electronic health record. The nurse should avoid using words that reflect personal judgment about the client's behavior, such as "complained." The nurse should avoid including subjective information when documenting client data in the electronic health record. The nurse should avoid including nonessential information or vague terminology when documenting client data in the electronic health record.

A nurse is planning to administer medication to a client who has a Clostridium difficile infection. Which of the following actions should the nurse plan to take to prevent the transmission of this infection to others? A. clean hands with an alcohol-based hand rub immediately after removing gloves B. remove the cover gown in the client's room after providing care C. place the client in a room with negative-pressure airflow D. wear a mask when administering oral medications to the client

C. The nurse should initiate contact precautions for clients who have a C. difficile infection. Contact precautions include the removal of the cover gown and other personal protective equipment inside the client's room to prevent the spread of infection. Alcohol-based hand rubs are not effective against C. difficile; therefore, the nurse should use soap and water to clean hands after providing care. Clients who have a C. difficile infection require contact precautions. A negative-pressure environment is a requirement for clients who are placed in airborne precautions. Clients who have a C. difficile infection require contact precautions. Therefore, the nurse should wear gloves and a gown when giving direct care to the client. A mask is a requirement when caring for clients who are placed in droplet precautions.

A nurse has inserted a dual lumen nasogastric (NG) tube for a client who has abdominal distention. Which of the following actions should the nurse take if unable to aspirate any gastric secretion? A. Clamp off the blue air vent of the tube. B. Flush the tube with 30 mL 0.9% sodium chloride. C. Inspect the posterior pharynx for coiling of the tube. D. Hook the tube up to wall suction.

C. The nurse should inspect the posterior pharynx for coiling of the tube if unable to aspirate any gastric secretion. The nurse should not clamp off the air vent of the NG tube because the vent needs to be open to air at all time to promote gastric patency. The nurse should not instill any solution through the NG tube until placement and patency is confirmed. The nurse should not connect the NG tube to wall suction until placement and patency is confirmed.

A charge nurse is reinforcing teaching with an assistive personnel (AP) about performing pulse oximetry. Which of the following information should the nurse include in the teaching? A. Select an alternate site to place the oximetry probe if the capillary refill is less than 2 seconds. B. Use an adhesive oximetry probe for a client who has a latex allergy. C. Remove polish from the client's fingernail before applying the oximetry probe. D. Lubricate the tip of the oximetry probe.

C. The nurse should instruct the AP to remove the client's fingernail polish on at least one finger before placing the probe on that finger because the sensor needs to detect a pulsating vascular bed to produce a reading. The nurse should instruct the AP to select an alternate site to place the probe if the capillary refill is greater than 2 seconds because of the inability of the sensor to detect a pulsating vascular bed to produce a reading. The nurse should instruct the AP not to apply an adhesive oximetry probe on the client who has a latex allergy because it can cause an anaphylactic reaction. The nurse should instruct the AP to ensure that the site is free of moisture and has adequate circulation to obtain an accurate reading.

A nurse is reinforcing teaching with a client who has hypertension and a prescription to measure their blood pressure daily. Which of the following client statements indicates an understanding of the teaching? A. "I will wait 15 minutes after drinking coffee to measure my blood pressure." B. "I will measure my blood pressure while my arm is elevated above my heart." C. "I should remove constrictive clothing prior to measuring my blood pressure." D. "I should measure my blood pressure immediately after eating breakfast."

C. The nurse should instruct the client to remove constrictive clothing prior to measuring their blood pressure because constrictive clothing can cause falsely elevated blood pressure readings. The nurse should instruct the client to wait 20 to 30 min after ingesting caffeine to measure their blood pressure. Stimulants such as caffeine and nicotine cause elevated blood pressure readings. The nurse should instruct the client to measure their blood pressure with their forearm at the level of their heart. Having their arm above or below heart level can result in inaccurate readings. The nurse should instruct the client to measure their blood pressure between meals. Measuring blood pressure immediately following a meal can alter blood pressure readings.

A nurse is reinforcing teaching with a new parent who is concerned about sudden infant death syndrome (SIDS). Which of the following statements by the client indicates an understanding of the teaching? A. "I will place my baby on her side to sleep." B. "I should avoid giving my baby a pacifier." C. "I will remove all stuffed animals from my baby's crib." D. "I will cover my baby with a light blanket when she is sleeping."

C. The nurse should reinforce the need to remove all stuffed animals and toys when the infant is sleeping to reduce the risk for SIDS. The nurse should reinforce the need to place the infant in a supine position during sleep to reduce the risk for SIDS. The nurse should reinforce that infants who use a pacifier during sleep until age 1 have a reduced risk for SIDS. The nurse should reinforce the need to remove blankets and all soft bedding when the infant is sleeping to reduce the risk for SIDS.

A nurse is reinforcing teaching with a client who needs to have a bladder scan to check for urinary retention. Which of the following information should the nurse provide about the procedure? A. The bladder scan will take place in the endoscopy unit. B. Deep pressure will be applied to the bladder area during the bladder scan. C. The bladder scan will be performed after urination. D. Pelvic muscle exercises will need to be performed during the bladder scan.

C. The nurse should reinforce with the client that the scan should occur within 10 min of voiding to ensure accuracy. The nurse should reinforce with the client that the bladder scan is a noninvasive procedure that is performed at the bedside. The nurse should reinforce with the client that light pressure will be applied in the area just above the symphysis pubis. The nurse should instruct the client to lie still in a supine position while the bladder scan is performed. Pelvic muscle exercises are performed for the treatment of urge incontinence and are not part of the bladder scan procedure.

A nurse is reinforcing teaching with a client who has a history of falls. Which of the following actions should the nurse take? A. Maintain the client's bed in a high position. B. Assist the client with putting socks on when getting out of bed. C. Leave the call light within the client's reach. D. Keep all four siderails up when the client is alone in the room.

C. The nurse should reinforce with the client to use the call light and ensure that the call light is within the client's reach. The client should call for assistance when attempting to get out of bed to prevent a fall. The nurse should keep the bed in the lowest position with the wheels locked to prevent a fall and as an additional safety precaution. The nurse should assist the client with applying nonskid footwear when getting out of bed to prevent a fall. Keeping four siderails up is a form of restraint; therefore, the nurse should keep two upper siderails elevated for safety measures. The client might attempt to get out of bed by climbing over the siderails and this can lead to a fall.

A nurse is taking notes of client information on a piece of paper while receiving report. Which of the following actions should the nurse take to dispose of the paper? A. Obscure the client's name with a marker prior to disposal. B. Place the paper in a trash can at the nurses' station. C. Shred the paper in a secure container. D. Secure the paper in the nurse's personal locker.

C. The nurse should shred any written information in a secure container after use to protect the client's privacy and adhere to HIPAA guidelines. Obscuring the client's name does not prevent the client's private information from being at risk for a violation of privacy and HIPAA guidelines. Placing the paper in a trash can at the nurses' station puts the client's private information at risk for a violation of privacy and HIPAA guidelines. The nurse should immediately dispose of the paper in a secure container after use to protect the client's privacy and adhere to HIPAA guidelines.

A nurse is speaking with a client who has type 2 diabetes mellitus and a prescription for insulin. The client verbalizes anger about having to take insulin. Which of the following responses should the nurse make? A. "Why are you angry about taking insulin?" B. "Don't worry. Diabetes runs in my family as well." C. "I see that you are angry. Let's sit down and talk." D. "You should take insulin, because it reduces the risk for complications."

C. This is an example of the therapeutic communication technique of offering self. It provides an opportunity for the nurse to understand the reason for the client's anger and provides a means for further communication. This response is probing and might make the client defensive. This response is unwarranted reassurance and dismisses the client's feelings. This response is judgmental, ignores the client's anger, and does not encourage the client to discuss their feelings.

A nurse is caring for a client who has recently undergone a total bilateral mastectomy. Which of the following statements by the client requires immediate action by the nurse? A. "I don't understand why everyone is so worried about me." B. "I don't know if I'll ever find someone who wants to marry me." C. "When I look at myself in the mirror, I don't know if I can go on." D. "I feel like the doctor pressured me into having the mastectomy."

C. This statement shows sadness and a decreased initiative. The greatest risk to this client is injury from suicidal ideation. Therefore, the priority action is for the nurse to immediately contact the client's provider regarding this statement. This statement reflects the client's denial of their situation. It is important to ensure that the client has an accurate understanding of their condition; however, another statement requires immediate action. This statement reflects the client's concerns about future intimacy. It is important to acknowledge the client's need for intimacy; however, another statement requires immediate action. This statement reflects the client's anger at their situation. It is important to acknowledge the client's feelings; however, another statement requires immediate action.

A nurse is providing care to a client who is 3 days postoperative and has a tracheostomy. In which of the following situations should the nurse identify a need to obtain immediate additional assistance? A. The client is coughing red tinged mucous during suctioning of the tracheostomy. B. The client's tracheostomy dressing has a moderate amount of dark red drainage. C. The client decannulated the tracheostomy tube. D. The client has increased oral secretions during suctioning of the tracheostomy.

C. When using the urgent vs nonurgent approach to client care, the nurse should stay with the client and call immediately for assistance to replace the old tracheostomy tube or place a new tube down the stoma, if available. The nurse should monitor and prepare to manually ventilate if the client becomes hypoxic. Coughing of red tinged mucous during suctioning is nonurgent because it is an expected finding for a client who has a new tracheostomy. The nurse should reassure the client and monitor for hypoxia. A moderate amount of dark red drainage on a new tracheostomy dressing is nonurgent because it is an expected finding. Drainage should subside as healing of the client's stoma occurs. Increased oral secretion is nonurgent because it is an expected finding until the client has adjusted to the tracheostomy tube. Oral suctioning is performed after suctioning the client's tracheostomy tube.

A nurse is reviewing the medical record of a client who has heart failure. The nurse should identify which of the following laboratory results as an indication that the client has fluid volume excess? A. Urine specific gravity 1.015 B. Hematocrit 42% C. Urine pH 6.5 D. BUN 8 mg/dL

D. A BUN of 8 mg/dL is below the expected reference range of 10 to 20 mg/dL. With fluid volume excess, the nurse should expect the client's BUN to be below the expected reference range due to hemodilution. A urine specific gravity of 1.015 is within the expected reference range of 1.005 to 1.030. With fluid volume excess, the nurse should expect the urine specific gravity to be below the expected reference range due to dilution of the urine. A hematocrit of 42% is within the expected reference range of 37% to 47% for females and 42% to 52% for males. With fluid volume excess, the nurse should expect the client's hematocrit to be below the expected reference range due to hemodilution. A urine pH of 6.5 is within the expected reference range of 4.6 to 8. Hydration status does not affect pH levels.

A nurse is caring for a client who has dysphagia following a stroke. Which of the following interventions should the nurse use when feeding the client? A. Offer the client a straw to drink liquids. B. Place food toward the back of the client's mouth. C. Encourage the client to lie down and rest for 30 min after meals. D.Instruct the client to tilt their head forward while eating.

D. A client who has dysphagia following a stroke should sit upright with their head tilted forward to facilitate swallowing and to prevent aspiration. A client who has dysphagia following a stroke should not drink with a straw. This can increase the risk for aspiration. Placing food toward the back of the mouth of a client who has dysphagia following a stroke increases the risk for choking and aspiration. Food should be placed on the unaffected side of the client's mouth to decrease this risk. A client who has dysphagia following a stroke should sit upright for at least 1 hr after meals to decrease the risk for aspiration.

A nurse discovers that they have administered a multivitamin to the wrong client. Which of the following actions should the nurse take? A. Obtain a prescription for the multivitamin from the client's provider. B. Take no action because the medication is unlikely to harm the client. C. Ask the client if they have taken multivitamins in the past. D. Complete an incident report about the medication error.

D. An incident report is required whenever there is an event outside the usual routine, such as a medication error, a client or visitor injury, an omission of a prescribed therapy, or a needlestick injury. The nurse should follow the facility's protocol for a medication error, including observing the client, completing an incident report, and reporting the occurrence to the charge nurse or supervisor and the client's provider. This action could create a discrepancy in the medical record and could later lead to the interpretation that the nurse was trying to "cover up" the error. Even if the provider prescribed the vitamin, the nurse should still document the time of administration as preceding the time of the prescription. The nurse is not in a position to decide that a medication the provider did not prescribe is harmless. The client also might vomit and aspirate the vitamin tablet, which could make the nurse liable for an unintentional tort, especially after the failure to disclose the error. It is not the nurse's role to attempt to evaluate the client's risk for injury from receiving a medication the provider did not prescribe. That is for the provider to determine. Asking this question could result in the interpretation that the nurse was trying to "cover up" the error.

A nurse is explaining ethics and values to a newly licensed nurse. The nurse should explain that allowing a client to make a decision about a treatment is an example of which of the following ethical principles? A. Confidentiality B. Nonmaleficence C. Accountability D. Autonomy

D. Autonomy is an ethical principle that refers to protecting a client's independence and right to make decisions about care. Confidentiality is an ethical principle that refers to protecting a client's right to privacy. Nonmaleficence is an ethical principle that refers to the avoidance of causing harm. Accountability is an ethical principle that refers to taking responsibility for one's actions.

A nurse has delegated various client care tasks to the assistive personnel (AP) on the care team. Which of the following actions by the AP should the nurse identify as correct? A.Using hand sanitizer to cleanse their hands of spilled food from a client's meal tray B. Setting aside their gown for future use in the room of a client who has a wound infection C. Removing their gloves after exiting a client's room D. Donning a mask to measure the vital signs of a client who has pertussis

D. Caring for clients who have pertussis requires droplet precautions. Therefore, the AP should wear a mask when within 1 m (3.3 feet) of the client. The AP should wash their hands with soap and running water whenever they are visibly soiled, such as when food has been spilled on them. The AP should don a new gown each time they enter the room because a gown is a single-use item. The AP should remove their gloves before leaving a client's room.

A nurse is assisting with the plan of care for a client who has aphasia following a stroke. Which of the following interventions should the nurse use to assist the client with communication? A. Provide an artificial voice box. B. Avoid using facial gestures. C. Speak to the client in a louder voice. D. Ask the client close-ended questions.

D. Clients who have aphasia can have difficulty forming words. Therefore, the nurse should ask the client questions that can be answered with a "yes" or "no" because the client can respond to these close-ended questions by shaking or nodding their head. The nurse should provide an artificial voice box for a client who had a laryngectomy. The nurse should use facial gestures when communicating with the client to assist the client in understanding the context of the conversation. The nurse should use a normal voice when speaking with the client. Speaking loudly can cause the client distress.

A nurse is assisting with the planning an educational session for older adult clients who have mobility limitations. Which of the following strategies should the nurse suggest using? A. Present extensive background information about the key learning points. B. Avoid references to a client's past experiences. C. Stand during presentations to establish an authoritative presence. D. Allow extra time for the clients to process the information and formulate questions.

D. Neurological changes that result from aging can cause slower neurotransmission, which can result in a decline in cognitive speed. The presenters should allow more time for absorbing information with an older adult population than with younger learners. Older adults tend to have more difficulty than younger learners in absorbing information that is not meaningful or practical for them. The presenters should limit information to the essential points and avoid including extra information. The presenters should explore a client's past experiences and use them to establish connections to new knowledge. Reminiscence can be a useful tool for helping an older adult learn new information. The presenters should sit at the same level as the group of clients, face them, and speak at a moderate to slow pace.

A nurse is caring for a client who is receiving palliative care at the end of life. The client tells the nurse that one of their worst fears is dying alone. Which of the following actions should the nurse take? A. Remind the client that they need to rest and cannot have someone with them all the time. B. Tell the client not to worry about being alone and that it is a common fear. C. Assure the client that the nursing staff will never leave them alone. D. Encourage the client's visitors to stay overnight.

D. Nighttime is especially difficult and lonely for clients who are dying. No matter what the facility's visiting times are, the nurse should make exceptions to help prevent the client from feeling alone. It is also comforting for visitors to have open access to the client. Not only does this response dismiss the client's concerns, but it also reflects a lack of prioritization of the client's needs at this time. This response reflects the nontherapeutic communication techniques of offering false reassurance and giving an automatic response. It displays poor judgment on the nurse's part and fails to offer hope and comfort. This response reflects the nontherapeutic communication technique of offering false reassurance. Not only does this response dismiss the client's concerns, but it also makes the client a promise the nurse might not be able to keep.

A nurse is reinforcing teaching with a client who has pneumonia and a productive cough. Which of the following instructions should the nurse include in the teaching? A. your visitors should wear a protective gown B. you should receive a pneumonia vaccine every year C. you should stande 1 foot away from others when coughing D. you should cover your mouth with a tissue when you cough

D. Pneumonia is spread by droplets. Covering the mouth with a tissue when coughing is an effective method of containing secretions to avoid spreading the infection. A client who has pneumonia requires droplet precautions rather than contact precautions; therefore, visitors should wear a mask rather than a gown. Clients should receive the pneumonia vaccine at age 65 and every 10 years thereafter. The nurse should instruct the client to stand at least 0.9 m (3 feet) away from others when coughing to prevent spreading the infection.

A nurse is reinforcing teaching with the caregiver of a client who is near death. Which of the following instructions should the nurse provide? A. "Encourage meals at least three times daily." B. "Keeping the room warm will help them breathe easier." C. "Help them onto their left side if they are experiencing nausea." D. "Provide mouth care to them at least every 2 hours."

D. Providing oral care as needed to a client who is near death will help reduce discomfort from dehydration, nausea, and dry mucous membranes. Clients who are near death can experience anorexia and nausea. Clients should be offered small, frequent meals of preferred foods, but should not be encouraged to eat if they prefer not to. The nurse should instruct the caregiver that keeping the room cool can provide comfort and facilitate ease of breathing. The nurse should instruct the caregiver to help the client turn onto their right side if experiencing nausea.

A nurse is caring for four clients. For which of the following clients should the nurse use the therapeutic technique of silence? A. A client who plans to leave the facility against medical advice B. A client who informs the nurse that they have made their funeral arrangements C. A client who tells the nurse that the night shift nurse did not bring their medication D. A client who has just experienced the death of their child

D. Silence is a therapeutic communication technique to use when a client is grieving. It demonstrates caring and patience and allows the client to speak when they are ready to do so. The nurse should collect more data to determine why the client has made this decision; therefore, the nurse should not use silence to communicate with the client. The nurse should clarify what the client is communicating with this statement; therefore, the nurse should not use silence to communicate with the client. The nurse should collect more data to clarify the client's statement; therefore, the nurse should not use silence to communicate with the client.

A nurse enters a client's room and finds smoke and flames coming from a wastebasket. Which of the following actions should the nurse take first? A. Activate the fire alarm system. B. Attempt to extinguish the fire. C. Close the door to the client's room. D. Move the client to the nearest common area.

D. The greatest risk to this client is injury from burns and smoke inhalation; therefore, the first action the nurse should take is to remove the client from the dangerous area. The acronym RACE is a reminder of the order of the actions to take in a fire: Rescue or remove the client from immediate danger, activate the fire alarm system, confine the fire by closing doors and windows, and extinguish the fire, if possible, with a fire extinguisher. The nurse should activate the fire alarm system to summon personnel to extinguish the fire and to alert them of the need for evacuation and other safety measures; however, the nurse should take another action first. The nurse should attempt to extinguish the fire to help prevent injury to themselves and others; however, the nurse should take another action first. The nurse should confine the fire by closing the doors in the immediate vicinity to help prevent injury to themselves and others; however, the nurse should take another action first.

A nurse is caring for a client who has a new diagnosis of cancer. Which of the following actions by the nurse maintains the client's confidentiality? A. Sharing the client's prognosis with a member of the client's family B. Discussing the client's status with a member of the spiritual support team C. Collaborating with a nurse from another unit about the client's care D. Providing client information to another nurse at change of shift

D. The nurse can share information with other staff who are caring for the client because it is essential to maintaining continuity of care, and does not violate the client's confidentiality. The nurse should only share information about the client with those directly involved in the client's care. The nurse should not share information with a member of the client's family without obtaining the client's consent. The nurse should not share information with a member of the spiritual support team without obtaining the client's consent. The nurse should not share information with health care team members who are not caring for the client.

A nurse is caring for a client who has new diagnosis of cancer. Which of the following actions by the nurse maintains the client's confidentiality? A. Sharing the client's prognosis with a member of the client's family B. Discussing the client's status with a member of the spiritual support team C. Collaborating with a nurse from another unit about the client's care D. Providing client information to another nurse at change of shift

D. The nurse can share information with other staff who are caring for the client because it is essential to maintaining continuity of care, and does not violate the client's confidentiality. The nurse should only share information about the client with those directly involved in the client's care. The nurse should not share information with a member of the client's family without obtaining the client's consent. The nurse should not share information with a member of the spiritual support team without obtaining the client's consent. The nurse should not share information with health care team members who are not caring for the client.

A nurse is caring for a client who has a new prescription for oxygen at 7 L/min via simple face mask. Which of the following actions should the nurse take to ensure client safety? A. Keep the side holes of the mask closed. B. Ensure the reservoir bag is inflated on expiration. C. Apply petroleum jelly to the client's nostrils. D. Attach a humidifier to the base of the flow meter.

D. The nurse should attach a humidifier at the base of the flow meter to moisten the air for the client. This action will prevent drying mucous membranes when the client is receiving oxygen at a rate greater than 4 L/min. A simple face mask has side holes to allow the carbon dioxide to escape; therefore, this is not an action the nurse should take. A simple face mask does not have a reservoir bag; therefore, this is not an action the nurse should take. Partial rebreather and nonrebreather masks use reservoir bags. The nurse should apply a water-based lubricant to the client's nostrils to relieve dryness.

A nurse is assisting with the plan of care for four clients. Which of the following tasks should the nurse assign to an assistive personnel (AP)? A. Ensure a client can use crutches before discharge. B. Check a client's ability to swallow following a stroke. C. Obtain a client's pain rating prior to physical therapy. D. Assist a client to get out of bed after a breathing treatment.

D. The nurse should delegate assisting a client to get out of bed because this task requires little technical skill or judgment and is within the AP's range of function. Ensuring a client can use crutches is a form of evaluation of care and is outside an AP's range of function. Checking to see if a client can swallow following a stroke is a form of data collection and is outside an AP's range of function. Obtaining a client's pain rating is a form of data collection and is outside an AP's range of function.

A nurse is reinforcing dietary teaching with a client who has chronic kidney disease and requires a low-potassium diet. Which of the following food choices by the client demonstrates an understanding of the teaching? A. 1 cup of cantaloupe B. 1 large baked potato C. 4 oz of banana chips D. 1 cup of applesauce

D. The nurse should determine that applesauce is the best food choice because 1 cup of applesauce contains 184 mg of potassium per serving. Therefore, the client's food choice of applesauce demonstrates an understanding of the teaching. The nurse should recommend that the client choose a different food that contains less potassium. One cup of cantaloupe contains 473 mg of potassium. The nurse should recommend that the client choose a different food that contains less potassium. One large baked potato contains 1,630 mg of potassium. The nurse should recommend that the client choose a different food that contains less potassium. Four ounces of banana chips contains 608 mg of potassium.

A nurse is caring for a client who is postoperative following a mastectomy. The client states, "I can barely look at myself in the mirror." The nurse should identify that the client is experiencing which of the following? A. complicated grief B. maturational loss C. disenfranchised grief D. actual loss

D. The nurse should identify that the client's comments indicate an actual loss, which is a loss that occurs when the person can no longer feel, see, hear, or know an object, another person, or a part of themselves, such as the loss of a body part. Complicated grief results when the usual stages of grieving do not take place. Maturational loss results from a developmental process, such as the growth of a child into an adult. Disenfranchised grief results when clients have a loss they are unable to share publicly and that society might view as controversial. An example is the death of a partner who had a spouse.

A nurse is preparing to remove staples from a client's incision. Which of the following actions should the nurse take? A. Lift the staple remover when squeezing the handle. B. Avoid completely closing the handle after squeezing. C. Expect the staples to bend at each outer side of the staple. D. Remove the staple from the skin after both sides are visible.

D. The nurse should remove the staple from the skin after both sides of the staple are visible, which indicates proper dislodgement of the staple and prevents pulling on the skin around the incision, which can cause needless discomfort. The nurse should avoid lifting the staple remover when squeezing the handle because it can cause pulling on the staple that is still embedded in the skin around the incision, which can cause needless discomfort. The nurse should completely close the handle of the staple remover to properly dislodge the staple for removal and to prevent pulling on the skin around the incision, which can cause needless discomfort. The nurse should expect the staple remover to cause the staples to bend at the center of each staple to properly dislodge the staple for removal and prevent pulling on the skin around the incision, which can cause needless discomfort.

A nurse is preparing to reinforce discharge instructions with a client who speaks a different language than the nurse. Which of the following actions should the nurse take? A. Confirm the client's understanding of discharge instructions by having them sign the form. B. Ask the client's family member to read the discharge instructions to the client. C. Provide the client only with written discharge instructions for home care. D. Use the facility's medical interpreter to convey and confirm discharge instructions.

D. The nurse should use a medical interpreter, not a family member, to convey the discharge instructions and confirm that the client understood them. The nurse should ask the client to repeat back the instructions through an interpreter to determine if the client understands the information. The nurse should avoid using a family member to interpret the discharge information with the client. The nurse should provide an interpreter to read the discharge instructions to the client. The nurse should provide the client with written home instructions in the client's spoken language and also provide an interpreter to further explain the discharge instructions.

A nurse in a long-term facility is collecting admission data from a client who uses a hearing aid. Which of the following actions should the nurse take? A. sit beside the client B. speak slowly and loudly to the client C. dim the lights in the client's room D. choose a private room for the interview

D. The nurse should use a private room, which will minimize background noise so the client is able to hear what the nurse is saying. The nurse should sit directly in front of the client so the client can read the nurse's lips while conversing. The nurse should speak clearly at a moderate rate and volume. Speaking loudly can make it more difficult for the client to understand. The nurse should provide lighting that is bright enough for the client to see the nurse's face.

A nurse is reinforcing teaching with a client who speaks a different language than the nurse. Which of the following actions should the nurse take? A. Avoid using gestures when communicating with the client. B. Communicate with the client using a translation dictionary. C. Speak loudly when communicating with the client. D. Use printed materials written in the client's language.

D. The nurse should use printed materials written in the client's language to reinforce teaching for the client and promote understanding. The nurse should use gestures and pictures when communicating with the client to promote understanding. The nurse should recognize that using a translation dictionary does not ensure accurate communication between the nurse and the client. The nurse should avoid speaking loudly when communicating with the client because this does not help to increase the client's understanding.

A nurse is reinforcing discharge teaching with a client who will receive home oxygen therapy. Which of the following client statements indicates an understanding of the teaching? A. "I'll keep my oxygen tank lying on the floor next to my recliner." B. "I'll keep my oxygen at least 4 feet away from any source of heat." C. "When my brother visits, I'll make sure he smokes in the next room." D. "I'll avoid wearing any wool or synthetic fabric when my oxygen is on."

D. The nurse should verify that the client understands that wool and synthetic fabrics can generate static electricity, which could cause a spark and, therefore, combustion. The nurse should instruct the client to wear cotton clothing and use cotton bedding. The client should always keep the oxygen cylinder upright in a rack or stand. Otherwise, there is a risk for uncontrolled movement of the tank, which could cause injury. The client should keep their oxygen supply at least 2.4 m (8 feet) away from any source of heat and 3 m (10 feet) from open flames because oxygen facilitates combustion. The client should ensure that any visitors or household members who smoke go outside the house to smoke.

A nurse is assisting with obtaining informed consent for a client who is perioperative. Which of the following actions should the nurse take? A. Explain the risks and the benefits of the surgery. B. Describe alternative treatments that are available. C. Inform the client about the procedure. D. Witness the client's signature.

D. The nurse's role during the informed consent process includes witnessing the client's signature on the informed consent form. The nurse also confirms that the client is competent to give voluntary consent and to sign the form. The surgeon should inform the client about the risks and the benefits of the surgery. The surgeon should inform the client about the alternative treatments that are available. The surgeon should inform the client about the surgical procedure.

A nurse has administered an intramuscular injection to a client. To prevent a needlestick injury, which of the following actions should the nurse take? A. Recap the needle while at the bedside. B. Place the needle and syringe in a biohazard bag. C. Dispose of the needle and syringe in the waste basket. D. Discard the needle and syringe in a sharps disposal container.

Without recapping the needle, the nurse should immediately deploy the needle safety device and drop the needle and syringe in a designated puncture-proof and leakproof sharps disposal container. This prevents any further handling of the needle by the nurse or any other staff members and thus reduces the risk for needlestick injuries. To prevent needlestick injuries, the nurse should not break, bend, recap, or manipulate used needles. A small deviation of the center of the cap from the needle could result in a needlestick injury. A biohazard bag is not puncture-proof. Anyone who handles the bag subsequently is at risk for a needlestick injury. To prevent needlestick injuries, the nurse should only dispose of the used needle and syringe in a designated puncture-proof and leakproof sharps disposal container. Placing needles in a waste basket puts the nurse and other health care team members at risk for a needlestick injury.