Fundamental HESI

The nurse plans a teaching session with a client but postponses the planned session based on which nursing diagnosis?

Activity intolerance related to postoperative pain.

The male client who is 2 days postoperative for exploratory abdominal surgery is ambulating in the hall with the practical nurse (PN). The client tells the PN, "I think something in my incision just let go." which action should the PN implement first?

Assist the client to a supine position.

Which action by the practical nurse (PN) demonstrates the value of dignity in client care?

Closes the door and covers the client during a bath.

Which client group is most likely to experience a therapeutic response from therapeutic touch?

Clients with headaches.

A client with metastatic cancer is preparing to make decisions about end of life issues. When the nurse explains a durable power of attorney for health care, which description is accurate?

It will identify someone that can make decisions for your health care if you are in a coma or vegetative state.

37.When the nurse enters a client's room to do an initial assessment, the client shouts, "Get out of my room! I'm tired of being bothered!" How should the nurse respond? A. There is no reason to be so angry. B. Why do I need to leave your room? C. What is concerning you this morning? D. Let me call the client advocate for you.

(C) is an open-ended question that encourages the client to discuss personal feelings. (A) devalues the client and hinders further communication. Acting defensively and asking why questions such as (B) are likely to elicit more anger and block communication. By deferring to the client advocate (D), the nurse fails to even address the client's feelings of anger and exasperation. Correct Answer: C

A client who is suspected of having tetanus asks a nurse about immunizations against tetanus. Before responding, what should the nurse consider about the benefits of tetanus antitoxin? 1 It stimulates plasma cells directly. 2 A high titer of antibodies is generated. 3 It provides immediate active immunity. 4

2 A long-lasting passive immunity is produced. Tetanus antitoxin provides antibodies, which confer immediate passive immunity. Antitoxin does not stimulate production of antibodies. It provides passive, not active, immunity. Passive immunity, by definition, is not long-lasting.

Which step(s) should the nurse take when administering ear drops to an adult client? (Select all that apply.) A. Place the client in a side-lying position. B. Pull the auricle upward and outward. C. Hold the dropper 6 cm above the ear canal. D. Place a cotton ball into the inner canal. E. Pull the auricle down and back.

Answer: A, B The correct answers (A and B) are the appropriate administration of ear drops. The dropper should be held 1 cm (½ inch) above the ear canal (C). A cotton ball should be placed in the outermost canal (D). The auricle is pulled down and back for a child younger than 3 years of age, but not an adult (E).

The nurse is preparing to administer 10 mL of liquid potassium chloride (Kay Ciel) through a feeding tube, followed by 10 mL of liquid acetaminophen (Tylenol). Which action should the nurse include in this procedure? A. Dilute each of the medications with sterile water prior to administration. B. Mix the medications in one syringe before opening the feeding tube. C. Administer water between the doses of the two liquid medications. D. Withdraw any fluid from the tube before instilling each medication.

Answer: C Water should be instilled into the feeding tube between administering the two medications (C) to maintain the patency of the feeding tube and ensure that the total dose of medication enters the stomach and does not remain in the tube. These liquid medications do not need to be diluted (A) when administered via a feeding tube and should be administered separately (B), with water instilled between each medication (D).

A client becomes angry while waiting for a supervised break to smoke a cigarette outside and states, "I want to go outside now and smoke. It takes forever to get anything done here!" Which intervention is best for the nurse to implement? A. Encourage the client to use a nicotine patch. B. Reassure the client that it is almost time for another break. C. Have the client leave the unit with another staff. D. Review the schedule of outdoor breaks with the client.

Answer: D The best nursing action is to review the schedule of outdoor breaks (D) and provide concrete information about the schedule. (A) is contraindicated if the client wants to continue smoking. (B) is insufficient to encourage a trusting relationship with the client. (C) is preferential for this client only and is inconsistent with unit rules.

An older female recently diagnosed with coronary artery disease (CAD) cooks at home using saturated fats, Which intervention should the practical nurse implement to help the client reduce modifiable risk factor(s)?

Encourage food preparation with various vegetable oils.

Which time frame should the practical nurse (PN) reposition a client?

Every 2 hours.

Which position is best for the practical nurse to place the client during administration of a rectal suppository for constipation?

Left Sim's position with upper leg flexed.

The practical nurse (PN) is giving oral care to an older female client with tender gums that bleed easily because of a medication she is taking. What intervention should the PN implement?

Obtain a soft-bristle brush for the client.

Which snack food is best for the nurse to provide a client with myasthenia gravis who is at risk for altered nutritional status?

Chocolate pudding

4.What action by the nurse demonstrates culturally sensitive care? A. Asks permission before touching a client. B. Avoids questions about male-female relationships. C. Explains the differences between Western medical care and cultural folk remedies. D. Applies knowledge of a cultural group unless a client embraces Western customs.

Correct Answer: A

5.A nurse is becoming increasingly frustrated by the family members' efforts to participate in the care of a hospitalized client. What action should the nurse implement to cope with these feelings of frustration? A. Suggest that other cultural practices be substituted by the family members. B. Examine one's own culturally based values, beliefs, attitudes, and practices. C. Explain to the family that multiple visitors are exhausting to the client. D. Allow the situation to continue until a family member's action may harm the client.

Correct Answer: B

Which action should the practical nurse (PN) follow when applying an elasticized bandage to a client's leg?

Overlap turns of the bandage equally.

Prior to transferring a client to a chair using a mechanical lift, what is teh most important client characteristic the nurse should assess?

Tolerance of exertion.

Following a cholecystectomy, a client asks the practical nurse (PN) about dietary restrictions that may need to be followed. Which diet should the PN recommend?

A well-balanced diet with no other restrictions.

The practical nurse (PN) observes a client who begins to choke during a meal. determining that the client cannot speak, what action should the PN implement?

Place a fist halfway between the xiphoid process and umbilicus.

After gastric surgery a client has a nasogastric tube in place. What should the nurse do when caring for this client? 1 Monitor for signs of electrolyte imbalance. 2 Change the tube at least once every 48 hours. 3 Connect the nasogastric tube to high continuous suction. 4 Assess placement by injecting 10 mL of water into the tube

1 Gastric secretions, which are electrolyte rich, are lost through the nasogastric tube; the imbalances that result can be life threatening. Changing the nasogastric tube every 48 hours is unnecessary and can damage the suture line. High continuous suction can cause trauma to the suture line. Injecting 10 mL of water into the nasogastric tube to test for placement is unsafe; if respiratory intubation has occurred aspiration will result

89.What action is most important for the nurse to implement when placing a client in the Sim's position? A. Raise the bed to a waist-high working level. B. Elevate the head of the bed 45 degrees. C. Place a pillow behind the client's back. D. Bring the client to one edge of the bed.

A waist-high bed height (A) is a comfortable and safe working height to maintain the nurse's proper body mechanics and prevent back injury. The head should be flat for a Sim's side-lying position, not raised (B). (C) is implemented after the client is positioned laterally. (D) brings the client closer to the nurse when being turned. Correct Answer: A

Heparin 20,000 units in 500 ml D5W at 50 ml/hour has been infusing for 5½ hours. How much heparin has the client received? A) 11,000 units. B) 13,000 units. C) 15,000 units. D) 17,000 units

A) 11,000 units

An older client is receiving nasogastric tube (NGT) feedings for several days

Abdominal distention and nausea.

A client with acute hemorrhagic anemia is to receive four units of packed RBCs (red blood cells) as rapidly as possible. Which intervention is most important for the nurse to implement? A) Obtain the pre-transfusion hemoglobin level. B) Prime the tubing and prepare a blood pump set-up. C) Monitor vital signs q15 minutes for the first hour. D) Ensure the accuracy of the blood type match.

D) Ensure the accuracy of the blood type match All interventions should be implemented prior to administering blood, but (D) has the highest priority. Any time blood is administered, the nurse should ensure the accuracy of the blood type match in order to prevent a possible hemolytic reaction

During a visit to the outpatient clinic, the nurse assess a client with severe osteoarthritis using a goniometer. Which finding should the nurse expect to measure?

Degree of flexion and extension of the client's knee joint.

When irrigating the eyes of a client, which action should the practical nurse implement?

Direct the irrigation flow from the inner canthus to the outter canthus of the affected eye.

An older client who is unable to swallow is receiving continuous nasogastric tube (NGT) feeding. Before administering medication through the NGT, what action should the practical nurse (PN) implement?

Flush the feeding tube with water.

The nurse is administering meds through a NG tube which is connected to suction. After ensuring correct tube placement, what action should the nurse take next?

Flush the tube with water. NGT should be flushed before, after, and in between each med adminstered.

An older client who complains of dry mouth is having trouble swallowing pills. What action should the practical nurse take when administering an enteric-coated tablet?

Place the whole tablet in a spoonful of pudding.

An african american grandmother tells the nurse that 4 year old grandson is suffering with miseries. Based on this statement, which focused assessment should the nurse conduct?

Inquire about the source and type of pain. Different cultural have different words.

When assessing a client with wrist restraints, the nurse observes that the fingers on the right hand are blue. What action should the nurse implement first?

Loosen the right wrist restraint.

A young mother of three complains of increased anxiety during her annual physical exam. What information should the nurse obtain first?

Nutritional history

A client receiving supplemental oxygen needs to be suctioned to remove excess secretions from the airway. Which intervention should the practical nurse implement to maximize the client's oxygenation?

Provide oxygen during rest periods between suctioning.

The practical nurse (PN) is assisting a client plan a balanced vegetarian diet that provides the highest in protein quality. Which selection should the PN recommend to the client?

Soybeans

A client is brought into the emergency department following a sudden cardiac arrest. A full code is started. FIve minutes later the family arrives with a durable power of attorney signed by the client requesting that no extraordinary measures be taken, including intubation, to save the client's life. What action should the nurse take?

Stop the code immediately.

What position should the practical nurse (PN) place a client in who is receiving an enteral tube feeding?

Supine with the head of the bed elevated 30 to 45 degrees.

A client is receiving a daily prescription for furosemide (Lasix) 40 mg PO, but is unable to swallow. The practical nurse (PN) should consult with the healthcare provider about which component of the prescription?

The route of administration.

Which action should the practical nurse (PN) implement when supporting an older client who is afraid of dying?

Use open-ended questions to encourage the client to share feelings.

The practical nurse (PN) is preparing to reconstitute a drug from powder for for IM administration. Which step should the PN implement first?

Verify the drug with the medication administration record (MAR).

31.When making the bed of a client who needs a bed cradle, which action should the nurse include? A. Teach the client to call for help before getting out of bed. B. Keep both the upper and lower side rails in a raised position. C. Keep the bed in the lowest position while changing the sheets. D. Drape the top sheet and covers loosely over the bed cradle.

A bed cradle is used to keep the top bedclothes off the client, so the nurse should drape the top sheet and covers loosely over the cradle (D). A client using a bed cradle may still be able to ambulate independently (A) and does not require raised side rails (B). (C) causes the nurse to use poor body mechanics. Correct Answer: D

The nurse is using a genogram while conducting a client's health assessment and past medical history. What information should the genogram provide? A) Genetic and familial health disorders. B) Chronic health problems. C) Reason for seeking health care. D) Undetected disorders.

A) Genetic and familial health disorders A genogram that is used during the health assessment process identifies genetic and familial health disorders (A). It may not identify the client's chronic health problems (B), so it is not a reason to seek health care (C). A genogram is not a diagnostic tool to detect disorders (D), such as those based on pathological findings or DNA.

By rolling contaminated gloves inside-out, the nurse is affecting which step in the chain of infection? A. Mode of transmission B. Portal of entry C. Reservoir D. Portal of exit

Answer: A The contaminated gloves serve as the mode of transmission (A) from the portal of exit (D) of the reservoir (C) to a portal of entry (B).

A client has a nasogastric tube connected to low intermittent suction. When administering medications through the nasogastric tube, which action should the nurse do first? A. Clamp the nasogastric tube. B. Confirm placement of the tube. C. Use a syringe to instill the medications. D. Turn off the intermittent suction device.

Answer: D The nurse should first turn off the suction (D) and then confirm placement of the tube in the stomach (B) before instilling the medications (C). To prevent immediate removal of the instilled medications and allow absorption, the tube should be clamped for a period of time (A) before reconnecting the suction.

A male client is upset with the healthcare provider's recommendation that he should consent to an above-knee amputation. He tells the practical nurse (PN), if they want to cut off my leg, they should just shoot me instead. How should the PN respond?

Ask the client how the surgery might effect his lifestyle.

A client is to receive 10 mEq of KCl diluted in 250 ml of normal saline over 4 hours. At what rate should the nurse set the client's intravenous infusion pump? A) 13 ml/hour. B) 63 ml/hour. C) 80 ml/hour. D) 125 ml/hour

B) 63 ml/hour

An elderly male client who is unresponsive following a cerebral vascular accident (CVA) is receiving bolus enteral feedings though a gastrostomy tube. What is the best client position for administration of the bolus tube feedings? A) Prone. B) Fowler's. C) Sims'. D) Supine.

B) Fowler's The client should be positioned in a semi-sitting (Fowler's) (B) position during feeding to decrease the occurrence of aspiration. A gastrostomy tube, known as a PEG tube, due to placement by a percutaneous endoscopic gastrostomy procedure, is inserted directly into the stomach through an incision in the abdomen for long-term administration of nutrition and hydration in the debilitated client. In (A and/or C), the client is placed on the abdomen, an unsafe position for feeding. Placing the client in (D) increases the risk of aspiration

Which food should the practical nurse (PN) recommend for a client to increase the dietary intake of potassium.

Baked potato.

The nurse is preparing to adminster IV fluid to a client with a strict fluid restriction. IV tubing with which feature is most important for the nurse to select?

Buterol attachment

Which assessment data would provide the most accurate determination of proper placement of a nasogastric tube? A) Aspirating gastric contents to assure a pH value of 4 or less. B) Hearing air pass in the stomach after injecting air into the tubing. C) Examining a chest x-ray obtained after the tubing was inserted. D) Checking the remaining length of tubing to ensure that the correct length was inserted.

C) Examining a chest x-ray obtained after the tubing was inserted Both (A and B) are methods used to determine proper placement of the NG tubing. However, the best indicator that the tubing is properly placed is (C). (D) is not an indicator of proper placement

Which action is most important for the nurse to implement when donning sterile gloves? A) Maintain thumb at a ninety degree angle. B) Hold hands with fingers down while gloving. C) Keep gloved hands above the elbows. D) Put the glove on the dominant hand first.

C) Keep gloved hands above the elbows Gloved hands held below waist level are considered unsterile (C). (A and B) are not essential to maintaining asepsis. While it may be helpful to put the glove on the dominant hand first, it is not necessary to ensure asepsis (D).

A client with chronic renal failure selects a scramble egg for his breakfast. Which action should the nurse take?

Commend the client for selecting a high biologic value protein.

10.A middle-aged woman who enjoys being a teacher and mentor feels that she should pass down her legacy of knowledge and skills to the younger generation. According to Erikson, she is involved in what developmental stage? A. Generativity. B. Ego integrity. C. Identification. D. Valuing wisdom.

Correct Answer: A

16.A client who has moderate, persistent, chronic neuropathic pain due to diabetic neuropathy takes gabapentin (Neurontin) and ibuprofen (Motrin, Advil) daily. If Step 2 of the World Health Organization (WHO) pain relief ladder is prescribed, which drug protocol should be implemented? A. Continue gabapentin. B. Discontinue ibuprofen. C. Add aspirin to the protocol. D. Add oral methadone to the protocol.

Correct Answer: A

Which finding indicates to the practical nurse (PN) that an older client who is receiving intravenous therapy is experiencing fluid overload?

Crackles in the lung fields.

The nurse mixes 50 mg of Nipride in 250 ml of D5W and plans to administer the solution at a rate of 5 mcg/kg/min to a client weighing 182 pounds. Using a drip factor of 60 gtt/ml, how many drops per minute should the client receive? A) 31 gtt/min. B) 62 gtt/min. C) 93 gtt/min. D) 124 gtt/min

D) 124 gtt/min

An older client who has been on bed rest in not eating well and is exhibiting abdominal distension, cramping, and is passing small amounts of liquid stool. Which prescribed action is most important for the practical nurse (PN) to implement?

Digitally remove a fecal impaction.

A client is prescribed a medication that is labeled as a sustained released (SR). What action should the practical nurse (PN) implement when administering this drug form?

Do not crush or dissolve the tablet or capsule contents.

The practical nurse (PN) is obtaining the vital signs for a client who has a urinary tract infection with Methicillin-resistant Staphylococcus Aureus (MRSA). How should the PN proceed?

Don a gown and gloves before entering the room.

Which food should the practical nurse (PN) recommend to a client as a source of complete protein?

Eggs.

The practical nurse (PN) is obtaining information for a male client's psychosocial assessment. Which action should the PN implement first?

Establish a therapeutic relationship.

54.The nurse working in the emergency department is assessing four clients' ability to tolerate pain. Which client is likely to tolerate a higher level of pain? A. A 10-year-old who was burned by a camp fire earlier today. B. A 70-year-old who has a postoperative infection from a surgery one week ago. C. A 23-year-old woman who sprained her knee while bicycling. D. A 55-year-old woman who has had moderate low back pain for three months.

Experiences with the same type of pain that has successfully been relieved makes it easier for a client to interpret the pain sensation, and as a result, the client is better prepared to take steps to relieve the pain (D). (A, B, and C) are having new experiences with pain. Correct Answer: D

Which action should the nurse implement when administering a prescription drug that should be given on an empty stomach?

Give one hour before or two hours after a meal. Average transit time from stomach to duodenum is 2 hours.

The nurse is instructing a client with high chholesterol about diet and life style modification. What comment from the client indicates that the teaching has been effective?

I will limit my intake of beef to 4 ounces per week. saturated fat from animal > cholesterol

24.The nurse is administering an intermittent infusion of an antibiotic to a client whose intravenous (IV) access is an antecubital saline lock. After the nurse opens the roller clamp on the IV tubing, the alarm on the infusion pump indicates an obstruction. What action should the nurse take first? A. Check for a blood return. B. Reposition the client's arm. C. Remove the IV site dressing. D. Flush the lock with saline.

If the client's elbow is bent, the IV may be unable to infuse, resulting in an obstruction alarm, so the nurse should first attempt to reposition the client's arm to alleviate any obstruction (B). After other sources of occlusion are eliminated, the nurse may need to check for a blood return (A), remove the dressing (C), or flush the saline lock (D) and then resume the intermittent infusion. Correct Answer: B

Which technique should the practical nurse use to give a Z-tract intramuscular (IM) injection?

Inject the medication into the dorsal gluteal site.

79.When assessing a client with an indwelling urinary catheter, which observation requires the most immediate intervention by the nurse? A. The drainage tubing is secured over the siderail. B. The clamp on the urinary drainage bag is open. C. There are no dependent loops in the drainage tubing. D. The urinary drainage bag is attached to the bed frame.

Maintaining a closed urinary drainage system is important to prevent infection, so the most immediate priority is to close the clamp (B) to reduce the risk for ascending microorganisms. If the drainage tubing is secured over the siderail (A), urine will not be able to flow out of the bladder, so the nurse should next reposition the tubing. (C and D) indicate correct care of the urinary drainage system, so documentation of an intact system is the last intervention needed. Correct Answer: B

An elderly resident of a long-term care facility is no longer able to perform self care and is becoming progressively weaker. The resident previously requested that no resusciative efforts be performed, and the family requests hospice care. WHat action should the nurse implement first?

Notify the healthcare provider of the family's request.

Which intervention should the practical nurse (PN) use to prevent obstruction of a gastric feeding tube?

Obtain a prescription for a liquid drug form instead of crushing tablets.

43.The nurse is digitally removing a fecal impaction for a client. The nurse should stop the procedure and take corrective action if which client reaction is noted? A. Temperature increases from 98.8° to 99.0° F. B. Pulse rate decreases from 78 to 52 beats/min. C. Respiratory rate increases from 16 to 24 breaths/min. D. Blood pressure increases from 110/84 to 118/88 mm/Hg.

Parasympathetic reaction can occur as a result of digital stimulation of the anal sphincter, which should be stopped if the client experiences a vagal response, such as bradycardia (B). (A, C, and D) do not warrant stopping the procedure. Correct Answer: B

90.The nurse is providing passive range of motion (ROM) exercises to the hip and knee for a client who is unconscious. After supporting the client's knee with one hand, what action should the nurse take next? A. Raise the bed to a comfortable working level. B. Bend the client's knee. C. Move the knee toward the chest as far as it will go. D. Cradle the client's heel.

Passive ROM exercise for the hip and knee is provided by supporting the joints of the knee and ankle (D) and gently moving the limb in a slow, smooth, firm but gentle manner. (A) should be done before the exercises are begun to prevent injury to the nurse and client. (B) is carried out after both joints are supported. After the knee is bent, then the knee is moved toward the chest to the point of resistance (C) two or three times. Correct Answer: D

The practical nurse (PN) is caring for an older client who is NPO after surgery. The client complains that his mouth and mucous membranes are dry. Which intervention should the PN implement to increase the client's comfort?

Preform oral hygiene frequently.

The nurse is assessing an older client and determines that the client's left upper eyelid droops, covering more of the iris than the right eyelid. Which description should the nurse use to document this finding?

Ptosis of the left eyelid.

The practical nurse (PN) is changing a postoperative dressing for a client with a horizontal lower abdominal incision. What method should the PN use to remove the tape from the dressing?

Remove all four sides by moving to the center of the incision.

The nurse dons gown, mask with eyeshield, and gloves before entering a client's room that has airborne precautions. Upon leaving the client's room, in which sequence should the nurse remove the personal protective equipment?

Remove gloves, gown, mask, wash hands

What nutritional information should the PN provide a client with heart failure (HF)?

Restrict dietary sodium intake.

39.When assessing a client with a nursing diagnosis of fluid volume deficit, the nurse notes that the client's skin over the sternum "tents" when gently pinched. Which action should the nurse implement? A. Confirm the finding by further assessing the client for jugular vein distention. B. Offer the client high protein snacks between regularly scheduled mealtimes. C. Continue the planned nursing interventions to restore the client's fluid volume. D. Change the plan of care to include a nursing diagnosis of impaired skin integrity.

Skin turgor is assessed by pinching the skin and observing for tenting. This finding confirms the diagnosis of fluid volume deficit, so the nurse should continue interventions to restore the client's fluid volume (C). Jugular vein distention (A) is a sign of fluid volume overload. High protein snacks (B) will not resolve the fluid volume deficit. Changes in the client's skin integrity are not evident (D). Correct Answer: C

48.How should the nurse handle linens that are soiled with incontinent feces? A. Put the soiled linens in an isolation bag, then place it in the dirty linen hamper. B. Place an isolation hamper in the client's room and discard the linens in it. C. Place the soiled linens in a pillow case and deposit them in the dirty linen hamper. D. Ask the housekeeping staff to pick up the soiled linen from the dirty utility room.

The nurse should be careful to keep the soiled linens from contaminating the fresh linens, and should handle the soiled linens like any other dirty linen (C). (A, B, and D) are not indicated. Correct Answer: C

The practical nurse (PN) is adding tap water to several medications for administration via feeding tube. Which preparation should the PN administer without delay?

Timed release capsule.

The practical nurse is administering scheduled morning medications to a client who states, I haven't seen that pill before. Are you sure it's correct? Which action should the PN take?

Verify the prescription before administrating the medication.

A client with gastroenteritis, nausea, and vomiting is currently on Nothing by mouth (NPO) status. The healthcare provider prescribes oral intake to be advanced as tolerated. Which fluid should the practical nurse offer first?

Water.

A young woman, who is the primary caregiver for her mother who has Alzheimer's disease, tells the practical nurse (PN), "Sometimes I hate my mother for living this long and my Dad for dying and not caring for her." What response should the PN offer?

What you do to cope with these feelings?

A nurse who is working on a medical-surgical unit receives a phone call requesting information about a client who has undergone surgery. The nurse observes that the client requested a do not publish (DNP) order on any information regarding condition or presence in the hospital. What is the best response by the nurse? 1 "We have no record of that client on our unit. Thank you for calling." 2 "The new privacy laws prevent me from providing any client information over the phone." 3 "The client has requested that no information be given out. You'll need to call the client directly." 4 "It is against the hospital's policy to provide you with any information regarding any of our clients."

1 The response "We have no record of that client on our unit. Thank you for calling." conforms to the request that no information be given regarding the client's condition or presence in the hospital. HIPAA laws do not prohibit the provision of information to others as long as the client consents. The response "The client has requested that no information be given out. You'll need to call the client directly." implies that the client is admitted to the facility; this violates the client's request that no information should be shared with others. Hospital policies do not prohibit the provision of information to others as long as the client consents. The response "It is against the hospital's policy to provide you with any information regarding any of our clients." also implies that the client is admitted to the facility.

What type of interview is most appropriate when a nurse admits a client to a clinic? 1 Directive 2 Exploratory 3 Problem solving 4 Information giving

1 The first step in the problem-solving process is data collection so that client needs can be identified. During the initial interview a direct approach obtains specific information, such as allergies, current medications, and health history. The exploratory approach is too broad because in a nondirective interview the client controls the subject matter. Problem solving and information giving are premature at the initial visit.

A nurse is caring for an older adult who is taking acetaminophen (Tylenol) for the relief of chronic pain. Which substance is most important for the nurse to determine if the client is taking because it intensifies the most serious adverse effect of acetaminophen? 1 Alcohol 2 Caffeine 3 Saw palmetto 4 St. John's wort

1 Too much ingestion of alcohol can cause scarring and fibrosis of the liver. Eighty-five to 95% of acetaminophen is metabolized by the liver. Acetaminophen and alcohol are both hepatotoxic substances. Metabolites of acetaminophen along with alcohol can cause irreversible liver damage. Caffeine affects (stimulates) the cardiovascular system, not the liver. In addition, caffeine does not interact with acetaminophen. Saw palmetto is not associated with increased liver damage when taking acetaminophen. It often is taken for benign prostatic hypertrophy because of its antiinflammatory and antiproliferative properties in prostate tissue. St. John's wort is classified as an antidepressant and is not associated with increased liver damage when taking acetaminophen. However, it does decrease the effectiveness of acetaminophen.

Twenty-four hours after a cesarean birth, a client elects to sign herself and her baby out of the hospital. Staff members are unable to contact her health care provider. The client arrives at the nursery and asks that her infant be given to her to take home. What is the most appropriate nursing action? 1 Give the infant to the client and instruct her regarding the infant's care. 2 Explain to the client that she can leave, but her infant must remain in the hospital. 3 Emphasize to the client that the infant is a minor and legally must remain until prescriptions are received. 4 Tell the client that hospital policy prevents the staff from releasing the infant until ready for discharge

1 When a client signs herself and her infant out of the hospital, she is legally responsible for her infant. The infant is the responsibility of the mother and can leave with the mother when she signs them out.

A nurse is obtaining a health history from the newly admitted client who has chronic pain in the knee. What should the nurse include in the pain assessment? Select all that apply. 1 Pain history, including location, intensity, and quality of pain 2 Client's purposeful body movement in arranging the papers on the bedside table 3 Pain pattern, including precipitating and alleviating factors 4 Vital signs such as increased blood pressure and heart rate 5 The client's family statement about increases in pain with ambulation

1,3 Accurate pain assessment includes pain history with the client's identification of pain location, intensity, and quality and helps the nurse to identify what pain means to the client. The pattern of pain includes time of onset, duration, and recurrence of pain and its assessment helps the nurse anticipate and meet the needs of the client. Assessment of the precipitating factors helps the nurse prevent the pain and determine it cause. Purposeless movements such as tossing and turning or involuntary movements such as a reflexive jerking may indicate pain. Physiological responses such as elevated blood pressure and heart rate are most likely to be absent in the client with chronic pain. Pain is a subjective experience and therefore the nurse has to ask the client directly instead of accepting statement of the family members.

A client is receiving albuterol (Proventil) to relieve severe asthma. For which clinical indicators should the nurse monitor the client? Select all that apply. 1 Tremors 2 Lethargy 3 Palpitations 4 Visual disturbances 5 Decreased pulse rate

1,3 Albuterol's sympathomimetic effect causes central nervous stimulation, precipitating tremors, restlessness, and anxiety. Albuterol's sympathomimetic effect causes cardiac stimulation that may result in tachycardia and palpitations. Albuterol may cause restlessness, irritability, and tremors, not lethargy. Albuterol may cause dizziness, not visual disturbances. Albuterol will cause tachycardia, not bradycardia.

A nurse is taking care of a client who has severe back pain as a result of a work injury. What nursing considerations should be made when determining the client's plan of care? Select all that apply. 1 Ask the client what is the client's acceptable level of pain. 2 Eliminate all activities that precipitate the pain. 3 Administer the pain medications regularly around the clock. 4 Use a different pain scale each time to promote patient education. 5 Assess the client's pain every 15 minutes

1,3 The nurse works together with the client in order to determine the tolerable level of pain. Considering that the client has chronic, not acute pain, the goal of the pain management is to decrease pain to the tolerable level instead of eliminating pain completely. Administration of pain medications around the clock will provide the stable level of pain medication in the blood and relieve the pain. Elimination of all activities that precipitate the client's pain is not possible even though the nurse will try to minimize such activities. The same pain scale should be used for assessment of the client's pain level helps to ensure consistency and accuracy in the pain assessment. Only management of acute pain such as postoperative pain requires the pain assessment at frequent intervals.

The nurse is preparing to administer eardrops to a client that has impacted cerumen. Before administering the drops, the nurse will assess the client for which contraindications? Select all that apply. 1 Allergy to the medication 2 Itching in the ear canal 3 Drainage from the ear canal 4 Tympanic membrane rupture 5 Partial hearing loss in the affected ear

1,3,4 Contraindications to eardrops include allergy to the medication, drainage from the ear canal, and tympanic membrane rupture. Partial hearing loss may occur with impacted cerumen and is not a contraindication to the use of eardrops. Itching may occur with some ear conditions and is not a contraindication to the use of eardrops.

A nurse is preparing to administer an ophthalmic medication to a client. What techniques should the nurse use for this procedure? Select all that apply. 1 Clean the eyelid and eyelashes. 2 Place the dropper against the eyelid. 3 Apply clean gloves before beginning of procedure. 4 Instill the solution directly onto cornea. 5 Press on the nasolacrimal duct after instilling the solution.

1,3,5 Cleaning of the eyelids and eyelashes helps to prevent contamination of the other eye and lacrimal duct. Application of gloves helps to prevent direct contact of the nurse with the client's body fluids. Applying pressure to the nasolacrimal duct prevents the medication from running out of the eye. The dropper should not touch the eyelids or eyelashes in order to prevent contamination of the medication in the dropper. The medication should not be instilled directly onto the cornea because cornea has many pain fibers and is therefore very sensitive. The medication is to be instilled into the lower conjunctival sac.

A nurse is teaching an adolescent about type 1 diabetes and self-care. Which questions from the client indicate a need for additional teaching in the cognitive domain? Select all that apply. 1 "What is diabetes?" 2 "What will my friends think?" 3 "How do I give myself an injection?" 4 "Can you tell me how the glucose monitor works?" 5 "How do I get the insulin from the vial into the syringe?

1,4 Acquiring knowledge or understanding aids in developing concepts, rather than skills or attitudes, and is a basic learning task in the cognitive domain. Values and self-realization are in the affective domain. Skills acquisition is in the psychomotor domain.

The nurse manager is planning to assign an unlicensed assistive personnel (UAP) to care for clients. What care can be delegated on a medical-surgical unit to a UAP? Select all that apply. Correct 1 Performing a bed bath for a client on bed rest 2 Evaluating the effectiveness of acetaminophen and codeine (Tylenol #3) 3 Obtaining an apical pulse rate before oral digoxin (Lanoxin) is administered Correct 4 Assisting a client who has patient-controlled analgesia (PCA) to the bathroom 5 Assessing the wound integrity of a client recovering from an abdominal laparotomy

1,4 Performing a bed bath for a client on bed rest is within the scope of practice of the UAP. Assisting a client who has PCA to the bathroom does not require professional nursing judgment and is within the job description of the UAP. Evaluating human responses to medications requires the expertise of a licensed professional nurse. Obtaining an apical pulse rate requires a professional nursing judgment to determine whether or not the medication should be administered. Evaluating human responses to health care interventions requires the expertise of a licensed professional nurse.

Which drug does a nurse anticipate may be prescribed to produce diuresis and inhibit formation of aqueous humor for a client with glaucoma? 1 Chlorothiazide (Diuril) 2 Acetazolamide (Diamox) 3 Bendroflumethiazide (Naturetin) 4 Demecarium bromide (Humorsol)

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A toddler screams and cries noisily after parental visits, disturbing all the other children. When the crying is particularly loud and prolonged, the nurse puts the crib in a separate room and closes the door. The toddler is left there until the crying ceases, a matter of 30 or 45 minutes. Legally, how should this behavior be interpreted? 1 Limits had to be set to control the child's crying. 2 The child had a right to remain in the room with the other children. 3 The child had to be removed because the other children needed to be considered. 4 Segregation of the child for more than half an hour was too long a period of time

2 Legally, a person cannot be locked in a room (isolated) unless there is a threat of danger either to the self or to others. Limit setting in this situation is not warranted. This is a reaction to separation from the parent, which is common at this age. Crying, although irritating, will not harm the other children. A child should never be isolated

A nurse is caring for a client with an impaired immune system. Which blood protein associated with the immune system is important for the nurse to consider? 1 Albumin 2 Globulin 3 Thrombin 4 Hemoglobin

2 The gamma-globulin fraction in the plasma is the fraction that includes the antibodies. Albumin helps regulate fluid shifts by maintaining plasma oncotic pressure. Thrombin is involved with clotting. Hemoglobin carries oxygen.

A nurse is preparing to administer an oil-retention enema and understands that it works primarily by: 1 Stimulating the urge to defecate. 2 Lubricating the sigmoid colon and rectum. 3 Dissolving the feces. 4 Softening the feces

2 The primary purpose of an oil-retention enema is to lubricate the sigmoid colon and rectum. Secondary benefits of an oil-retention enema include stimulating the urge to defecate and softening feces. An oil-retention enema does not dissolve feces.

An 85-year-old client has just been admitted to a nursing home. When designing a plan of care for this older adult the nurse recalls what expected sensory losses associated with aging? Select all that apply. 1 Difficulty in swallowing 2 Diminished sensation of pain 3 Heightened response to stimuli 4 Impaired hearing of high-frequency sounds 5 Increased ability to tolerate environmental heat

2,4 Because of aging of the nervous system an older adult has a diminished sensation of pain and may be unaware of a serious illness, thermal extremes, or excessive pressure. As people age they experience atrophy of the organ of Corti and cochlear neurons, loss of the sensory hair cells, and degeneration of the stria vascularis, which affects an older person's ability to perceive high-frequency sounds. An interference with swallowing is a motor, not a sensory, loss, nor is it an expected response to aging. There is a decreased, not heightened, response to stimuli in older adults. There is a decreased, not increased, ability to physiologically adjust to extremes in environmental temperature.

The nurse recognizes that which are important components of a neurovascular assessment? Select all that apply. 1 Orientation 2 Capillary refill 3 Pupillary response 4 Respiratory rate 5 Pulse and skin temperature 6 Movement and sensation

2,5,6, A neurovascular assessment involves evaluation of nerve and blood supply to an extremity involved in an injury. The area involved may include an orthopedic and/or soft tissue injury. A correct neurovascular assessment should include evaluation of capillary refill, pulses, warmth and paresthesias, and movement and sensation. Orientation, pupillary response, and respiratory rate are components of a neurological assessment.

The nurse is providing postoperative care to a client who had a submucosal resection (SMR) for a deviated septum. The nurse should monitor for what complication associated with this type of surgery? Incorrect1 Occipital headache 2 Periorbital crepitus 3 Expectoration of blood 4 Changes in vocalization

3 After an SMR, hemorrhage from the area should be suspected if the client is swallowing frequently or expelling blood with saliva. A headache in the back of the head is not a complication of a submucosal resection. Crepitus is caused by leakage of air into tissue spaces; it is not an expected complication of SMR. The nerves and structures involved with speech are not within the operative area. However, the sound of the voice is altered temporarily by the presence of nasal packing and edema.

The triage nurse in the emergency department receives four clients simultaneously. Which of the clients should the nurse determine can be treated last? 1 Multipara in active labor 2 Middle-aged woman with substernal chest pain 3 Older adult male with a partially amputated finger 4 Adolescent boy with an oxygen saturation of 91%

3 Although a client with a partially amputated finger needs control of bleeding, the injury is not life threatening and the client can wait for care. A woman in active labor should be assessed immediately because birth may be imminent. A woman with chest pain may be experiencing a life-threatening illness and should be assessed immediately. An adolescent with significant hypoxia may be experiencing a life-threatening illness and should be assessed immediately.

The nurse is caring for a client that is on a low carbohydrate diet. With this diet, there is decreased glucose available for energy, and fat is metabolized for energy resulting in an increased production of which substance in the urine? 1 Protein 2 Glucose 3 Ketones 4 Uric Acid

3 As a result of fat metabolism, ketone bodies are formed and the kidneys attempt to decrease the excess by filtration and excretion. Excessive ketones in the blood can cause metabolic acidosis. A low carbohydrate diet does not cause increased protein, glucose, or uric acid in the urine. Study Tip: The old standbys of enough sleep and adequate nutritional intake also help keep excessive stress at bay. Although nursing students learn about the body's energy needs in anatomy and physiology classes, somehow they tend to forget that glucose is necessary for brain cells to work. Skipping breakfast or lunch or surviving on junk food puts the brain at a disadvantage.

A client comes to the clinic complaining of a productive cough with copious yellow sputum, fever, and chills for the past two days. The first thing the nurse should do when caring for this client is to: 1 Encourage fluids. 2 Administer oxygen. 3 Take the temperature. 4 Collect a sputum specimen

3 Baseline vital signs are extremely important; physical assessment precedes diagnostic measures and intervention. This is done after the health care provider makes a medical diagnosis; this is not an independent function of the nurse. Encouraging fluids might be done after it is determined whether a specimen for blood gases is needed; this is not usually an independent function of the nurse. Oxygen is administered independently by the nurse only in an emergency situation. A sputum specimen should be obtained after vital signs and before administration of antibiotics.

A nurse is caring for a client diagnosed with methicillin-resistant Staphylococcus aureus (MRSA) in the urine. The health care provider orders an indwelling urinary catheter to be inserted. Which precaution should the nurse take during this procedure? 1 Droplet precautions 2 Reverse isolation 3 Surgical asepsis 4 Medical asepsis

3 Catheter insertion requires the procedure to be performed under sterile technique . Droplet precautions are used with certain respiratory illnesses. Reverse isolation is used with clients who may be immunocompromised. Medical asepsis involves clean technique/gloving.

A client has been admitted with a urinary tract infection. The nurse receives a urine culture and sensitivity report that reveals the client has vancomycin-resistant Entercoccus (VRE). After notifying the physician, which action should the nurse take to decrease the risk of transmission to others? 1 Insert a urinary catheter. 2 Initiate droplet precautions. 3 Move the client to a private room. 4 Use a high efficiency particulate air (HEPA) respirator during care.

3 Contact precautions are used for clients with known or suspected infections transmitted by direct contact or contact with items in the environment; therefore infectious clients must be placed in a private room. There is no need to insert an indwelling catheter, as this can increase the risk for additional infection. Droplet precautions are used for clients known or suspected to have infections transmitted by the droplet route. These infections are caused by organisms in droplets that may travel 3 feet, but are not suspended for long periods.

The nurse is preparing discharge instructions for a client who has begun to demonstrate signs of early Alzheimer dementia. The client lives alone. The client's adult children live nearby. According to the prescribed medication regimen the client is to take medications six times throughout the day. What is the priority nursing intervention to assist the client with taking the medication? 1 Contact the client's children and ask them to hire a private duty aide who will provide round-the-clock care. 2 Develop a chart for the client, listing the times the medication should be taken. 3 Contact the primary health care provider and discuss the possibility of simplifying the medication regimen. 4 Instruct the client and client's children to put medications in a weekly pill organizer

3 Contacting a medical care provider and discussing the possibility of simplifying the client's medication regimen will make it possible to use a weekly pill organizer : an empty pill box will remind the client who has a short-term memory deficit due to Alzheimer dementia that medication was taken and will prevent medication being taken multiple times. The client does not require 24-hour supervision because the client is in the outset of the Alzheimer dementia and the major issue is a short-term memory loss. A chart may be complex and difficult to understand for the client and will require the client to perform cognitive tasks multiple times on daily basis that may be beyond the client's ability. Use of the weekly pill organizers will be difficult with the current medication regimen when the client has to take medications six times a day; the medication regimen has to be simplified first.

The nurse should instruct a client with an ileal conduit to empty the collection device frequently because a full urine collection bag may: 1 Force urine to back up into the kidneys. 2 Suppress production of urine. 3 Cause the device to pull away from the skin. 4 Tear the ileal conduit

3 If the device becomes full and is not emptied, it may pull away from the skin and leak urine. Urine in contact with unprotected skin will irritate and cause skin breakdown. A full urine collection bag will not cause urine to back up into the kidneys, suppress the production of urine, or tear the ileal conduit.

A client is to have mafenide (Sulfamylon) cream applied to burned areas. For which serious side effect of mafenide therapy should the nurse monitor this client? 1 Curling ulcer 2 Renal shutdown 3 Metabolic acidosis 4 Hemolysis of red blood cells

3 Mafenide interferes with the kidneys' role in hydrogen ion excretion, resulting in metabolic acidosis. Curling ulcer, renal shutdown, and hemolysis of red blood cells are not adverse effects of the drugs.

The nurse reviews a medical record and is concerned that the client may develop hyperkalemia. Which disease increases the risk of hyperkalemia? 1 Crohn's 2 Cushing's 3 End-stage renal 4 Gastroesophageal reflux .

3 One of the kidneys' functions is to eliminate potassium from the body; diseases of the kidneys often interfere with this function, and hyperkalemia may develop, necessitating dialysis. Clients with Crohn's disease have diarrhea, resulting in potassium loss. Clients with Cushing's disease will retain sodium and excrete potassium. Clients with gastroesophageal reflux disease are prone to vomiting that may lead to sodium and chloride loss with minimal loss of potassium

When a client files a lawsuit against a nurse for malpractice, the client must prove that there is a link between the harm suffered and actions performed by the nurse that were negligent. This is known as: 1 Evidence 2 Tort discovery 3 Proximate cause 4 Common cause

3 Proximate cause is the legal concept meaning that the client must prove that the nurse's actions contributed to or caused the client's injury. Evidence is data presented in proof of the facts, which may include witness testimony, records, documents, or objects. A tort is a wrongful act, not including a breach of contract of trust that results in injury to another person. Common cause means to unite one's interest with another's.

What is a basic concept associated with rehabilitation that the nurse should consider when formulating discharge plans for clients? 1 Rehabilitation needs are met best by the client's family and community resources. Incorrect2 Rehabilitation is a specialty area with unique methods for meeting clients' needs. Correct3 Immediate or potential rehabilitation needs are exhibited by clients with health problems. 4 Clients who are returning to their usual activities following hospitalization do not require rehabilitation.

3 Rehabilitation refers to a process that assists clients to obtain optimal functioning. Care should be initiated immediately when a health problem exists to avoid complications and facilitate recuperation. All resources that can be beneficial to client rehabilitation, including the private health care provider and acute care facilities, should be used. Rehabilitation is a commonality in all areas of nursing practice. Rehabilitation is necessary to help clients return to a previous or optimal level of functioning.

A nurse discusses the philosophy of Alcoholics Anonymous (AA) with the client who has a history of alcoholism. What need must self-help groups such as AA meet to be successful? 1 Trust 2 Growth 3 Belonging 4 Independence

3 Self-help groups are successful because they support a basic human need for acceptance. A feeling of comfort and safety and a sense of belonging may be achieved in a nonjudgmental, supportive, sharing experience with others. AA meets dependency needs rather than focusing on independence, trust, and growth.

A nurse receives a subpoena in a court case involving a child. The nurse is preparing to appear in court. In addition to the state Nurse Practice Act and the American Nursing Association (ANA) Code for Nurses, what else should the nurse review? 1 Nursing's Social Policy Statement 2 State law regarding protection of minors 3 ANA Standards of Clinical Nursing Practice 4 References regarding a child's right to consent

3 The ANA Standards of Clinical Nursing Practice guidelines govern safe nursing practice; nurses are legally responsible to perform according to these guidelines. Nursing's Social Policy Statement explains what the public can expect from nurses, but it is not used to govern nursing practice. There are no data that indicate state law regarding protection of minors and references regarding a child's right to consent are necessary.

A nurse cares for a client that has been bitten by a large dog. A bite by a large dog can cause which type of trauma? 1 Abrasion 2 Fracture 3 Crush injury 4 Incisional laceration

3 The bite of a large dog can exert between 150 and 400 psi of pressure, causing a crush injury. A crush injury may or may not include a fracture. Abrasions and incisional lacerations are not caused by this form of trauma.

A client has undergone a subtotal thyroidectomy. The client is being transferred from the post anesthesia care unit/recovery area to the inpatient nursing unit. What emergency equipment is most important for the nurse to have available for this client? 1 A defibrillator 2 An IV infusion pump 3 A tracheostomy tray 4 An electrocardiogram (ECG) monitor

3 The client who has undergone a subtotal thyroidectomy is at high risk for airway occlusion resulting from postoperative edema. With this in mind, emergency airway equipment such as a tracheostomy set and intubation supplies should be immediately available to the client. A defibrillator, an IV infusion pump, and an electrocardiogram (ECG) monitor are all equipment items that should be available to all postoperative clients.

A client asks about the purpose of a pulse oximeter. The nurse explains that it is used to measure the: 1 Respiratory rate. 2 Amount of oxygen in the blood. 3 Percentage of hemoglobin-carrying oxygen. 4 Amount of carbon dioxide in the blood

3 The pulse oximeter measures the oxygen saturation of blood by determining the percentage of hemoglobin-carrying oxygen. A pulse oximeter does not interpret the amount of oxygen or carbon dioxide carried in the blood, nor does it measure respiratory rate.

A client reaches the point of acceptance during the stages of dying. What response should the nurse expect the client to exhibit? 1 Apathy 2 Euphoria 3 Detachment 4 Emotionalism

3 When an individual reaches the point of being intellectually and psychologically able to accept death, anxiety is reduced and the individual becomes detached from the environment. Although detached, the client is not apathetic but still may be concerned and use time constructively. Although resigned to death, the individual is not euphoric. In the stage of acceptance, the client is no longer angry or depressed.

A client is admitted with severe diarrhea that resulted in hypokalemia. The nurse should monitor for what clinical manifestations of the electrolyte deficiency? Select all that apply. 1 Diplopia 2 Skin rash 3 Leg cramps 4 Tachycardia 5 Muscle weakness

3,5 Leg cramps occur with hypokalemia because of potassium deficit. Muscle weakness occurs with hypokalemia because of the alteration in the sodium potassium pump mechanism. Diplopia does not indicate an electrolyte deficit. A skin rash does not indicate an electrolyte deficit. Tachycardia is not associated with hypokalemia, bradycardia is.

A client receiving steroid therapy states, "I have difficulty controlling my temper which is so unlike me, and I don't know why this is happening." What is the nurse's best response? 1 Tell the client it is nothing to worry about. 2 Talk with the client further to identify the specific cause of the problem. 3 Instruct the client to attempt to avoid situations that cause irritation. 4 Interview the client to determine whether other mood swings are being experienced.

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A client receiving steroid therapy states, "I have difficulty controlling my temper which is so unlike me, and I don't know why this is happening." What is the nurse's best response? 1 Tell the client it is nothing to worry about. 2 Talk with the client further to identify the specific cause of the problem. 3 Instruct the client to attempt to avoid situations that cause irritation. 4 Interview the client to determine whether other mood swings are being experienced.

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Following a surgery on the neck, the client asks the nurse why the head of the bed is up so high. The nurse should tell the client that the high-Fowler position is preferred for what reason? 1 To avoid strain on the incision 2 To promote drainage of the wound 3 To provide stimulation for the client 4 To reduce edema at the operative site

4 This position prevents fluid accumulation in the tissue, thereby minimizing edema. This position will neither increase nor decrease strain on the suture line. Drainage from the wound will not be affected by this position. This position will not affect the degree of stimulation.

A nurse in the surgical intensive care unit is caring for a client with a large surgical incision. The nurse reviews a list of vitamins and expects that which medication will be prescribed because of its major role in wound healing? 1 Vitamin A (Aquasol A) 2 Cyanocobalamin (Cobex) 3 Phytonadione (Mephyton) 4 Ascorbic acid (Ascorbicap)

4 Vitamin C (ascorbic acid) plays a major role in wound healing . It is necessary for the maintenance and formation of collagen, the major protein of most connective tissues. Vitamin A is important for the healing process; however, vitamin C is the priority because it cements the ground substance of supportive tissue. Cyanocobalamin is a vitamin B12 preparation needed for red blood cell synthesis and a healthy nervous system. Phytonadione is vitamin K, which plays a major role in blood coagulation.

The nurse plans care for a client with a somatoform disorder based on the understanding that the disorder is: 1 A physiological response to stress 2 A conscious defense against anxiety 3 An intentional attempt to gain attention 4 An unconscious means of reducing stress

4 When emotional stress overwhelms an individual's ability to cope, the unconscious seeks to reduce stress. A conversion reaction removes the client from the stressful situation, and the conversion reaction's physical/sensory manifestation causes little or no anxiety in the individual. This lack of concern is called la belle indifference. No physiologic changes are involved with this unconscious resolution of a conflict. The conversion of anxiety to physical symptoms operates on an unconscious level.

73.The charge nurse observes an unlicensed assistive personnel (UAP) bending at the waist to lift a 20-pound box of medical supplies off the treatment room floor. What instruction should the charge nurse provide to the UAP? A. Ask another staff member for assistance. B. Request that supplies are delivered in smaller containers. C. Push the box against the wall to provide support while lifting. D. Bend at the knees when lifting heavy objects.

A 20-pound box is safely lifted by bending the knees (D), holding the box close to the center of gravity, and extending the legs using the quadriceps muscles. (A and B) might be helpful, but the charge nurse should use this opportunity to reinforce proper body mechanics techniques. Pushing the box against the wall (C) does not assist with lifting. Correct Answer: D

30.As the nurse prepares the equipment to be used to start an IV on a 4-year-old boy in the treatment room, he cries continuously. What intervention should the nurse implement? A. Take the child back to his room. B. Recruit others to restrain the child. C. Ask the mother to be present to soothe the child. D. Show the child how to manipulate the equipment.

A 4-year-old typically has a vivid imagination and lacks concrete thinking abilities. The mother's assistance (C) can provide a stabilizing presence to help soothe the preschooler, who may perceive the invasive procedure as mutilating. To preserve the child's sense of security associated with the hospital room, it is best to perform difficult or painful procedures in another area (A). (B) may be necessary to prevent injury if the child is unable to cooperate with the mother's coaxing. (D) is best done before going to the treatment room when the child feels less threatened. Correct Answer: C

63.The nurse is preparing to give a client with dehydration IV fluids delivered at a continuous rate of 175 ml/hour. Which infusion device should the nurse use? A. Portable syringe pump. B. Cassette infusion pump. C. Volumetric controller. D. Nonvolumetric controller.

A cassette pump (B) should be used to accurately deliver large volumes of fluid over longer periods of time with extreme precise, such as ml/hour. A syringe pump (A) is accurate for low-dose continuous infusion of low-dose medication at a basal rate, but not large fluid volume replacement. Volumetric (C) and nonvolumetric (D) controllers count drops/minute to administer fluid volume and are inherently inaccurate because of variation in drop size. Correct Answer: B

87.An older client who is able to stand but not to ambulate receives a prescription to be mobilized into a chair as tolerated during each day. What is the best action for the nurse to implement when assisting the client from the bed to the chair? A. Use a mechanical lift to transfer from the bed to a chair. B. Place a roller board under the client who is sitting on the side of the bed and slide the client to the chair. C. Lift the client out of bed to the chair with another staff member using a coordinated effort on the count of three. D. Place a transfer belt around the client, assist to stand, and pivot to a chair that is placed at a right angle to the bed.

A client who can stand can safely be assisted to pivot and transfer with the use of a transfer belt (D). A mechanical lift (A) is usually used for a client who is obese, unable to be weight-bearing, and who is unable to assist. Roller boards (B) placed under a sheet are used to facilitate the transfer of a recumbent client who is being transferred to and from a stretcher. Lifting a client (C) out of bed places the client and nurses at risk for injury and should only be implemented by skilled lift teams. Correct Answer: D

21.A client is demonstrating a positive Chvostek's sign. What action should the nurse take? A. Observe the client's pupil size and response to light. B. Ask the client about numbness or tingling in the hands. C. Assess the client's serum potassium level. D. Restrict dietary intake of calcium-rich foods.

A positive Chvostek's sign is an indication of hypocalcemia, so the client should be assessed for the subjective symptoms of hypocalcemia, such as numbness or tingling of the hands (B) or feet. (A and C) are unrelated assessment data. (D) is contraindicated because the client is hypocalcemic and needs additional dietary calcium. Correct Answer: B

While instructing a male client's wife in the performance of passive range-of-motion exercises to his contracted shoulder, the nurse observes that she is holding his arm above and below the elbow. What nursing action should the nurse implement? A) Acknowledge that she is supporting the arm correctly. B) Encourage her to keep the joint covered to maintain warmth. C) Reinforce the need to grip directly under the joint for better support. D) Instruct her to grip directly over the joint for better motion.

A) Acknowledge that she is supporting the arm correctly The wife is performing the passive ROM correctly, therefore the nurse should acknowledge this fact (A). The joint that is being exercised should be uncovered (B) while the rest of the body should remain covered for warmth and privacy. (C and D) do not provide adequate support to the joint while still allowing for joint movement

An obese male client discusses with the nurse his plans to begin a long-term weight loss regimen. In addition to dietary changes, he plans to begin an intensive aerobic exercise program 3 to 4 times a week and to take stress management classes. After praising the client for his decision, which instruction is most important for the nurse to provide? A) Be sure to have a complete physical examination before beginning your planned exercise program. B) Be careful that the exercise program doesn't simply add to your stress level, making you want to eat more. C) Increased exercise helps to reduce stress, so you may not need to spend money on a stress management class. D) Make sure to monitor your weight loss regularly to provide a sense of accomplishment and motivation.

A) Be sure to have a complete physical examination before beginning your planned exercise program The most important teaching is (A), so that the client will not begin a dangerous level of exercise when he is not sufficiently fit. This might result in chest pain, a heart attack, or stroke. (B, C, and D) are important instructions, but are of less priority than (A).

The nurse plans to obtain health assessment information from a primary source. Which option is a primary source for the completion of the health assessment? A) Client. B) Healthcare provider. C) A family member. D) Previous medical records

A) Client A primary source of information for a health assessment is the client (A). (B, C, and D) are considered secondary sources about the client's health history, but other details, such as subjective data, can only be provided directly from the client.

A client with chronic renal failure selects a scrambled egg for his breakfast. What action should the nurse take? A) Commend the client for selecting a high biologic value protein. B) Remind the client that protein in the diet should be avoided. C) Suggest that the client also select orange juice, to promote absorption. D) Encourage the client to attend classes on dietary management of CRF

A) Commend the client for selecting a high biologic value protein Foods such as eggs and milk (A) are high biologic proteins which are allowed because they are complete proteins and supply the essential amino acids that are necessary for growth and cell repair. Although a low-protein diet is followed (B), some protein is essential. Orange juice is rich in potassium, and should not be encouraged (C). The client has made a good diet choice, so (D) is not necessary

An adult male client with a history of hypertension tells the nurse that he is tired of taking antihypertensive medications and is going to try spiritual meditation instead. What should be the nurse's first response? A) It is important that you continue your medication while learning to meditate. B) Spiritual meditation requires a time commitment of 15 to 20 minutes daily. C) Obtain your healthcare provider's permission before starting meditation. D) Complementary therapy and western medicine can be effective for you.

A) It is important that you continue your medication while learning to meditate The prolonged practice of meditation may lead to a reduced need for antihypertensive medications. However, the medications must be continued (A) while the physiologic response to meditation is monitored. (B) is not as important as continuing the medication. The healthcare provider should be informed, but permission is not required to meditate (C). Although it is true that this complimentary therapy might be effective (D), it is essential that the client continue with antihypertensive medications until the effect of meditation can be measured

During the daily nursing assessment, a client begins to cry and states that the majority of family and friends have stopped calling and visiting. What action should the nurse take? A) Listen and show interest as the client expresses these feelings. B) Reinforce that this behavior means they were not true friends. C) Ask the healthcare provider for a psychiatric consult. D) Continue with the assessment and tell the client not to worry.

A) Listen and show interest as the client expresses these feelings When a client begins to cry and express feelings, a therapeutic nursing intervention is to listen and show interest as the client expresses feelings (A). (B) is not therapeutic option and the nurse does not know the dynamics of their relationships. (C) is not indicated at this time. (D) is non-therapeutic and offers false hope

A client who is 5' 5" tall and weighs 200 pounds is scheduled for surgery the next day. What question is most important for the nurse to include during the preoperative assessment? A) What is your daily calorie consumption? B) What vitamin and mineral supplements do you take? C) Do you feel that you are overweight? D) Will a clear liquid diet be okay after surgery?

A) What is your daily calorie consumption? Vitamin and mineral supplements (B) may impact medications used during the operative period. (A and C) are appropriate questions for long-term dietary counseling. The nature of the surgery and anesthesia will determine the need for a clear liquid diet (D), rather than the client's preference

While instructing a male client's wife in the performance of passive range of motion exercises to his contracted shoulder, the nurse observes that she is holding his arm above and below the elbow. What nursing action should the nurse implement?

Acknowledge that she is supporting the arm correctly.

91.The nurse is caring for a client who is weak from inactivity because of a 2-week hospitalization. In planning care for the client, the nurse should include which range of motion (ROM) exercises? A. Passive ROM exercises to all joints on all extremities four times a day. B. Active ROM exercises to both arms and legs two or three times a day. C. Active ROM exercises with weights twice a day with 20 repetitions each. D. Passive ROM exercises to the point of resistance and slightly beyond.

Active, rather than passive, ROM is best to restore strength and (B) is an effective schedule. Passive ROM 4 times a day (A) is not as beneficial for the client as (B). With weights (C), the client may fatigue quickly and develop muscle soreness. ROM is not performed beyond the point of resistance or pain (D) because of the risk of damage to underlying structures. Correct Answer: B

40.When teaching a female client to perform intermittent self-catheterization, the nurse should ensure the client's ability to perform which action? A. Locate the perineum. B. Transfer to a commode. C. Attach the catheter to a drainage bag. D. Manipulate a syringe to inflate the balloon.

Adequate visualization or palpation of the perineum (A) is essential to ensure correct placement of the catheter. (B) is not necessary to perform self-catheterization. During a self-catheterization, the client typically allows the urine to drain into an open collection device, rather than a drainage bag (C), and uses a straight catheter without a balloon (D). Correct Answer: A

18.A male client with acquired immunodeficiency syndrome (AIDS) develops cryptococcal meningitis and tells the nurse he does not want to be resuscitated if his breathing stops. What action should the nurse implement? A. Document the client's request in the medical record. B. Ask the client if this decision has been discussed with his healthcare provider. C. Inform the client that a written, notarized advance directive, is required to withhold resuscitation efforts. D. Advise the client to designate a person to make healthcare decisions when the client is unable to do so.

Advance directives are written statements of a person's wishes regarding medical care, and verbal directives may be given to a healthcare provider with specific instructions in the presence of two witnesses. To obtain this prescription, the client should discuss his choice with the healthcare provider (B). (A) is insufficient to implement the client's request without legal consequences. Although (C and D) provide legal protection of the client's wishes, the present request needs additional action. Correct Answer: B

41.A client in hospice care develops audible gurgling sounds on inspiration. Which nursing action has the highest priority? A. Ensure cultural customs are observed. B. Increase oxygen flow to 4L/minute. C. Auscultate bilateral lung fields. D. Inform the family that death is imminent.

An audible gurgling sound produced by a dying client is characteristic of ineffective clearance of secretions from the lungs or upper airways, causing a rattling sound as air moves through the accumulated fluid. The nursing priority in this situation is to convey to the family that the client's death is imminent (D). Although culturally sensitive care should be observed throughout the client's plan of care (A), this is not the priority at this time. Administration of oxygen may be expected care, but a flow rate greater than 2 L/minute (B) is not palliative care. (C) may provide additional information, but is not necessary as death approaches. Correct Answer: D

61.The daughter of an older woman who became depressed following the death of her husband asks, "My mother was always well-adjusted until my father died. Will she tend to be sick from now on?" Which response is best for the nurse to provide? A. She is almost sure to be less able to adapt than before. B. It's highly likely that she will recover and return to her pre-illness state. C. If you can interest her in something besides religion, it will help her stay well. D. Cultural strains contribute to each woman's tendencies for recurrences of depression.

Analysis of behavior patterns using Erikson's framework can identify age-appropriate or arrested development of normal interpersonal skills. Erikson describes the successful resolution of a developmental crisis in the later years (older than 65-years) to include the achievement of a sense of integrity and fulfillment, wisdom, and a willingness to face one's own mortality and accept the death of others (B). Depression is a component of normal grieving, and (A) does not represent susceptible adaptation to the developmental crisis of an older adult, Integrity vs despair. (C and D) are judgmental and not therapeutic. Correct Answer: B

While reviewing the side effects of a newly prescribed medication, a 72-year-old client notes that one of the side effects is a reduction in sexual drive. Which is the best response by the nurse? A. "How will this affect your present sexual activity?" B. "How active is your current sex life?" C. "How has your sex life changed as you have become older?" D. "Tell me about your sexual needs as an older adult."

Answer: A (A) offers an open-ended question most relevant to the client's statement. (B) does not offer the client the opportunity to express concerns. (C and D) are even less relevant to the client's statement.

Which nonverbal action should the nurse implement to demonstrate active listening? A. Sit facing the client. B. Cross arms and legs. C. Avoid eye contact. D. Lean back in the chair.

Answer: A Active listening is conveyed using attentive verbal and nonverbal communication techniques. To facilitate therapeutic communication and attentiveness, the nurse should sit facing the client (A), which lets the client know that the nurse is there to listen. Active listening skills include postures that are open to the client, such as keeping the arms open and relaxed, not (B), and leaning toward the client, not (D). To communicate involvement and willingness to listen to the client, eye contact should be established and maintained (C).

The nurse is obtaining a lie-sit-stand blood pressure reading on a client. Which action is most important for the nurse to implement? A. The family can provide the consent required in this situation because the older adult is in no condition to make such decisions. B. Because the client is mentally incompetent, the son has the right to waive informed consent for her. C. The court will allow the health care provider to make the decision to withhold informed consent under therapeutic privilege. D. If informed consent is withheld from a client, health care providers could be found guilty of negligence.

Answer: A Although all these measures are important, (A) is most important because it helps ensure client safety. (B) is necessary but does not have the priority of (A). (C and D) are important measures to ensure accuracy of the recording but are of less importance than providing client safety.

An older client who had abdominal surgery 3 days earlier was given a barbiturate for sleep and is now requesting to go to the bathroom. Which action should the nurse implement? A. Assist the client to walk to the bathroom and do not leave the client alone. B. Request that the UAP assist the client onto a bedpan. C. Ask if the client needs to have a bowel movement or void. D. Assess the client's bladder to determine if the client needs to urinate.

Answer: A Barbiturates cause central nervous system (CNS) depression and individuals taking these medications are at greater risk for falls. The nurse should assist the client to the bathroom (A). A bedpan (B) is not necessary as long as safety is ensured. Whether the client needs to void or have a bowel movement, (C) is irrelevant in terms of meeting this client's safety needs. There is no indication that this client cannot voice her or his needs, so assessment of the bladder is not needed (D).

In taking a client's history, the nurse asks about the stool characteristics. Which description should the nurse report to the health care provider as soon as possible? A. Daily black, sticky stool B. Daily dark brown stool C. Firm brown stool every other day D. Soft light brown stool twice a day

Answer: A Black sticky stool (melena) is a sign of gastrointestinal bleeding and should be reported to the health care provider promptly (A). (C) indicates constipation, which is a lesser priority. (B and D) are variations of normal.

Which client is most likely to be at risk for spiritual distress? A. Roman Catholic woman considering an abortion B. Jewish man considering hospice care for his wife C. Seventh-Day Adventist who needs a blood transfusion D. Muslim man who needs a total knee replacement

Answer: A In the Roman Catholic religion, any type of abortion is prohibited (A), so facing this decision may place the client at risk for spiritual distress. There is no prohibition of hospice care for members of the Jewish faith (B). Jehovah's Witnesses prohibit blood transfusions, not Seventh-Day Adventists (C). There is no conflict in the Muslim faith with regard to joint replacement (D).

A hospitalized client has had difficulty falling asleep for 2 nights and is becoming irritable and restless. Which action by the nurse is best? A. Determine the client's usual bedtime routine and include these rituals in the plan of care as safety allows. B. Instruct the UAP not to wake the client under any circumstances during the night. C. Place a "Do Not Disturb" sign on the door and change assessments from every 4 to every 8 hours. D. Encourage the client to avoid pain medication during the day, which might increase daytime napping.

Answer: A Including habitual rituals that do not interfere with the client's care or safety may allow the client to go to sleep faster and increase the quality of care (A). (B, C, and D) decrease the client's standard of care and compromise safety.

A nurse is working in an occupational health clinic when an employee walks in and states that he was struck by lightning while working in a truck bed. The client is alert but reports feeling faint. Which assessment will the nurse perform first? A. Pulse characteristics B. Open airway C. Entrance and exit wounds D. Cervical spine injury

Answer: A Lightning is a jolt of electrical current and can produce a "natural" defibrillation, so assessment of the pulse rate and regularity (A) is a priority. Because the client is talking, he has an open airway (B), so that assessment is not necessary. Assessing for (C and D) should occur after assessing for adequate circulation.

The nurse is aware that malnutrition is a common problem among clients served by a community health clinic for the homeless. Which laboratory value is the most reliable indicator of chronic protein malnutrition? A. Low serum albumin level B. Low serum transferrin level C. High hemoglobin level D. High cholesterol level

Answer: A Long-term protein deficiency is required to cause significantly lowered serum albumin levels (A). Albumin is made by the liver only when adequate amounts of amino acids (from protein breakdown) are available. Albumin has a long half-life, so acute protein loss does not significantly alter serum levels. (B) is a serum protein with a half-life of only 8 to 10 days, so it will drop with an acute protein deficiency. Neither (C or D) are clinical measures of protein malnutrition.

A male client is laughing at a television program with his wife when the evening nurse enters the room. He says his foot is hurting and he would like a pain pill. How should the nurse respond? A. Ask him to rate his pain on a scale of 1 to 10. B. Encourage him to wait until bedtime so the pill can help him sleep. C. Attend to an acutely ill client's needs first because this client is laughing. D. Instruct him in the use of deep breathing exercises for pain control.

Answer: A Obtaining a subjective estimate of the pain experience by asking the client to rate his pain (A) helps the nurse determine which pain medication should be administered and also provides a baseline for evaluating the effectiveness of the medication. Medicating for pain should not be delayed so that it can be used as a sleep medication (B). (C) is judgmental. (D) should be used as an adjunct to pain medication, not instead of medication.

The nurse-manager of a skilled nursing (chronic care) unit is instructing UAPs on ways to prevent complications of immobility. Which intervention should be included in this instruction? A. Perform range-of-motion exercises to prevent contractures. B. Decrease the client's fluid intake to prevent diarrhea. C. Massage the client's legs to reduce embolism occurrence. D. Turn the client from side to back every shift.

Answer: A Performing range-of-motion exercises (A) is beneficial in reducing contractures around joints. (B, C, and D) are all potentially harmful practices that place the immobile client at risk of complications.

When emptying 350 mL of pale yellow urine from a client's urinal, the nurse notes that this is the first time the client has voided in 4 hours. Which action should the nurse take next? A. Record the amount on the client's fluid output record. B. Encourage the client to increase oral fluid intake. C. Notify the health care provider of the findings. D. Palpate the client's bladder for distention.

Answer: A The amount and appearance of the client's urine output is within normal limits, so the nurse should record the output (A), but no additional action is needed (B, C, and D).

Based on the nursing diagnosis of Risk for infection, which intervention is best for the nurse to implement when providing care for an older incontinent client? A. Maintain standard precautions. B. Initiate contact isolation measures. C. Insert an indwelling urinary catheter. D. Instruct client in the use of adult diapers.

Answer: A The best action to decrease the risk of infection in vulnerable clients is hand washing (A). (B) is not necessary unless the client has an infection. (C) increases the risk of infection. (D) does not reduce the risk of infection.

The nurse is using the Glasgow Coma Scale to perform a neurologic assessment. A comatose client winces and pulls away from a painful stimulus. Which action should the nurse take next? A. Document that the client responds to painful stimulus. B. Observe the client's response to verbal stimulation. C. Place the client on seizure precautions for 24 hours. D. Report decorticate posturing to the health care provider.

Answer: A The client has demonstrated a purposeful response to pain, which should be documented as such (A). Response to painful stimulus is assessed after response to verbal stimulus, not before (B). There is no indication for placing the client on seizure precautions (C). Reporting (D) is nonpurposeful movement.

While conducting an intake assessment of an adult male at a community mental health clinic, the nurse notes that his affect is flat, he responds to questions with short answers, and he reports problems with sleeping. He reports that his life partner recently died from pneumonia. Which action is most important for the nurse to implement? A. Encourage the client to see the clinic's grief counselor. B. Determine if the client has a family history of suicide attempts. C. Inquire about whether the life partner was suffering from AIDS. D. Consult with the health care provider about the client's need for antidepressant medications.

Answer: A The client is exhibiting normal grieving behaviors, so referral to a grief counselor (A) is the most important intervention for the nurse to implement. (B) is indicated, but is not a high-priority intervention. (C) is irrelevant at this time but might be important when determining the client's risk for contracting the illness. An antidepressant may be indicated (D), depending on further assessment, but grief counseling is a better action at this time because grief is an expected reaction to the loss of a loved one.

In assisting an older adult client prepare to take a tub bath, which nursing action is most important? A. Check the bath water temperature. B. Shut the bathroom door. C. Ensure that the client has voided. D. Provide extra towels.

Answer: A To prevent burns or excessive chilling, the nurse must check the bath water temperature (A). (B, C, and D) promote comfort and privacy and are important interventions but are of less priority than promoting safety.

The nurse prepares to insert a nasogastric tube in a client with hyperemesis who is awake and alert. Which intervention(s) is(are) correct? (Select all that apply.) A. Place the client in a high Fowler's position. B. Help the patient assume a left side-lying position. C. Measure the tube from the tip of the nose to the umbilicus. D. Instruct the client to swallow after the tube has passed the pharynx. E. Assist the client in extending the neck back so the tube may enter the larynx.

Answer: A, D (A and D) are the correct steps to follow during nasogastric intubation. Only the unconscious or obtunded client should be placed in a left side-lying position (B). The tube should be measured from the tip of the nose to behind the ear and then from behind the ear to the xiphoid process (C). The neck should only be extended back prior to the tube passing the pharynx and then the client should be instructed to position the neck forward (E).

When assisting a client from the bed to a chair, which procedure is best for the nurse to follow? A. Place the chair parallel to the bed, with its back toward the head of the bed and assist the client in moving to the chair. B. With the nurse's feet spread apart and knees aligned with the client's knees, stand and pivot the client into the chair. C. Assist the client to a standing position by gently lifting upward, underneath the axillae. D. Stand beside the client, place the client's arms around the nurse's neck, and gently move the client to the chair.

Answer: B (B) describes the correct positioning of the nurse and affords the nurse a wide base of support while stabilizing the client's knees when assisting to a standing position. The chair should be placed at a 45-degree angle to the bed, with the back of the chair toward the head of the bed (A). Clients should never be lifted under the axillae (C); this could damage nerves and strain the nurse's back. The client should be instructed to use the arms of the chair and should never place his or her arms around the nurse's neck (D); this places undue stress on the nurse's neck and back and increases the risk for a fall.

After a needlestick occurs while removing the cap from a sterile needle, which action should the nurse implement? A. Complete an incident report. B. Select another sterile needle. C. Disinfect the needle with an alcohol swab. D. Notify the supervisor of the department immediately.

Answer: B After a needlestick, the needle is considered used, so the nurse should discard it and select another needle (B). Because the needle was sterile when the nurse was stuck and the needle was not in contact with any other person's body fluids, the nurse does not need to complete an incident report (A) or notify the occupational health nurse (D). Disinfecting a needle with an alcohol swab (C) is not in accordance with standards for safe practice and infection control.

The nurse is assessing several clients prior to surgery. Which factor in a client's history poses the greatest threat for complications to occur during surgery? A. Taking birth control pills for the past 2 years B. Taking anticoagulants for the past year C. Recently completing antibiotic therapy D. Having taken laxatives PRN for the last 6 months

Answer: B Anticoagulants (B) increase the risk for bleeding during surgery, which can pose a threat for the development of surgical complications. The health care provider should be informed that the client is taking these drugs. Although clients who take birth control pills (A) may be more susceptible to the development of thrombi, such problems usually occur postoperatively. A client with (C or D) is at less of a surgical risk than (B).

The health care provider has changed a client's prescription from the PO to the IV route of administration. The nurse should anticipate which change in the pharmacokinetic properties of the medication? A. The client will experience increased tolerance to the drug's effects and may need a higher dose. B. The onset of action of the drug will occur more rapidly, resulting in a more rapid effect. C. The medication will be more highly protein-bound, increasing the duration of action. D. The therapeutic index will be increased, placing the client at greater risk for toxicity.

Answer: B Because the absorptive process is eliminated when medications are administered via the IV route, the onset of action is more rapid, resulting in a more immediate effect (B). Drug tolerance (A), protein binding (C), and the drug's therapeutic index (D) are not affected by the change in route from PO to IV. In addition, an increased therapeutic index reduces the risk of drug toxicity.

When turning an immobile bedridden client without assistance, which action by the nurse best ensures client safety? A. Securely grasp the client's arm and leg. B. Put bed rails up on the side of bed opposite from the nurse. C. Correctly position and use a turn sheet. D. Lower the head of the client's bed slowly.

Answer: B Because the nurse can only stand on one side of the bed, bed rails should be up on the opposite side to ensure that the client does not fall out of bed (B). (A) can cause client injury to the skin or joint. (C and D) are useful techniques while turning a client but have less priority in terms of safety than use of the bed rails.

The nurse identifies a potential for infection in a patient with partial-thickness (second-degree) and full-thickness (third-degree) burns. What intervention has the highest priority in decreasing the client's risk of infection? A. Administration of plasma expanders B. Use of careful hand washing technique C. Application of a topical antibacterial cream D. Limiting visitors to the client with burns

Answer: B Careful hand washing technique (B) is the single most effective intervention for the prevention of contamination to all clients. (A) reverses the hypovolemia that initially accompanies burn trauma but is not related to decreasing the proliferation of infective organisms. (C and D) are recommended by various burn centers as possible ways to reduce the chance of infection. (B) is a proven technique to prevent infection.

The nurse is instructing a client with cholecystitis regarding diet choices. Which meal best meets the dietary needs of this client? A. Steak, baked beans, and a salad B. Broiled fish, green beans, and an apple C. Pork chops, macaroni and cheese, and grapes D. Avocado salad, milk, and angel food cake

Answer: B Clients with cholecystitis (inflammation of the gallbladder) should follow a low-fat diet, such as (B). (A) is a high-protein diet and (C and D) contain high-fat foods, which are contraindicated for this client.

During evacuation of a group of clients from a medical unit because of a fire, the nurse observes an ambulatory client walking alone toward the stairway at the end of the hall. Which action should the nurse take? A. Assign an unlicensed assistive personnel to transport the client via a wheelchair. B. Remind the client to walk carefully down the stairs until reaching a lower floor. C. Ask the client to help by assisting a wheelchair-bound client to a nearby elevator. D. Open the closest fire doors so that ambulatory clients can evacuate more rapidly.

Answer: B During evacuation of a unit because of fire, ambulatory clients should be evacuated via the stairway if at all possible and reminded to walk carefully (B). Ambulatory clients do not require the assistance of a wheelchair to be evacuated (A). Elevators (C) should not be used during a fire and fire doors should be kept closed (D) to help contain the fire.

The nurse teaches the use of a gait belt to a male caregiver whose wife has right-sided weakness and needs assistance with ambulation. The caregiver performs a return demonstration of the skill. Which observation indicates that the caregiver has learned how to perform this procedure correctly? A. Standing on his wife's strong side, the caregiver is ready to hold the gait belt if any evidence of weakness is observed. B. Standing on his wife's weak side, the caregiver provides security by holding the gait belt from the back. C. Standing behind his wife, the caregiver provides balance by holding both sides of the gait belt. D. Standing slightly in front and to the right of his wife, the caregiver guides her forward by gently pulling on the gait belt.

Answer: B His wife is most likely to lean toward the weak side and needs extra support on that side and from the back (B) to prevent falling. (A, C, and D) provide less security for her.

A female nurse is assigned to care for a close friend, who says, "I am worried that friends will find out about my diagnosis." The nurse tells her friend that legally she must protect a client's confidentiality. Which resource describes the nurse's legal responsibilities? A. Code of Ethics for Nurses B. State Nurse Practice Act C. Patient's Bill of Rights D. ANA Standards of Practice

Answer: B The State Nurse Practice Act (B) contains legal requirements for the protection of client confidentiality and the consequences for breaches in confidentiality. (A) outlines ethical standards for nursing care but does not include legal guidelines. (C and D) describe expectations for nursing practice but do not address legal implications.

The nurse selects the best site for insertion of an IV catheter in the client's right arm. Which documentation should the nurse use to identify placement of the IV access? A. Left brachial vein B. Right cephalic vein C. Dorsal side of the right wrist D. Right upper extremity

Answer: B The cephalic vein is large and superficial and identifies the anatomic name of the vein that is accessed, which should be included in the documentation (B). The basilic vein of the arm is used for IV access, not the brachial vein (A), which is too deep to be accessed for IV infusion. Although veins on the dorsal side of the right wrist (C) are visible, they are fragile and using them would be painful, so they are not recommended for IV access. (D) is not specific enough for documenting the location of the IV access.

The nurse is instructing a client in the proper use of a metered-dose inhaler. Which instruction should the nurse provide the client to ensure the optimal benefits from the drug? A. "Fill your lungs with air through your mouth and then compress the inhaler." B. "Compress the inhaler while slowly breathing in through your mouth." C. "Compress the inhaler while inhaling quickly through your nose." D. "Exhale completely after compressing the inhaler and then inhale."

Answer: B The medication should be inhaled through the mouth simultaneously with compression of the inhaler (B). This will facilitate the desired destination of the aerosol medication deep in the lungs for an optimal bronchodilation effect. (A, C, and D) do not allow for deep lung penetration.

The nurse is counting a client's respiratory rate. During a 30-second interval, the nurse counts six respirations and the client coughs three times. In repeating the count for a second 30-second interval, the nurse counts eight respirations. Which respiratory rate should the nurse document? A. 14 B. 16 C. 17 D. 28

Answer: B The most accurate respiratory rate is the second count obtained by the nurse, which was not interrupted by coughing. Because it was counted for 30 seconds, the rate should be doubled (B). (A, C, and D) are inaccurate recordings.

A 65-year-old client who attends an adult daycare program and is wheelchair-mobile has redness in the sacral area. Which instruction is most important for the nurse to provide? A. Take a vitamin supplement tablet once a day. B. Change positions in the chair at least every hour. C. Increase daily intake of water or other oral fluids. D. Purchase a newer model wheelchair.

Answer: B The most important teaching is to change positions frequently (B) because pressure is the most significant factor related to the development of pressure ulcers. Increased vitamin and fluid intake (A and C) may also be beneficial promote healing and reduce further risk. (D) is an intervention of last resort because this will be very expensive for the client.

A seriously ill female client tells the nurse, "I am so tired and in so much pain! Please help me to die." Which is the best response for the nurse to provide? A. Administer the prescribed maximum dose of pain medication. B. Talk with the client about her feelings related to her own death. C. Collaborate with the health care provider about initiating antidepressant therapy. D. Refer the client to the ethics committee of her local health care facility.

Answer: B The nurse should first assess the client's feelings about her death and determine the extent to which this statement expresses her true feelings (B). The client may need additional pain management, but further assessment is needed before implementing (A). (C and D) are both premature interventions and should not be implemented until further assessment is obtained.

The nurse assesses a 2-year-old who is admitted for dehydration and finds that the peripheral IV rate by gravity has slowed, even though the venous access site is healthy. What should the nurse do next? A. Apply a warm compress proximal to the site. B. Check for kinks in the tubing and raise the IV pole. C. Adjust the tape that stabilizes the needle. D. Flush with normal saline and recount the drop rate.

Answer: B The nurse should first check the tubing and height of the bag on the IV pole (B), which are common factors that may slow the rate. Gravity infusion rates are influenced by the height of the bag, tubing clamp closure or kinks, needle size or position, fluid viscosity, client blood pressure (crying in the pediatric client), and infiltration. Venospasm can slow the rate and often responds to warmth over the vessel (A), but the nurse should first adjust the IV pole height. The nurse may need to adjust the stabilizing tape on a positional needle (C) or flush the venous access with normal saline (D), but less invasive actions should be implemented first.

Ten minutes after signing an operative permit for a fractured hip, an older client states, "The aliens will be coming to get me soon!" and falls asleep. Which action should the nurse implement next? A. Make the client comfortable and allow the client to sleep. B. Assess the client's neurologic status. C. Notify the surgeon about the comment. D. Ask the client's family to co-sign the operative permit.

Answer: B This statement may indicate that the client is confused. Informed consent must be provided by a mentally competent individual, so the nurse should further assess the client's neurologic status (B) to be sure that the client understands and can legally provide consent for surgery. (A) does not provide sufficient follow-up. If the nurse determines that the client is confused, the surgeon must be notified (C) and permission obtained from the next of kin (D).

The nurse observes a UAP taking a client's blood pressure in the lower extremity. Which observation of this procedure requires the nurse's intervention? A. The cuff wraps around the girth of the leg. B. The UAP auscultates the popliteal pulse with the cuff on the lower leg. C. The client is placed in a prone position. D. The systolic reading is 20 mm Hg higher than the blood pressure in the client's arm.

Answer: B When obtaining the blood pressure in the lower extremities, the popliteal pulse is the site for auscultation when the blood pressure cuff is applied around the thigh. The nurse should intervene with the UAP who has applied the cuff on the lower leg (B). (A) ensures an accurate assessment, and (C) provides the best access to the artery. Systolic pressure in the popliteal artery is usually 10 to 40 mm Hg higher (D) than in the brachial artery.

Which action should the nurse implement when providing wound care instructions to a client who does not speak English? A. Ask an interpreter to provide wound care instructions. B. Speak directly to the client, with an interpreter translating. C. Request the accompanying family member to translate. D. Instruct a bilingual employee to read the instructions.

Answer: B Wound care instructions should be given directly to the client by the nurse with an interpreter (B) who is trained to provide accurate and objective translation in the client's primary language, so that the client has the opportunity to ask questions during the teaching process. The interpreter usually does not have any health care experience, so the nurse must provide client teaching (A). Family members should not be used to translate instructions (C) because the client or family member may alter the instructions during conversation or be uncomfortable with the topics discussed. The employee should be a trained interpreter (D) to ensure that the nurse's instructions are understood accurately by the client.

The nurse is teaching an obese client, newly diagnosed with arteriosclerosis, about reducing the risk of a heart attack or stroke. Which health promotion brochure is most important for the nurse to provide to this client? A. "Monitoring Your Blood Pressure at Home" B. "Smoking Cessation as a Lifelong Commitment" C. "Decreasing Cholesterol Levels Through Diet" D. "Stress Management for a Healthier You"

Answer: C A health promotion brochure about decreasing cholesterol (C) is most important to provide this client, because the most significant risk factor contributing to development of arteriosclerosis is excess dietary fat, particularly saturated fat and cholesterol. (A) does not address the underlying causes of arteriosclerosis. (B and D) are also important factors for reversing arteriosclerosis but are not as important as lowering cholesterol (C).

A female client with frequent urinary tract infections (UTIs) asks the nurse to explain her friend's advice about drinking a glass of juice daily to prevent future UTIs. Which response is best for the nurse provide? A. Orange juice has vitamin C that deters bacterial growth. B. Apple juice is the most useful in acidifying the urine. C. Cranberry juice stops pathogens' adherence to the bladder. D. Grapefruit juice increases absorption of most antibiotics.

Answer: C Cranberry juice (C) maintains urinary tract health by reducing the adherence of Escherichia coli bacteria to cells within the bladder. (A, B, and D) have not been shown to be as effective as cranberry juice (C) in preventing UTIs.

When taking a client's blood pressure, the nurse is unable to distinguish the point at which the first sound was heard. Which is the best action for the nurse to take? A. Deflate the cuff completely and immediately reattempt the reading. B. Reinflate the cuff completely and leave it inflated for 90 to 110 seconds before taking the second reading. C. Deflate the cuff to zero and wait 30 to 60 seconds before reattempting the reading. D. Document the exact level visualized on the sphygmomanometer where the first fluctuation was seen.

Answer: C Deflating the cuff for 30 to 60 seconds (C) allows blood flow to return to the extremity so that an accurate reading can be obtained on that extremity a second time. (A) could result in a falsely high reading. (B) reduces circulation, causes pain, and could alter the reading. (D) is not an accurate method of assessing blood pressure.

Urinary catheterization is prescribed for a postoperative female client who has been unable to void for 8 hours. The nurse inserts the catheter, but no urine is seen in the tubing. Which action will the nurse take next? A. Clamp the catheter and recheck it in 60 minutes. B. Pull the catheter back 3 inches and redirect upward. C. Leave the catheter in place and reattempt with another catheter. D. Notify the health care provider of a possible obstruction.

Answer: C It is likely that the first catheter is in the vagina, rather than the bladder. Leaving the first catheter in place will help locate the meatus when attempting the second catheterization (C). The client should have at least 240 mL of urine after 8 hours. (A) does not resolve the problem. (B) will not change the location of the catheter unless it is completely removed, in which case a new catheter must be used. There is no evidence of a urinary tract obstruction if the catheter could be easily inserted (D).

One week after being told that she has terminal cancer with a life expectancy of 3 weeks, a female client tells the nurse, "I think I will plan a big party for all my friends." How should the nurse respond? A. "You may not have enough energy before long to hold a big party." B. "Do you mean to say that you want to plan your funeral and wake?" C. "Planning a party and thinking about all your friends sounds like fun." D. "You should be thinking about spending your last days with your family."

Answer: C Setting goals that bring pleasure are appropriate and should be encouraged by the nurse (C) as long as the nurse does not perpetuate a client's denial. (A) is a negative response, implying that the client should not plan a party. (B) puts words in the client's mouth that may not be accurate. The nurse should support the client's goals rather than telling the client how to spend her time (D).

A community hospital is opening a mental health services department. Which document should the nurse use to develop the unit's nursing guidelines? A. Americans with Disability Act of 1990 B. ANA Code of Ethics with Interpretative Statements C. ANA's Scope and Standards of Nursing Practice D. Patient's Bill of Rights of 1990

Answer: C The ANA Scope of Standards of Practice for Psychiatric-Mental Health Nursing (C) serves to direct the philosophy and standards of psychiatric nursing practice. (A and D) define the client's rights. (B) provides ethical guidelines for nursing.

A nurse stops at a motor vehicle collision site to render aid until the emergency personnel arrive and applies pressure to a groin wound that is bleeding profusely. Later the client has to have the leg amputated and sues the nurse for malpractice. Which is the most likely outcome of this lawsuit? A. The Patient's Bill of Rights protects clients from malicious intents, so the nurse could lose the case. B. The lawsuit may be settled out of court, but the nurse's license is likely to be revoked. C. There will be no judgment against the nurse, whose actions were protected under the Good Samaritan Act. D. The client will win because the four elements of negligence (duty, breach, causation, and damages) can be proved.

Answer: C The Good Samaritan Act (C) protects health care professionals who practice in good faith and provide reasonable care from malpractice claims, regardless of the client outcome. Although the Patient's Bill of Rights protects clients, this nurse is protected by the Good Samaritan Act (A). The state Board of Nursing has no reason to revoke a registered nurse's license (B) unless there was evidence that actions taken in the emergency were not done in good faith or that reasonable care was not provided. All four elements of malpractice were not shown (D).

When bathing an uncircumcised boy older than 3 years, which action should the nurse take? A. Remind the child to clean his genital area. B. Defer perineal care because of the child's age. C. Retract the foreskin gently to cleanse the penis. D. Ask the parents why the child is not circumcised.

Answer: C The foreskin (prepuce) of the penis should be gently retracted to cleanse all areas that could harbor bacteria (C). The child's cognitive development may not be at the level at which (A) would be effective. Perineal care needs to be provided daily regardless of the client's age (B). (D) is not indicated and may be perceived as intrusive.

An older adult who recently began self-administration of insulin calls the nurse daily to review the steps that should be taken when giving an injection. The nurse has assessed the client's skills during two previous office visits and knows that the client is capable of giving the daily injection. Which response by the nurse is likely to be most helpful in encouraging the client to assume total responsibility for the daily injections? A. "I know you are capable of giving yourself the insulin." B. "Giving yourself the injection seems to make you nervous." C. "When I watched you give yourself the injection, you did it correctly." D. "Tell me what you want me to do to help you give yourself the injection at home."

Answer: C The nurse needs to focus on the client's positive behaviors, so focusing on the client's demonstrated ability to self-administer the injection (C) is likely to reinforce his level of competence without sounding punitive. (A) does not focus on the specific behaviors related to giving the injection and could be interpreted as punitive. (B) uses reflective dialogue to assess the client's feelings, but telling the client that he is nervous may serve as a negative reinforcement of this behavior. (D) reinforces the client's dependence on the nurse.

The nurse who is preparing to give an adolescent client a prescribed antipsychotic medication notes that parental consent has not been obtained. Which action should the nurse take? A. Review the chart for a signed consent for hospitalization. B. Get the health care provider's permission to give the medication. C. Do not give the medication and document the reason. D. Complete an incident report and notify the parents.

Answer: C The nurse should not give the medication and should document the reason (C) because the client is a minor and needs a guardian's permission to receive medications. Permission to give medications is not granted by a signed hospital consent (A) or a health care provider's permission (B), unless conditions are met to justify coerced treatment. (D) is not necessary unless the medication had previously been administered.

After the nurse tells an older client that an IV line needs to be inserted, the client becomes very apprehensive, loudly verbalizing a dislike for all health care providers and nurses. How should the nurse respond? A. Ask the client to remain quiet so the procedure can be performed safely. B. Concentrate on completing the insertion as efficiently as possible. C. Calmly reassure the client that the discomfort will be temporary. D. Tell the client a joke as a means of distraction from the procedure.

Answer: C The nurse should respond with a calm demeanor (C) to help reduce the client's apprehension. After responding calmly to the client's apprehension, the nurse may implement (A, B, or D) to ensure safe completion of the procedure.

In completing a client's preoperative routine, the nurse finds that the operative permit is not signed. The client begins to ask more questions about the surgical procedure. Which action should the nurse take next? A. Witness the client's signature to the permit. B. Answer the client's questions about the surgery. C. Inform the surgeon that the operative permit is not signed and the client has questions about the surgery. D. Reassure the client that the surgeon will answer any questions before the anesthesia is administered.

Answer: C The surgeon should be informed immediately that the permit is not signed (C). It is the surgeon's responsibility to explain the procedure to the cliesxnt and obtain the client's signature on the permit. Although the nurse can witness an operative permit (A), the procedure must first be explained by the health care provider or surgeon, including answering the client's questions (B). The client's questions should be addressed before the permit is signed (D).

A client in a long-term care facility reports to the nurse that he has not had a bowel movement in 2 days. Which intervention should the nurse implement first? A. Instruct the caregiver to offer a glass of warm prune juice at mealtimes. B. Notify the health care provider and request a prescription for a large-volume enema. C. Assess the client's medical record to determine the client's normal bowel pattern. D. Instruct the caregiver to increase the client's fluids to five 8-ounce glasses per day.

Answer: C This client may not routinely have a daily bowel movement, so the nurse should first assess this client's normal bowel habits before attempting any intervention (C). (A, B, or D) may then be implemented, if warranted.

Which instruction is most important for the nurse to include when teaching a client with limited mobility strategies to prevent venous thrombosis? A. Perform cough and deep breathing exercises hourly. B. Turn from side to side in bed at least every 2 hours. C. Dorsiflex and plantarflex the feet 10 times each hour. D. Drink approximately 4 ounces of water every hour.

Answer: C To reduce the risk of venous thrombosis, the nurse should instruct the client in measures that promote venous return, such as dorsiflexion and plantar flexion (C). (A, B, and D) are helpful to prevent other complications of immobility but are less effective in preventing venous thrombus formation than (C).

The nurse is assisting a client to the bathroom. When the client is 5 feet from the bathroom door, he states, "I feel faint." Before the nurse can get the client to a chair, the client starts to fall. Which is the priority action for the nurse to take? A. Check the client's carotid pulse. B. Encourage the client to get to the toilet. C. In a loud voice, call for help. D. Gently lower the client to the floor.

Answer: D (D) is the most prudent intervention and is the priority nursing action to prevent injury to the client and the nurse. Lowering the client to the floor should be done when the client cannot support his own weight. The client should be placed in a bed or chair only when sufficient help is available to prevent injury. (A) is important but should be done after the client is in a safe position. Because the client is not supporting himself, (B) is impractical. (C) is likely to cause chaos on the unit and might alarm the other clients.

During a routine assessment, an obese 50-year-old female client expresses concern about her sexual relationship with her husband. Which is the best response by the nurse? A. Reassure the client that many obese people have concerns about sex. B. Remind the client that sexual relationships need not be affected by obesity. C. Determine the frequency of sexual intercourse. D. Ask the client to talk about specific concerns.

Answer: D (D) provides an opportunity for the client to verbalize her concerns and provides the nurse with more assessment data. (A and B) may not be related to her current concern, assume that obesity is the problem, and are communication blocks. (C) may be appropriate after discussing the concerns she is having.

A 20-year-old female client with a noticeable body odor has refused to shower for the last 3 days. She states, "I have been told that it is harmful to bathe during my period." Which action should the nurse take first? A. Accept and document the client's wish to refrain from bathing. B. Offer to give the client a bed bath, avoiding the perineal area. C. Obtain written brochures about menstruation to give to the client. D. Teach the importance of personal hygiene during menstruation with the client.

Answer: D Because a shower is most beneficial for the client in terms of hygiene, the client should receive teaching first (D), respecting any personal beliefs such as cultural or spiritual values. After client teaching, the client may still choose (A or B). Brochures reinforce the teaching (C).

A client's blood pressure reading is 156/94 mm Hg. Which action should the nurse take first? A. Tell the client that the blood pressure is high and that the reading needs to be verified by another nurse. B. Contact the health care provider to report the reading and obtain a prescription for an antihypertensive medication. C. Replace the cuff with a larger one to ensure an ample fit for the client to increase arm comfort. D. Compare the current reading with the client's previously documented blood pressure readings.

Answer: D Comparing this reading with previous readings (D) will provide information about what is normal for this client; this action should be taken first. (A) might unnecessarily alarm the client. (B) is premature. Further assessment is needed to determine if the reading is abnormal for this client. (C) could falsely decrease the reading and is not the correct procedure for obtaining a blood pressure reading.

When the health care provider diagnoses metastatic cancer and recommends a gastrostomy for an older female client in stable condition, the son tells the nurse that his mother must not be told the reason for the surgery because she "can't handle" the cancer diagnosis. Which legal principle is the court most likely to uphold regarding this client's right to informed consent? A. The family can provide the consent required in this situation because the older adult is in no condition to make such decisions. B. Because the client is mentally incompetent, the son has the right to waive informed consent for her. C. The court will allow the health care provider to make the decision to withhold informed consent under therapeutic privilege. D. If informed consent is withheld from a client, health care providers could be found guilty of negligence.

Answer: D Health care providers may be found guilty of negligence (D), specifically assault and battery, if they carry out a treatment without the client's consent. The client's condition is stable, so (A) is not a valid rationale. Advanced age does not automatically authorize the son to make all decisions for his mother, and there is no evidence that the client is mentally incompetent (B). Although (C) may have been upheld in the past, when paternalistic medical practice was common, today's courts are unlikely to accept it.

Which nursing diagnosis has the highest priority when planning care for a client with an indwelling urinary catheter? A. Self-care deficit B. Functional incontinence C. Fluid volume deficit D. High risk for infection

Answer: D Indwelling urinary catheters are a major source of infection (D). (A and B) are both problems that may require an indwelling catheter. (C) is not affected by an indwelling catheter.

The nurse transcribes the postoperative prescriptions for a client who returns to the unit following surgery and notes that an antihypertensive medication that was prescribed preoperatively is not listed. Which action should the nurse take? A. Consult with the pharmacist about the need to continue the medication. B. Administer the antihypertensive medication as prescribed preoperatively. C. Withhold the medication until the client is fully alert and vital signs are stable. D. Contact the health care provider to renew the prescription for the medication.

Answer: D Medications prescribed preoperatively must be renewed postoperatively, so the nurse should contact the health care provider if the antihypertensive medication is not included in the postoperative prescriptions (D). The pharmacist (A) does not prescribe medications or renew prescriptions. The nurse must have a current prescriptions before administering any medications (B and C).

Which serum laboratory value should the nurse monitor carefully for a client who has a nasogastric (NG) tube to suction for the past week? A. White blood cell count B. Albumin C. Calcium D. Sodium

Answer: D Monitoring serum sodium levels (D) for hyponatremia is indicated during prolonged NG suctioning because of loss of fluids. Changes in levels of (A, B, or C) are not typically associated with prolonged NG suctioning.

The nurse is preparing an older client for discharge. Which method is best for the nurse to use when evaluating the client's ability to perform a dressing change at home? A. Determine how the client feels about changing the dressing. B. Ask the client to describe the procedure in writing. C. Seek a family member's evaluation of the client's ability to change the dressing. D. Observe the client change the dressing unassisted.

Answer: D Observing the client directly (D) will allow the nurse to determine if mastery of the skill has been obtained and provide an opportunity to affirm the skill. (A) may be therapeutic but will not provide an opportunity to evaluate the client's ability to perform the procedure. (B) may be threatening to an older client and will not determine his ability. (C) is not as effective as direct observation by the nurse.

The nurse determines that a postoperative client's respiratory rate has increased from 18 to 24 breaths/min. Based on this assessment finding, which intervention is most important for the nurse to implement? A. Encourage the client to increase ambulation in the room. B. Offer the client a high-carbohydrate snack for energy. C. Force fluids to thin the client's pulmonary secretions. D. Determine if pain is causing the client's tachypnea.

Answer: D Pain, anxiety, and increasing fluid accumulation in the lungs (D) can cause tachypnea (increased respiratory rate). Encouraging (A) when the respiratory rate is rising above normal limits puts the client at risk for further oxygen desaturation. (B) can increase the client's carbon metabolism, so an alternative source of energy, such as Pulmocare liquid supplement, should be offered instead. (C) could increase respiratory congestion in a client with a poorly functioning cardiopulmonary system, placing the client at risk of fluid overload.

During a clinic visit, the mother of a 7-year-old reports to the nurse that her child is often awake until midnight playing and is then very difficult to awaken in the morning for school. Which assessment data should the nurse obtain in response to the mother's report? A. The occurrence of any episodes of sleep apnea B. The child's blood pressure, pulse, and respirations C. Length of rapid eye movement (REM) sleep that the child is experiencing D. Description of the family's home environment

Answer: D School-age children often resist bedtime. The nurse should begin by assessing the environment of the home (D) to determine factors that may not be conducive to the establishment of bedtime rituals that promote sleep. (A) often causes daytime fatigue rather than resistance to going to sleep. (B) is unlikely to provide useful data. The nurse cannot determine (C).

When performing sterile wound care in the acute care setting, the nurse obtains a bottle of normal saline from the bedside table that is labeled "opened" and dated 48 hours prior to the current date. Which is the best action for the nurse to take? A. Use the normal saline solution once more and then discard. B. Obtain a new sterile syringe to draw up the labeled saline solution. C. Use the saline solution and then relabel the bottle with the current date. D. Discard the saline solution and obtain a new unopened bottle.

Answer: D Solutions labeled as opened within 24 hours may be used for clean procedures, but only newly opened solutions are considered sterile. This solution is not newly opened and is out of date, so it should be discarded (D). (A, B, and C) describe incorrect procedures.

The mental health nurse plans to discuss a client's depression with the health care provider in the emergency department. There are two clients sitting across from the emergency department desk. Which nursing action is best? A. Only refer to the client by gender. B. Identify the client only by age. C. Avoid using the client's name. D. Discuss the client another time.

Answer: D The best nursing action is to discuss the client another time (D). Confidentiality must be observed at all times, so the nurse should not discuss the client when the conversation can be overheard by others. Details can identify the client when referring to the client by gender (A) or age (B), and even when not using the client's name (C).

The nurse is administering the 0900 medications to a client who was admitted during the night. Which client statement indicates that the nurse should further assess the medication order? A. "At home I take my pills at 8:00 am." B. "It costs a lot of money to buy all of these pills." C. "I get so tired of taking pills every day." D. "This is a new pill I have never taken before."

Answer: D The client's recognition of a "new" pill requires further assessment (D) to verify that the medication is correct, if it is a new prescription or a different manufacturer, or if the client needs further instruction. The time difference may not be as significant in terms of its effect, but this should be explained (A). Although comments about cost (B) should be considered when developing a discharge plan, (D) is a higher priority. The client's feelings (C) should be acknowledged, but observation of the five rights of medication administration is most essential.

The nurse is teaching a client how to perform progressive muscle relaxation techniques to relieve insomnia. A week later the client reports that he is still unable to sleep, despite following the same routine every night. Which action should the nurse take first? A. Instruct the client to add regular exercise as a daily routine. B. Determine if the client has been keeping a sleep diary. C. Encourage the client to continue the routine until sleep is achieved. D. Ask the client to describe the routine that the client is currently following.

Answer: D The nurse should first evaluate whether the client has been adhering to the original instructions (D). A verbal report of the client's routine will provide more specific information than the client's written diary (B). The nurse can then determine which changes need to be made (A). The routine practiced by the client is clearly unsuccessful, so encouragement alone is insufficient (C).

The nurse finds a client crying behind a locked bathroom door. The client will not open the door. Which action should the nurse implement first? A. Instruct an unlicensed assistive personnel (UAP) to stay and keep talking to the client. B. Sit quietly in the client's room until the client leaves the bathroom. C. Allow the client to cry alone and leave the client in the bathroom. D. Talk to the client and attempt to find out why the client is crying.

Answer: D The nurse's first concern should be for the client's safety, so an immediate assessment of the client's situation is needed (D). (A) is incorrect; the nurse should implement the intervention. The nurse may offer to stay nearby after first assessing the situation more fully (B). Although (C) may be correct, the nurse should determine if the client's safety is compromised and offer assistance, even if it is refused.

Which intervention is most important to include in the plan of care for a client at high risk for the development of postoperative thrombus formation? A. Instruct in the use of the incentive spirometer. B. Elevate the head of the bed during all meals. C. Use aseptic technique to change the dressing. D. Encourage frequent ambulation in the hallway.

Answer: D Thrombus (clot) formation can occur in the lower extremities of immobile clients, so the nurse should plan to encourage activities to increase mobility, such as frequent ambulation (D) in the hallway. (A) helps promote alveolar expansion, reducing the risk for atelectasis. (B) reduces the risk for aspiration. (C) reduces the risk for postoperative infection.

After receiving written and verbal instructions from a clinic nurse about a newly prescribed medication, a client asks the nurse what to do if questions arise about the medication after getting home. How should the nurse respond? A. Provide the client with a list of Internet sites that answer frequently asked questions about medications. B. Advise the client to obtain a current edition of a drug reference book from a local bookstore or library. C. Reassure the client that information about the medication is included in the written instructions. D. Encourage the client to call the clinic nurse or health care provider if any questions arise.

Answer: D To ensure safe medication use, the nurse should encourage the client to call the nurse or health care provider (D) if any questions arise. (A, B, and C) may all include useful information, but these sources of information cannot evaluate the nature of the client's questions and the follow-up needed.

55.A 4-year-old boy who is scheduled for a tonsillectomy and adenoidectomy asks the nurse, Will it hurt to have my tonsils and adenoids taken out? Which response is best for the nurse to provide? A. It may hurt a little because of the incision made in your throat. B. It won't hurt because you're such a big boy. C. It won't hurt because we put you to sleep. D. It may hurt but we'll give you medicine to help you feel better.

Answering questions simply and directly provides comfort for the preschool-age child and builds confidence in the health care team (D). (A) uses language (i.e. 'incision') that could create anxiety for the child. Four-year-olds are in the Initiative vs. Guilt stage (Erikson's psychosocial development), and (B) contributes to guilt when the child hurts. (C) is not helpful because the child may associate being put to sleep with the postoperative throat pain and then become fearful of going to sleep. Correct Answer: D

86.A healthcare provider is performing a sterile procedure at a client's bedside. Near the end of the procedure, the nurse observes the healthcare provider contaminate a sterile glove and the sterile field. What is the best action for the nurse to implement? A. Report the healthcare provider for the violation in aseptic technique. B. Allow the completion of the procedure. C. Ask if the glove and sterile field are contaminated. D. Identify the break in surgical asepsis and provide another set of sterile supplies.

Any possible break in surgical asepsis that is identified when others are unaware should be considered contaminated and new sterile supplies added to maintain the sterile field (D). Reporting the healthcare provider is not indicated (A). When sterility is suspect during aseptic technique, it should not be questioned (C) but all members of the team should move forward with reestablishing a sterile field. Allowing the procedure to progress under unsterile conditions (B) places the client at risk for infection and is an act of omission (negligence) by the nurse and other healthcare team members. Correct Answer: D

22.When preparing to administer an intravenous medication through a central venous catheter, the nurse aspirates a blood return in one of the lumens of the triple lumen catheter. Which action should the nurse implement? A. Flush the lumen with the saline solution and administer the medication through the lumen. B. Determine if a PRN prescription for a thrombolytic agent is listed on the medication record. C. Clamp the lumen and obtain a syringe of a dilute heparin solution to flush through the tubing. D. Withdraw the aspirated blood into the syringe and use a new syringe to administer the medication.

Aspiration of a blood return in the lumen of a central venous catheter indicates that the catheter is in place and the medication can be administered. The nurse should flush the tubing with the saline solution, administer the medication (A), then flush the lumen with saline again. (B and C) are not necessary. The aspirated blood can be flushed back through the closed system into the client's bloodstream, but does not need to be withdrawn (D). Correct Answer: A

A male client being discharged with a prescription for the bronchodilator theophylline tells the nurse that he understands he is to take three doses of the medication each day. Since, at the time of discharge, timed-release capsules are not available, which dosing schedule should the nurse advise the client to follow? A) 9 a.m., 1 p.m., and 5 p.m. B) 8 a.m., 4 p.m., and midnight. C) Before breakfast, before lunch and before dinner. D) With breakfast, with lunch, and with dinner.

B) 8 a.m., 4 p.m., and midnight Theophylline should be administered on a regular around-the-clock schedule (B) to provide the best bronchodilating effect and reduce the potential for adverse effects. (A, C, and D) do not provide around-the-clock dosing. Food may alter absorption of the medication (D).

What is the most important reason for starting intravenous infusions in the upper extremities rather than the lower extremities of adults? A) It is more difficult to find a superficial vein in the feet and ankles. B) A decreased flow rate could result in the formation of a thrombosis. C) A cannulated extremity is more difficult to move when the leg or foot is used. D) Veins are located deep in the feet and ankles, resulting in a more painful procedure

B) A decreased flow rate could result in the formation of a thrombosis Venous return is usually better in the upper extremities. Cannulation of the veins in the lower extremities increases the risk of thrombus formation (B) which, if dislodged, could be life-threatening. Superficial veins are often very easy (A) to find in the feet and legs. Handling a leg or foot with an IV (C) is probably not any more difficult than handling an arm or hand. Even if the nurse did believe moving a cannulated leg was more difficult, this is not the most important reason for using the upper extremities. Pain (D) is not a consideration

The nurse is assessing the nutritional status of several clients. Which client has the greatest nutritional need for additional intake of protein? A) A college-age track runner with a sprained ankle. B) A lactating woman nursing her 3-day-old infant. C) A school-aged child with Type 2 diabetes. D) An elderly man being treated for a peptic ulcer.

B) A lactating woman nursing her 3-day-old infant A lactating woman (B) has the greatest need for additional protein intake. (A, C, and D) are all conditions that require protein, but do not have the increased metabolic protein demands of lactation

On admission, a client presents a signed living will that includes a Do Not Resuscitate (DNR) prescription. When the client stops breathing, the nurse performs cardiopulmonary resuscitation (CPR) and successfully revives the client. What legal issues could be brought against the nurse? A) Assault. B) Battery. C) Malpractice. D) False imprisonment.

B) Battery Civil laws protect individual rights and include intentional torts, such as assault (an intentional threat to engage in harmful contact with another) or battery (unwanted touching). Performing any procedure against the client's wishes can potentially poise a legal issue, such as battery (B), even if the procedure is of questionable benefit to the client. (A, C, and D) are not examples against the client's request

A client who is a Jehovah's Witness is admitted to the nursing unit. Which concern should the nurse have for planning care in terms of the client's beliefs? A) Autopsy of the body is prohibited. B) Blood transfusions are forbidden. C) Alcohol use in any form is not allowed. D) A vegetarian diet must be followed

B) Blood transfusions are forbidden Blood transfusions are forbidden (B) in the Jehovah's Witness religion. Judaism prohibits (A). Buddhism forbids the use of (C) and drugs. Many of these sects are vegetarian (D), but the direct impact on nursing care is (B).

The nurse is teaching a client proper use of an inhaler. When should the client administer the inhaler-delivered medication to demonstrate correct use of the inhaler? A) Immediately after exhalation. B) During the inhalation. C) At the end of three inhalations. D) Immediately after inhalation

B) During the inhalation The client should be instructed to deliver the medication during the last part of inhalation (B). After the medication is delivered, the client should remove the mouthpiece, keeping his/her lips closed and breath held for several seconds to allow for distribution of the medication. The client should not deliver the dose as stated in (A or D), and should deliver no more than two inhalations at a time (C).

A client is receiving a cephalosporin antibiotic IV and complains of pain and irritation at the infusion site. The nurse observes erythema, swelling, and a red streak along the vessel above the IV access site. Which action should the nurse take at this time? A) Administer the medication more rapidly using the same IV site. B) Initiate an alternate site for the IV infusion of the medication. C) Notify the healthcare provider before administering the next dose. D) Give the client a PRN dose of aspirin while the medication infuses

B) Initiate an alternate site for the IV infusion of the medication A cephalosporin antibiotic that is administered IV may cause vessel irritation. Rotating the infusion site minimizes the risk of thrombophlebitis, so an alternate infusion site should be initiated (B) before administering the next dose. Rapid administration (A) of intravenous cephalosporins can potentiate vessel irritation and increase the risk of thrombophlebitis. (C) is not necessary to initiate an alternative IV site. Although aspirin has antiinflammatory actions, (D) is not indicated

Three days following surgery, a male client observes his colostomy for the first time. He becomes quite upset and tells the nurse that it is much bigger than he expected. What is the best response by the nurse? A) Reassure the client that he will become accustomed to the stoma appearance in time. B) Instruct the client that the stoma will become smaller when the initial swelling diminishes. C) Offer to contact a member of the local ostomy support group to help him with his concerns. D) Encourage the client to handle the stoma equipment to gain confidence with the procedure

B) Instruct the client that the stoma will become smaller when the initial swelling diminishes Postoperative swelling causes enlargement of the stoma. The nurse can teach the client that the stoma will become smaller when the swelling is diminished (B). This will help reduce the client's anxiety and promote acceptance of the colostomy. (A) does not provide helpful teaching or support. (C) is a useful action, and may be taken after the nurse provides pertinent teaching. The client is not yet demonstrating readiness to learn colostomy care (D).

Examination of a client complaining of itching on his right arm reveals a rash made up of multiple flat areas of redness ranging from pinpoint to 0.5 cm in diameter. How should the nurse record this finding? A) Multiple vesicular areas surrounded by redness, ranging in size from 1 mm to 0.5 cm. B) Localized red rash comprised of flat areas, pinpoint to 0.5 cm in diameter. C) Several areas of red, papular lesions from pinpoint to 0.5 cm in size. D) Localized petechial areas, ranging in size from pinpoint to 0.5 cm in diameter.

B) Localized red rash comprised of flat areas, pinpoint to 0.5 cm in diameter Macules are localized flat skin discolorations less than 1 cm in diameter. However, when recording such a finding the nurse should describe the appearance (B) rather than simply naming the condition. (A) identifies vesicles -- fluid filled blisters -- an incorrect description given the symptoms listed. (C) identifies papules -- solid elevated lesions, again not correctly identifying the symptoms. (D) identifies petechiae -- pinpoint red to purple skin discolorations that do not itch, again an incorrect identification

A young mother of three children complains of increased anxiety during her annual physical exam. What information should the nurse obtain first? A) Sexual activity patterns. B) Nutritional history. C) Leisure activities. D) Financial stressors

B) Nutritional history Caffeine, sugars, and alcohol can lead to increased levels of anxiety, so a nutritional history (C) should be obtained first so that health teaching can be initiated if indicated. (A and C) can be used for stress management. Though (D) can be a source of anxiety, a nutritional history should be obtained first

A female client with a nasogastric tube attached to low suction states that she is nauseated. The nurse assesses that there has been no drainage through the nasogastric tube in the last two hours. What action should the nurse take first? A) Irrigate the nasogastric tube with sterile normal saline. B) Reposition the client on her side. C) Advance the nasogastric tube an additional five centimeters. D) Administer an intravenous antiemetic prescribed for PRN use.

B) Reposition the client on her side The immediate priority is to determine if the tube is functioning correctly, which would then relieve the client's nausea. The least invasive intervention, (B), should be attempted first, followed by (A and C), unless either of these interventions is contraindicated. If these measures are unsuccessful, the client may require an antiemetic (D).

In developing a plan of care for a client with dementia, the nurse should remember that confusion in the elderly A) is to be expected, and progresses with age. B) often follows relocation to new surroundings. C) is a result of irreversible brain pathology. D) can be prevented with adequate sleep

B) often follows relocation to new surroundings Relocation (B) often results in confusion among elderly clients--moving is stressful for anyone. (A) is a stereotypical judgment. Stress in the elderly often manifests itself as confusion, so (C) is wrong. Adequate sleep is not a prevention (D) for confusion

47.What client statement indicates to the nurse that the client requires assistance with bathing? A. I wasn't able to pack a bag before I left for the hospital. B. I don't understand why I'm so weak and tired. C. I only bathe every other day. D. I left my eyeglasses at home.

Bathing often makes a client feel weak, and if a client is already feeling weak (B), assistance is required during the bathing process to ensure the client's safety. (A and C) do not pose safety issues. Although (D) may pose a safety issue, further assessment is needed to determine if this in fact poses a safety issue for the client. Correct Answer: B

The practical nurse (PN) identifies several findings in an older female who is on prolonged bed rest. Which finding requires prompt action by the PN?

Bowel movements decrease to one every third day.

Which response by a client with a nursing diagnosis of Spiritual distress, indicates to the nurse that a desired outcome measure has been met? A) Expresses concern about the meaning and importance of life B) Remains angry at God for the continuation of the illness. C) Accepts that punishment from God is not related to illness. D) Refuses to participate in religious rituals that have no meaning.

C) Accepts that punishment from God is not related to illness Acceptance that she is not being punished by God indicates a desired outcome (C) for some degree of resolution of spiritual distress. (A, B, and D) do not support the concept of grief, loss, and cultural/spiritual acceptance.

During a physical assessment, a female client begins to cry. Which action is best for the nurse to take? A) Request another nurse to complete the physical assessment. B) Ask the client to stop crying and tell the nurse what is wrong. C) Acknowledge the client's distress and tell her it is all right to cry. D) Leave the room so that the client can be alone to cry in private.

C) Acknowledge the client's distress and tell her it is all right to cry Acknowledging the client's distress and giving the client the opportunity to verbalize her distress (C) is a supportive response. (A, B, and D) are not supportive and do not facilitate the client's expression of feelings

A hospitalized male client is receiving nasogastric tube feedings via a small-bore tube and a continuous pump infusion. He reports that he had a bad bout of severe coughing a few minutes ago, but feels fine now. What action is best for the nurse to take? A) Record the coughing incident. No further action is required at this time. B) Stop the feeding, explain to the family why it is being stopped, and notify the healthcare provider. C) After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube. D) Inject 30 ml of air into the tube while auscultating the epigastrium for gurgling.

C) After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube Coughing, vomiting, and suctioning can precipitate displacement of the tip of the small bore feeding tube upward into the esophagus, placing the client at increased risk for aspiration. Checking the sample of fluid withdrawn from the tube (after clearing the tube with 30 ml of air) for acidic (stomach) or alkaline (intestine) values is a more sensitive method for these tubes, and the nurse should assess tube placement in this way prior to taking any other action (C). (A and B) are not indicated. The auscultating method (D) has been found to be unreliable for small-bore feeding tubes.

During a visit to the outpatient clinic, the nurse assesses a client with severe osteoarthritis using a goniometer. Which finding should the nurse expect to measure? A) Adequate venous blood flow to the lower extremities. B) Estimated amount of body fat by an underarm skinfold. C) Degree of flexion and extension of the client's knee joint. D) Change in the circumference of the joint in centimeters

C) Degree of flexion and extension of the client's knee joint The goniometer is a two-piece ruler that is jointed in the middle with a protractor-type measuring device that is placed over a joint as the individual extends or flexes the joint to measure the degrees of flexion and extension on the protractor (C). A doppler is used to measure blood flow (A). Calipers are used to measure body fat (B). A tape measure is used to measure circumference of body parts (D).

A client who has been NPO for 3 days is receiving an infusion of D5W 0.45 normal saline (NS) with potassium chloride (KCl) 20 mEq at 83 ml/hour. The client's eight-hour urine output is 400 ml, blood urea nitrogen (BUN) is 15 mg/dl, lungs are clear bilaterally, serum glucose is 120 mg/dl, and the serum potassium is 3.7 mEq/L. Which action is most important for the nurse to implement? A) Notify healthcare provider and request to change the IV infusion to hypertonic D10W. B) Decrease in the infusion rate of the current IV and report to the healthcare provider. C) Document in the medical record that these normal findings are expected outcomes. D) Obtain potassium chloride 20 mEq in anticipation of a prescription to add to present IV.

C) Document in the medical record that these normal findings are expected outcomes The results are all within normal range.(C) No changes are needed. (A,B, and D)

A resident in a skilled nursing facility for short-term rehabilitation after a hip replacement tells the nurse, "I don't want any more blood taken for those useless tests." Which narrative documentation should the nurse enter in the client's medical record? A) Healthcare provider notified of failure to collect specimens for prescribed blood studies. B) Blood specimens not collected because client no longer wants blood tests performed. C) Healthcare provider notified of client's refusal to have blood specimens collected for testing. D) Client irritable, uncooperative, and refuses to have blood collected. Healthcare provider notified

C) Healthcare provider notified of client's refusal to have blood specimens collected for testing When a client refuses a treatment, the exact words of the client regarding the client's refusal of care should be documented in a narrative format (C). (A, B, and D) do not address the concepts of informatics and legal issues

The nurse is instructing a client with high cholesterol about diet and life style modification. What comment from the client indicates that the teaching has been effective? A) If I exercise at least two times weekly for one hour, I will lower my cholesterol. B) I need to avoid eating proteins, including red meat. C) I will limit my intake of beef to 4 ounces per week. D) My blood level of low density lipoproteins needs to increase.

C) I will limit my intake of beef to 4 ounces per week Limiting saturated fat from animal food sources to no more than 4 ounces per week (C) is an important diet modification for lowering cholesterol. To be effective in reducing cholesterol, the client should exercise 30 minutes per day, or at least 4 to 6 times per week (A). Red meat and all proteins do not need to be eliminated (B) to lower cholesterol, but should be restricted to lean cuts of red meat and smaller portions (2-ounce servings). The low density lipoproteins (D) need to decrease rather than increase

The nurse is caring for a client who is receiving 24-hour total parenteral nutrition (TPN) via a central line at 54 ml/hr. When initially assessing the client, the nurse notes that the TPN solution has run out and the next TPN solution is not available. What immediate action should the nurse take? A) Infuse normal saline at a keep vein open rate. B) Discontinue the IV and flush the port with heparin. C) Infuse 10 percent dextrose and water at 54 ml/hr D) Obtain a stat blood glucose level and notify the healthcare provider.

C) Infuse 10 percent dextrose and water at 54 ml/hr TPN is discontinued gradually to allow the client to adjust to decreased levels of glucose. Administering 10% dextrose in water at the prescribed rate (C) will keep the client from experiencing hypoglycemia until the next TPN solution is available. The client could experience a hypoglycemic reaction if the current level of glucose (A) is not maintained or if the TPN is discontinued abruptly (B). There is no reason to obtain a stat blood glucose level (D) and the healthcare provider cannot do anything about this situation

When conducting an admission assessment, the nurse should ask the client about the use of complimentary healing practices. Which statement is accurate regarding the use of these practices? A) Complimentary healing practices interfere with the efficacy of the medical model of treatment. B) Conventional medications are likely to interact with folk remedies and cause adverse effects. C) Many complimentary healing practices can be used in conjunction with conventional practices. D) Conventional medical practices will ultimately replace the use of complimentary healing practices.

C) Many complimentary healing practices can be used in conjunction with conventional practices Conventional approaches to health care can be depersonalizing and often fail to take into consideration all aspects of an individual, including body, mind, and spirit. Often complimentary healing practices can be used in conjunction with conventional medical practices (C), rather than interfering (A) with conventional practices, causing adverse effects (B), or replacing conventional medical care (D).

The nurse assigns a UAP to obtain vital signs from a very anxious client. What instructions should the nurse give the UAP? A) Remain calm with the client and record abnormal results in the chart. B) Notify the medication nurse immediately if the pulse or blood pressure is low. C) Report the results of the vital signs to the nurse. D) Reassure the client that the vital signs are normal.

C) Report the results of the vital signs to the nurse. Interpretation of vital signs is the responsibility of the nurse, so the UAP should report vital sign measurements to the nurse (C). (A, B, and D) require the UAP to interpret the vital signs, which is beyond the scope of the UAP's authority

An unlicensed assistive personnel (UAP) places a client in a left lateral position prior to administering a soap suds enema. Which instruction should the nurse provide the UAP? A) Position the client on the right side of the bed in reverse Trendelenburg. B) Fill the enema container with 1000 ml of warm water and 5 ml of castile soap. C) Reposition in a Sim's position with the client's weight on the anterior ilium. D) Raise the side rails on both sides of the bed and elevate the bed to waist level.

C) Reposition in a Sim's position with the client's weight on the anterior ilium The left sided Sims' position allows the enema solution to follow the anatomical course of the intestines and allows the best overall results, so the UAP should reposition the client in the Sims' position, which distributes the client's weight to the anterior ilium (C). (A) is inaccurate. (B and D) should be implemented once the client is positioned

The nurse is evaluating client learning about a low-sodium diet. Selection of which meal would indicate to the nurse that this client understands the dietary restrictions? A) Tossed salad, low-sodium dressing, bacon and tomato sandwich. B) New England clam chowder, no-salt crackers, fresh fruit salad. C) Skim milk, turkey salad, roll, and vanilla ice cream. D) Macaroni and cheese, diet Coke, a slice of cherry pie.

C) Skim milk, turkey salad, roll, and vanilla ice cream Skim milk, turkey, bread, and ice cream (C), while containing some sodium, are considered low-sodium foods. Bacon (A), canned soups (B), especially those with seafood, hard cheeses, macaroni, and most diet drinks (D) are very high in sodium

A postoperative client will need to perform daily dressing changes after discharge. Which outcome statement best demonstrates the client's readiness to manage his wound care after discharge? The client A) asks relevant questions regarding the dressing change. B) states he will be able to complete the wound care regimen. C) demonstrates the wound care procedure correctly. D) has all the necessary supplies for wound care.

C) demonstrates the wound care procedure correctly A return demonstration of a procedure (C) provides an objective assessment of the client's ability to perform a task, while (A and B) are subjective measures. (D) is important, but is less of a priority prior to discharge than the nurse's assessment of the client's ability to complete the wound care

45.A 35-year-old female client with cancer refuses to allow the nurse to insert an IV for a scheduled chemotherapy treatment, and states that she is ready to go home to die. What intervention should the nurse initiate? A. Review the client's medical record for an advance directive. B. Determine if a do-not-resuscitate prescription has been obtained. C. Document that the client is being discharged against medical advice. D. Evaluate the client's mental status for competence to refuse treatment.

Competent clients have the right to refuse treatment, so the nurse should first ensure that the client is competent (D). (A and C) are not necessary for a competent client to refuse treatment. The nurse cannot document (C) until the healthcare provider is notified of the client's wishes and a discharge prescription is obtained. Correct Answer: D

The nurse notices that the mother of a 9 year old Vietnamese child always looks at the floor when she talks to the nurse. What action should the nurse take?

Continue asking the mother questions about the child.

11.Which statement best describes durable power of attorney for health care? A. The client signs a document that designates another person to make legally binding healthcare decisions if client is unable to do so. B. The healthcare decisions made by another person designated by the client are not legally binding. C. Instructions about actions to be taken in the event of a client's terminal or irreversible condition are not legally binding. D. Directions regarding care in the event of a terminal or irreversible condition must be documented to ensure that they are legally binding.

Correct Answer: A

15.A female client who has breast cancer with metastasis to the liver and spine is admitted with constant, severe pain despite around-the-clock use of oxycodone (Percodan) and amitriptyline (Elavil) for pain control at home. During the admission assessment, which information is most important for the nurse to obtain? A. Sensory pattern, area, intensity, and nature of the pain. B. Trigger points identified by palpation and manual pressure of painful areas. C. Schedule and total dosages of drugs currently used for breakthrough pain. D. Sympathetic responses consistent with onset of acute pain.

Correct Answer: A

12.A male client with an infected wound tells the nurse that he follows a macrobiotic diet. Which type of foods should the nurse recommend that the client select from the hospital menu? A. Low fat and low sodium foods. B. Combination of plant proteins to provide essential amino acids. C. Limited complex carbohydrates and fiber. D. Increased amount of vitamin C and beta carotene rich foods.

Correct Answer: B

7.A 73-year-old Hispanic client is seen at the community health clinic with a history of protein malnutrition. What information should the nurse obtain first? A. Amount of liquid protein supplements consumed daily. B. Foods and liquids consumed during the past 24 hours. C. Usual weekly intake of milk products and red meats. D. Grains and legume combinations used by the client.

Correct Answer: B

14.A female client informs the nurse that she uses herbal therapies to supplement her diet and manage common ailments. What information should the nurse offer the client about general use of herbal supplements? A. Most herbs are toxic or carcinogenic and should be used only when proven effective. B. There is no evidence that herbs are safe or effective as compared to conventional supplements in maintaining health. C. Herbs should be obtained from manufacturers with a history of quality control of their supplements. D. Herbal therapies may mask the symptoms of serious disease, so frequent medical evaluation is required during use.

Correct Answer: C

6.Which technique is most important for the nurse to implement when performing a physical assessment? A. A head-to-toe approach. B. The medical systems model. C. A consistent, systematic approach. D. An approach related to a nursing model.

Correct Answer: C

1.What is the rationale for using the nursing process in planning care for clients? A. As a scientific process to identify nursing diagnoses of a clients' healthcare problems. B. To establish nursing theory that incorporates the biopsychosocial nature of humans. C. As a tool to organize thinking and clinical decision making about clients' healthcare needs. D. To promote the management of client care in collaboration with other healthcare professionals.

Correct Answer: C)

13.A client with Raynaud's disease asks the nurse about using biofeedback for self-management of symptoms. What response is best for the nurse to provide? A. The responses to biofeedback have not been well established and may be a waste of time and money. B. Biofeedback requires extensive training to retrain voluntary muscles, not involuntary responses. C. Although biofeedback is easily learned, it is mostly often used to manage exacerbation of symptoms. D. Biofeedback allows the client to control involuntary responses to promote peripheral vasodilation.

Correct Answer: D

3.Which statement is an example of a correctly written nursing diagnosis statement? A. Altered tissue perfusion related to congestive heart failure. B. Altered urinary elimination related to urinary tract infection. C. Risk for impaired tissue integrity related to client's refusal to turn. D. Ineffective coping related to response to positive biopsy test results.

Correct Answer: D

8.The nurse formulates the nursing diagnosis of, "Ineffective health maintenance related to lack of motivation" for a client with Type 2 diabetes. Which finding supports this nursing diagnosis? A. Does not check capillary blood glucose as directed. B. Occasionally forgets to take daily prescribed medication. C. Cannot identify signs or symptoms of high and low blood glucose. D. Eats anything and does not think diet makes a difference in health.

Correct Answer: D

client expresses concern about being exposed to radiation therapy because it can cause cancer. What should the nurse emphasize when informing the client about exposure to radiation? 1 The dosage is kept at a minimum. 2 Only a small part of the body is irradiated. 3 The client's physical condition is not a risk factor. 4 Nutritional environment of the affected cells is a risk factor.

Current radiation therapy accurately targets malignant lesions with pinpoint precision, minimizing the detrimental effects of radiation to healthy tissue. The dose is not as significant as the extent of tissue being irradiated. When radiation therapy is prescribed, the health care provider takes into consideration the ability of the client to tolerate the therapy, determining that the benefit outweighs the risk. Nutritional environment of the affected cells does not influence radiation's effect.

The UAPs working on a chronic neuro unit ask the nurse to help them determine the safest way to transfer an elderly client with left-sided weakness from the bed to the chair. What method describes the correct transfer procedure for this client? A) Place the chair at a right angle to the bed on the client's left side before moving. B) Assist the client to a standing position, then place the right hand on the armrest. C) Have the client place the left foot next to the chair and pivot to the left before sitting. D) Move the chair parallel to the right side of the bed, and stand the client on the right foot

D) Move the chair parallel to the right side of the bed, and stand the client on the right foot (D) uses the client's stronger side, the right side, for weight-bearing during the transfer, and is the safest approach to take. (A, B, and C) are unsafe methods of transfer and include the use of poor body mechanics by the caregiver.

An elderly resident of a long-term care facility is no longer able to perform self-care and is becoming progressively weaker. The resident previously requested that no resuscitative efforts be performed, and the family requests hospice care. What action should the nurse implement first? A) Reaffirm the client's desire for no resuscitative efforts. B) Transfer the client to a hospice inpatient facility. C) Prepare the family for the client's impending death. D) Notify the healthcare provider of the family's request.

D) Notify the healthcare provider of the family's request The nurse should first communicate with the healthcare provider (D). Hospice care is provided for clients with a limited life expectancy, which must be identified by the healthcare provider. (A) is not necessary at this time. Once the healthcare provider supports the transfer to hospice care, the nurse can collaborate with the hospice staff and healthcare provider to determine when (B and C) should be implemented

An older client who is a resident in a long term care facility has been bedridden for a week. Which finding should the nurse identify as a client risk factor for pressure ulcers? A) Generalized dry skin. B) Localized dry skin on lower extremities. C) Red flush over entire skin surface. D) Rashes in the axillary, groin, and skin fold regions

D) Rashes in the axillary, groin, and skin fold regions Immobility, constant contact with bed clothing, and excessive heat and moisture in areas where air flow is limited contributes to bacterial and fungal growth, which increases the risk for rashes (D), skin breakdown, and the development of pressure ulcers. (A, B, and C) do not address the concepts of inflammation and tissue integrity

The nurse is performing nasotracheal suctioning. After suctioning the client's trachea for fifteen seconds, large amounts of thick yellow secretions return. What action should the nurse implement next? A) Encourage the client to cough to help loosen secretions. B) Advise the client to increase the intake of oral fluids. C) Rotate the suction catheter to obtain any remaining secretions. D) Re-oxygenate the client before attempting to suction again.

D) Re-oxygenate the client before attempting to suction again Suctioning should not be continued for longer than ten to fifteen seconds, since the client's oxygenation is compromised during this time (D). (A, B, and C) may be performed after the client is re-oxygenated and additional suctioning is performed.

A female client asks the nurse to find someone who can translate into her native language her concerns about a treatment. Which action should the nurse take? A) Explain that anyone who speaks her language can answer her questions. B) Provide a translator only in an emergency situation. C) Ask a family member or friend of the client to translate. D) Request and document the name of the certified translator.

D) Request and document the name of the certified translator A certified translator should be requested to ensure the exchanged information is reliable and unaltered. To adhere to legal requirements in some states, the name of the translator should be documented (D). Client information that is translated is private and protected under HIPAA rules, so (A) is not the best action. Although an emergency situation may require extenuating circumstances (B), a translator should be provided in most situations. Family members may skew information and not translate the exact information, so (C) is not preferred.

An Arab-American woman, who is a devout traditional Muslim, lives with her married son's family, which includes several adult children and their children. What is the best plan to obtain consent for surgery for this client? A) Obtain an interpreter to explain the procedure to the client. B) Encourage the client to make her own decision regarding surgery. C) Ask the family members to provide an interpretation of the surgeon's explanation to the client. D) Tell the surgeon that the son will decide after explanation of the proposed surgery is provided.

D) Tell the surgeon that the son will decide after explanation of the proposed surgery is provided Traditional Muslim women live in a patriarchal family where decisions are made by men. Most likely, the son will make the decision for his mother, so (D) provides the surgeon with culturally sensitive information. (A) may be necessary if a language barrier exists, but the son is the patriarch in the client's family at this time. It is culturally insensitive to encourage the woman to go against her religious and cultural worldview, as in (B). Family members are more likely to misinterpret medical information, but the son should be the primary decision-maker for his mother (C).

Which nutritional assessment data should the nurse collect to best reflect total muscle mass in an adolescent? A) Height in inches or centimeters. B) Weight in kilograms or pounds. C) Triceps skin fold thickness. D) Upper arm circumference.

D) Upper arm circumference Upper arm circumference (D) is an indirect measure of muscle mass. (A and B) do not distinguish between fat (adipose) and muscularity. (C) is a measure of body fat.

76.In assessing a client's femoral pulse, the nurse must use deep palpation to feel the pulsation while the client is in a supine position. What action should the nurse implement? A. Elevate the head of the bed and attempt to palpate the site again. B. Document the presence and volume of the pulse palpated. C. Use a thigh cuff to measure the blood pressure in the leg. D. Record the presence of pitting edema in the inguinal area.

Deep palpation may be required to palpate the femoral pulse; and, when palpated, the nurse should document the presence and volume of the pulse (B). The site is best palpated with the client supine; elevation of the head of the bed requires even deeper palpation (A). The use of deep palpation to feel the femoral pulse does not indicate a problem requiring further assessment, such as (C), and does not reflect the presence of edema (D). Correct Answer: B

70.The home health nurse visits an elderly client who lives at home with her husband. The client is experiencing frequent episodes of diarrhea and bowel incontinence. Which problem, for which the client is at risk, has the greatest priority when planning the client's care? A. Disturbed sleep pattern. B. Caregiver role strain. C. Impaired skin integrity. D. Fluid volume imbalance.

Diarrhea can lead to fluid volume loss, which is potentially life-threatening, so the highest priority is to prevent a fluid volume imbalance (D). Diarrhea and bowel incontinence can also lead to (A, B, and C), but these are of less potential harm than a fluid volume deficit. Correct Answer: D

62.A client provides the nurse with information about the reason for seeking care. The nurse realizes that some information about past hospitalizations is missing. How should the nurse obtain this information? A. Solicit information on hospitalization from the insurance company. B. Look up previous medical records from archived hospital documents. C. Ask the client to discuss previous hospitalizations in the last 5 years. D. Elicit specific facts about past hospitalizations with direct questions.

Direct questions should be used after the client's opening narrative to fill in any details that have been left out or during the review of systems to elicit specific facts (D) about past health problems. (A and B) are time consuming, and may require the client's permission to access information about other hospitalizations. (C) may not produce the specific data needed. Correct Answer: D

The nurse is teaching a client proper use of an inhaler. When should the client administer the inhaler-delivered medication to demonstrated correct use of the inhaler?

During the inhalation.

56.A female nurse who sometimes tries to save time by putting medications in her uniform pocket to deliver to clients, confides that after arriving home she found a hydrocodone (Vicoden) tablet in her pocket. Which possible outcome of this situation should be the nurse's greatest concern? A. Accused of diversion. B. Reported for stealing. C. Reported for a HIPAA violation. D. Accused of unprofessional conduct.

Even if this is only one incident, the nurse may be suspected of taking medications on a regular basis and the incident could be interpreted as diversion (A), or diverting narcotics for her own use, which should be reported to the peer review committee and to the State Board of Nursing. (B, C, and D) are also of concern, but (A) is the most serious possible outcome. Correct Answer: A

The practical nurse (PN) obtains an elevated blood pressure reading for an older male client who is alert. When the PN offers the client his morning blood pressure medication, he refuses to take it. What action should the PN take?

Explain the importance of routine use of antihypertensives.

For several days after her husband's death, a client who is admitted with acute depression repeats over and over, I should have made him go to the doctor when he said he didn't feel well. Which descriptor should the practical nurse use to document the client's feedings?

Guilt.

A male Native American client with tuberculosis is visiting a health care clinic for follow up treatment. During the interview, the practical nurse (PN) notices that the client keeps his eyes on the floor and does not make eye contact. How should the PN interpret this client's behavior?

His culture finds sustained eye contact rude or disrespectful.

33.A client has a nursing diagnosis of, "Spiritual distress related to a loss of hope, secondary to impending death." What intervention is best for the nurse to implement when caring for this client? A. Help the client to accept the final stage of life. B. Assist and support the client in establishing short-term goals. C. Encourage the client to make future plans, even if they are unrealistic. D. Instruct the client's family to focus on positive aspects of the client's life.

Hopefulness is necessary to sustain a meaningful existence, even close to death. The nurse should help the client set short-term goals, and recognize the achievement of immediate goals (B), such as seeing a family member, or listening to music. (A) is too vague to be a helpful intervention. (C) does not help the client deal with this nursing diagnosis. (D) might be implemented, but does not have the priority of (B). Correct Answer: B

38.The nurse encounters resistance when inserting the tubing into a client's rectum for a tap water enema. What action should the nurse implement? A. Withdraw the tube and apply additional lubricant to the tube. B. Encourage the client to bear down and continue to insert the tube. C. Remove the tube and check the client for a fecal impaction. D. Ask the client to relax and run a small amount of fluid into the rectum.

If resistance is encountered during the initial insertion of an enema tube, the client should be instructed to relax while a small amount of solution runs through the tube into the rectum (D) to promote dilation. (A) is unlikely to resolve the problem. (B) may cause injury. (C) should not be implemented until other, less invasive actions, such as (D) have been taken. Correct Answer: D

26.In evaluating client care, which action should the nurse take first? A. Determine if the expected outcomes of care were achieved. B. Review the rationales used as the basis of nursing actions. C. Document the care plan goals that were successfully met. D. Prioritize interventions to be added to the client's plan of care.

In evaluating care, the nurse should first determine if the expected outcomes of the plan of care were achieved (A). As indicated, the nurse may then review the initial nursing actions and the rationales for those actions (B), document successful completion of the care plan goals (C), and revise the plan of care (D). Correct Answer: A

The nurse determines that a client's body weight is 105% above teh standardized height-weight scale. Which related factor should the nurse include in the nursing diagnosis, "Imbalanced nutrition: more than body requirements?

Inadequate lifestyle changes in diet and exercise.

A client who had abdominal surgery is receiving patient-controlled analgesia (PCA) intravenously to manage pain. The pump is programmed to deliver a basal dose and bolus doses that can be accessed by the client with a lock-out time frame of 10 minutes. The nurse assesses use of the pump during the last hour and identifies that the client attempted to self-administer the analgesic 10 times. Further assessment reveals that the client is experiencing pain still. What should the nurse do first? 1 Monitor the client's pain level for another hour. 2 Determine the integrity of the intravenous delivery system. 3 Reprogram the pump to deliver a bolus dose every eight minutes. 4 Arrange for the client to be evaluated by the health care provider.

Initially, integrity of the intravenous system should be verified to ensure that the client is receiving medication. The intravenous tubing may be kinked or compressed, or the catheter may be dislodged. Continued monitoring will result in the client experiencing unnecessary pain. The nurse may not reprogram the pump to deliver larger or more frequent doses of medication without a health care provider's prescription. The health care provider should be notified if the system is intact and the client is not obtaining relief from pain. The prescription may have to be revised; the basal dose may be increased, the length of the delay may be reduced, or another medication or mode of delivery may be prescribed.

74.A client is admitted to the hospital with intractable pain. What instruction should the nurse provide the unlicensed assistive personnel (UAP) who is preparing to assist this client with a bed bath? A. Take measures to promote as much comfort as possible. B. Report any signs of drug addiction to the nurse immediately. C. Wait until the client's pain is gone before assisting with personal care. D. This client's pain will be difficult to manage, since the cause is unknown.

Intractable pain is highly resistant to pain relief measures, so it is important to promote comfort (A) during all activities. A client with intractable pain may develop drug tolerance and dependence, but (B) is inappropriate for a UAP. Since intractable pain is resistant to relief measures, (C) may not be possible. Psychogenic pain (D) is a painful sensation that is perceived but has no known cause. Correct Answer: A

29.A male nurse is assigned to care for a female Muslim client. When the nurse offers to bathe the client, the client requests that a female nurse perform this task. How should the male nurse respond? A. May I ask your daughter to help you with your personal hygiene? B. I will ask one of the female nurses to bathe you. C. A staff member on the next shift will help you. D. I will keep you draped and hand you the supplies as you need them.

Many female Muslim clients are very modest and prefer to receive personal care from another female because of their religious and cultural beliefs. The most culturally sensitive response is for the male nurse to ask a female colleague to perform this task (B). (A and D) are less respectful of the client's cultural and spiritual preferences. (C) delays the client's care. Correct Answer: B

83.While caring for a child and mother from Cambodia, what action should the nurse implement to accommodate the clients' cultural needs? A. Speak initially with the oldest family member to show respect. B. Realize that Southeast Asians may not take Western medications. C. Ask the husband to step out during the mother's pelvic examination. D. Tell the family that planning health care is provided in private with the client.

Members of the Asian culture have high respect for others, especially those in positions of authority. Extended family members need to be included in the nursing care plan (A). Southeast Asians do not necessarily refuse Western medications (B). Asians also believe that touching strangers is not acceptable, particularly health professionals whom they have not previously known, so the husband should be allowed to remain with his wife during the pelvic exam (C). Provided that the presence of other family members is not harmful to the client's well-being, (D) is not correct. Correct Answer: A

A nurse is reviewing studies to answer a clinical question as part of an evidence-based practice project. The study design determines the level of evidence. Place each methodology in order from the most reliable to the least reliable. Correct 1. Meta-analysis 2. Randomized controlled trial 3. Expert opinion based on scientific principles 4. Cohort study 5. Controlled trial without randomization

Meta-analysis is a synthesis of evidence from associated randomized controlled trials. Meta-analysis is more reliable than a randomized controlled trial. Randomized controlled trials are studies where subjects randomly are assigned to a treatment or control group. A randomized control trial is more reliable than a controlled trial without randomization. Controlled trials without randomization are studies in which subjects are assigned nonrandomly to a treatment or control group. A controlled trial without randomization is more reliable than a cohort study. Cohort studies observe a group to determine the development of an outcome. Expert opinion based on principles is not based on actual evidence; it is relied on when there is no evidence from research. Topics

A client reports fatigue and dyspnea and appears pale. The nurse questions the client about medications currently being taken. In light of the symptoms, which medication causes the nurse to be most concerned? 1 Famotidine (Pepcid) 2 Methyldopa (Aldomet) 3 Ferrous sulfate (Feosol) 4 Levothyroxine (Synthroid)

Methyldopa is associated with acquired hemolytic anemia and should be discontinued to prevent progression and complications. Famotidine will not cause these symptoms; it decreases gastric acid secretion, which will decrease the risk of gastrointestinal bleeding. Ferrous sulfate is an iron supplement to correct, not cause, symptoms of anemia. Levothyroxine is not associated with red blood cell destruction.

The nurse observes that a male client has removed the covering from an ice pack applied to his knee. Which action should the nurse take first?

Observe the appearance of the skin under the ice pack.

A client reports feeling dizzy and lightheaded when moving from a supine position to a sitting position. What is the practical nurse's priority intervention?

Obtain orthostatic blood pressures.

The healthcare provider prescribes a cleansing enema for an adult prior to bowel surgery. Which intervention(s) should the practical nurse implement to ensure adequate bowel cleansing? (Select all that apply)

Place the client on the left side in Sim's position. Use enema fluid that is near 105 F (40.4 C). Instill 500 mL to 1,000 mL fluids slowly. Raise the enema container 20 inches above anus. Encourage the client to retain fluid 10 to 15 minutes.

While taking an adult's vital signs, the practical nurse (PN) notes an irregular radial pulse, What action should the PN implement to obtain the most accurate assessment?

Preform an apical-radial pulse assessment with another nurse.

A client with cancer who has been taking opioid analgesics for two years now requires increased doses to obtain pain relief. he client expresses fear about becoming addicted to these drugs. What information should the practical nurse (PN) provide?

Prescribed opiates for cancer pain relief improve quality of life.

69.On the third postoperative day following thoracic surgery, a client reports feeling constipated. Which intervention should the nurse implement to promote bowel elimination? A. Remind the client to turn every two hours while lying in bed. B. Provide warm prune juice before the client goes to bed at night. C. Teach the client to splint the incision while walking to the bathroom. D. Administer an analgesic before the client attempts to defecate.

Prune juice is a natural laxative that stimulates peristalsis, and warming the prune juice (B) facilitates peristalsis. (A) is also helpful in promoting peristalsis but is less likely to relieve the client's constipation. (C) reduces discomfort during ambulation, but will not help relieve the client's constipation. Defecation is not painful following most surgeries, and many analgesics used postoperatively cause constipation, so (D) is contraindicated. Correct Answer: B

Which growth and developmental characteristic should the practical nurse (PN) consider when discussing spirituality with an adolescent client?

Questions religious practices and values.

A female client asks the nurse to find someone who can translate into her native language her concerns about a treatment. Which action should the nurse take?

Request and document the name of the certified translator.

The client is receiving a continuous tube feeding. While checking the gastric residual volume, the practical nurse (PN) aspirates 150 mL of gastric contents. What action should the PN take?

Return all the aspirated contents to the stomach followed with water and consult the agency policy.

Which information should the practical nurse provide a client who is selecting a site for self-injection of insulin?

Rotate sites within the same location for a week before choosing a new location.

When documenting assessment data, which statement should the nurse record in the narrative nursing notes?

S1 murmur auscultated in supine position: Objective data

51.The home health nurse visits an elderly female client who had a brain attack three months ago and is now able to ambulate with the assistance of a quad cane. Which assessment finding has the greatest implications for this client's care? A. The husband, who is the caregiver, begins to weep when the nurse asks how he is doing. B. The client tells the nurse that she does not have much of an appetite today. C. The nurse notes that there are numerous scatter rugs throughout the house. D. The client's pulse rate is 10 beats higher than it was at the last visit one week ago.

Scatter rugs (C) pose a safety hazard because the client can trip on them when ambulating, so this finding has the greatest significance in planning this client's care. Psychological support of the caregiver (A) is a less acute need than that of client safety. The nurse needs to obtain more information about (B), but this is not a safety issue. (D) is not a significant increase, and additional assessment might provide information about the reason for the increase (anxiety, exercise, etc.). Correct Answer: C

52.The nurse removes the dressing on a client's heel that is covering a pressure sore one-inch in diameter and finds that there is straw-colored drainage seeping from the wound. What description of this finding should the nurse include in the client's record? A. Stage 1 pressure sore draining sero-sanguineous drainage. B. Pressure sore at bony prominence with exudate noted. C. One-inch pressure sore draining serous fluid. D. Pressure sore on heel with a small amount of purulent drainage.

Serous drainage is clear watery plasma, so (C) provides accurate documentation based on the information provided. Information to stage this pressure score (A) is not provided, and sero-sanguineous drainage is pale and watery with a combination of plasma and red cells, and may be blood-streaked. Exudate (B) is fluid such as pus and serum. Purulent drainage (D) is thick, yellow, green, or brown indicating the presence of dead or living organisms and white blood cells. Correct Answer: C

A nurse takes a female client to the examination room and asks her to remove her clothes and put on an examination gown with the front open. The woman states "I have special undergarments that I do not remove for religious reasons." How should the nurse respond?

Tell me about your undergarments so we can discuss how you can have your examination comfortably.

49.When caring for an immobile client, what nursing diagnosis has the highest priority? A. Risk for fluid volume deficit. B. Impaired gas exchange. C. Risk for impaired skin integrity. D. Altered tissue perfusion.

The ABCs of caring for clients are airway, breathing, and circulation. Impaired gas exchange (B) implies that the client is having trouble with breathing, which has the highest priority of the nursing diagnoses listed. Though an immobilized client presents a multitude of nursing care challenges, (A, C, and D) do not have the priority of (B). Correct Answer: B

25.Which nursing intervention is most beneficial in reducing the risk of urosepsis in a hospitalized client with an indwelling urinary catheter? A. Ensure that the client's perineal area is cleansed twice a day. B. Maintain accurate documentation of the fluid intake and output. C. Encourage frequent ambulation if allowed or regular turning if on bedrest. D. Obtain a prescription for removal of the catheter as soon as possible.

The best intervention to reduce the risk for urosepsis (spread of an infectious agent from the urinary tract to systemic circulation) is removal of the urinary catheter as quickly as possible (D). (A, B, and C) are helpful to reduce the risk of infection, but are of less priority than (D) in reducing the risk of urosepsis. Correct Answer: D

57.A signed consent form indicated a client should have an electromyogram, but a myelogram was performed instead. Though the myelogram revealed the cause of the client's back pain, which was subsequently treated, the client filed a lawsuit against the nurse and healthcare provider for performing the incorrect procedure. The court is likely to rule in favor of the plaintiff because these events represent what infraction? A. A quasi-intentional tort because a similar mistake can happen to anyone. B. Failure to respect client autonomy to choose based on intentional tort law. C. Assault and battery with deliberate intent to deviate from the consent form. D. An unintentional tort because the client benefited from having the myelogram.

The client was not properly informed of the procedure, and failure to obtain informed consent constitutes assault and battery (C). (A) is injury to economics and dignity, such as invasion of privacy or defamation of character. This is not an incident of failure to respect the client's autonomy (B). An unintentional tort (D) is an act in which the outcome was not expected, such as negligence or malpractice. Correct Answer: C

The practical nurse (PN) is assessing a client with dark skin who is in respiratory distress. Which client response should the PN evaluate to determine cyanosis in this client?

The lips and mucous membranes of a client with dark skin are dusky in color.

32.A male client has a nursing diagnosis of "spiritual distress." What intervention is best for the nurse to implement when caring for this client? A. Use distraction techniques during times of spiritual stress and crisis. B. Reassure the client that his faith will be regained with time and support. C. Consult with the staff chaplain and ask that the chaplain visit with the client. D. Use reflective listening techniques when the client expresses spiritual doubts.

The most beneficial nursing intervention is to use nonjudgmental reflective listening techniques, to allow the client to feel comfortable expressing his concerns (D). (A and B) are not therapeutic. The client should be consulted before implementing (C). Correct Answer: D

27.Prior to administering a newly prescribed medication to a client, the nurse reviews the adverse effects of the medication listed in a drug reference guide and determines the priority risks to the client. While performing this action, the nurse is engaged in which step of the nursing process? A. Assessment. B. Analysis. C. Implementation. D. Evaluation.

The nurse is analyzing (B) data to establish an individualized nursing diagnosis, such as, "Risk for injury related to side effects of drugs." This analysis is based on assessment (A) and guides the planning and implementation (C) of care, such as the decision to monitor the client frequently. (D) provides the nurse with information about the effectiveness of the plan of care. Correct Answer: B

34.The nurse overhears the healthcare provider explaining to the client that the tumor removed was non-malignant and that the client will be fine. However, the nurse has read in the pathology report that the tumor was malignant and that there is extensive metastasis. Who should the nurse consult with first regarding the situation? A. Healthcare provider. B. Client's family. C. Case manager. D. Chief of staff.

The nurse should address the healthcare provider with the written report and discuss why he/she did not tell the client the truth--this may be at the family's request (A). (B, C, and D) may be indicated, but first the nurse should confer with the healthcare provider to obtain all needed information. Correct Answer: A

58.A nurse observes a student nurse taking a copy of a client's medication administration record. When questioned, the student states, Another student is scheduled to administer medications for this client tomorrow, so I am going to make a copy to help my friend prepare for tomorrow's clinical. What response should the nurse provide first? A. Ask the nursing supervisor to meet with the students. B. Notify the student's clinical instructor of the situation. C. Ask the student if permission was obtained from the client. D. Explain that the records are hospital property and may not be removed.

The nurse should deal with the issue immediately and explain that a client's records are the property of the hospital and cannot be removed (D), even with the client's permission (C). Next, the clinical instructor should be notified (B)so that all students can be educated regarding copying and removing clinical records from the healthcare agency. The nursing supervisor (A) should also be alerted to ensure appropriate supervision of students as well as protection of client information. Correct Answer: D

35.A single mother of two teenagers, ages 16 and 18, was just told that she has advanced cancer. She is devastated by the news, and expresses her concern about who will care for her children. Which statement by the nurse is likely to be most helpful at this time? A. Your children are old enough to help you make decisions about their futures. B. The social worker can tell you about placement alternatives for your children. C. Tell me what you would like to see happen with your children in the future. D. You have just received bad news, and you need some time to adjust to it.

The nurse should first assess what the client desires (C). (A) is somewhat judgmental and attempts to solve the problem for the client without eliciting the client's feelings. Though a referral to the social worker (B) may be indicated, the nurse should first offer support. Time is likely to help the client cope with this news (D), but the nurse should first provide support and assess what the client wants to see happen with her children. Correct Answer: C

59.An older female client with rheumatoid arthritis is complaining of severe joint pain that is caused by the weight of the linen on her legs. What action should the nurse implement first? A. Apply flannel pajamas to provide warmth. B. Administer a PRN dose of ibuprofen. C. Perform range of motion exercises in a warm tub. D. Drape the sheets over the footboard of the bed.

The nurse should first provide an immediate comfort measure to address the client's complaint about the linens and drape the linens over the footboard of the bed (D) instead of tucking them under the mattress, which can add pressure perceived by the client as the source of her pain. (A, B, and C) may be components of the client's plan of care, but the nurse should first address the client's complaint. Correct Answer: D

28.The nurses determines a client's IV solution is infusing at 250 ml/hr. The prescribed rate is 125 ml/hr. What action should the nurse take first? A. Determine when the IV solution was started. B. Slow the IV infusion to keep vein open rate. C. Assess the IV insertion site for swelling. D. Report the finding to the healthcare provider.

The nurse should first slow the IV flow rate to keep vein open (KVO) rate (B) to prevent further risk of fluid volume overload, then gather additional assessment data, such as when the IV solution was started (A) and the appearance of the IV insertion site (C) before contacting the healthcare provider (D) for further instructions. Correct Answer: B

72.A client who has been on bedrest for several days now has a prescription to progress activity as tolerated. When the nurse assists the client out of bed for the first time, the client becomes dizzy. What action should the nurse implement? A. Encourage the client to take several slow, deep breaths while ambulating. B. Help the client to remain standing by the bedside until the dizziness is relieved. C. Instruct the client to remain on bedrest until the healthcare provider is contacted. D. Advise the client to sit on the side of the bed for a few minutes before standing again.

The nurse should implement (D), because orthostatic hypotension is a common result of immobilization, causing the client to feel dizzy when first getting out of bed following a period of bedrest. To prevent this problem, it is helpful to have the body acclimate to a standing position by sitting upright for a short period (D) before rising to a standing position. (A) is unlikely to alleviate the dizziness. (B) may result in a loss of consciousness. (C) is not indicated and will increase the potential for complications associated with prolonged immobility. Correct Answer: D

20.The nurse is preparing a male client who has an indwelling catheter and an IV infusion to ambulate from the bed to a chair for the first time following abdominal surgery. What action(s) should the nurse implement prior to assisting the client to the chair? (Select all that apply.) A. Pre-medicate the client with an analgesic. B. Inform the client of the plan for moving to the chair. C. Obtain and place a portable commode by the bed. D. Ask the client to push the IV pole to the chair. E. Clamp the indwelling catheter. F. Assess the client's blood pressure.

The nurse should plan to implement (A, B, D, and F). Pre-medicating the client with an analgesic (A) reduces the client's pain during mobilization and maximizes compliance. To ensure the client's cooperation and promote independence, the nurse should inform the client about the plan for moving to the chair (B) and encourage the client to participate by pushing the IV pole when walking to the chair (D). The nurse should assess the client's blood pressure (F) prior to mobilization, which can cause orthostatic hypotension. (C and E) are not indicated. Correct Answer: A, B, D, F

68.Before administering a client's medication, the nurse assesses a change in the client's condition and decides to withhold the medication until consulting with the healthcare provider. After consultation with the healthcare provider, the dose of the medication is changed and the nurse administers the newly prescribed dose an hour later than the originally scheduled time. What action should the nurse implement in response to this situation? A. Notify the charge nurse that a medication error occurred. B. Submit a medication variance report to the supervisor. C. Document the events that occurred in the nurses' notes. D. Discard the original medication administration record.

The nurse took the correct action and should document the events that occurred in the nurses' notes (C). (A) did not occur and (B) is not indicated. The medication administration record is part of the client's medical record and should be placed in the chart, (D) when no longer current. Correct Answer: C

88.What action should the nurse implement to prevent the formation of a sacral ulcer for a client who is immobile? A. Maintain in a lateral position using protective wrist and vest devices. B. Position prone with a small pillow below the diaphragm. C. Raise the head and knee gatch when lying in a supine position. D. Transfer into a wheelchair close to the nurse's station for observation.

The prone position (B) using a small pillow below the diaphragm maintains alignment and provides the best pressure relief over the sacral bony prominence. Using protective (restraining) devices (A) is not indicated. Raising the head and bed gatch (C) may reduce shearing forces due to sliding down in bed, but it interferes with venous return from the legs and places pressure on the sacrum, predisposing to ulcer formation. Sitting in a wheelchair (D) places the body weight over the ischial tuberosities and predisposes to a potential pressure point. Correct Answer: B

The nurse assesses a client's pulse and documents the strength of the pulse as 3+. The nurse understands that this indicates the pulse is: 1 faint, barely detectable. 2 slightly weak, palpable. 3 normal. 4 bounding.

The strength of a pulse is a measurement of the force at which blood is ejected against the arterial wall. Palpation should be done using the fingertips and intensity of the pulse graded on a scale of 0 to 4 + with 0 indicating no palpable pulse, 1 + indicating a faint, but detectable pulse, 2 + suggesting a slightly more diminished pulse than normal, 3 + is a normal pulse, and 4 + indicating a bounding pulse.

44.A client is admitted with a stage four pressure ulcer that has a black, hardened surface and a light-pink wound bed with a malodorous green drainage. Which dressing is best for the nurse to use first? A. Hydrogel. B. Exudate absorber. C. Wet to moist dressing. D. Transparent adhesive film.

To provide moisture and loosen the necrotic tissue, the eschar should be covered first with wet to moist dressings (C), which are discontinued and then a hydrogel alginate can be placed in the prepared wound bed to prevent further damage of granulating any surrounding tissue. Although a hydrogel (A) liquefies necrotic tissue of slough and rehydrates the wound bed, it does not address wicking the purulent drainage from the wound. Exudate absorbers (B) provide a moist wound surface, absorb exudate, and support debridement, but do not prepare the wound bed for proper healing. Transparent dressings (D) are used to protect against contamination and friction while maintaining a clean moist surface. Correct Answer: C

85.What action should the nurse implement when adding sterile liquids to a sterile field? A. Use an outdated sterile liquid if the bottle is sealed and has not been opened. B. Consider the sterile field contaminated if it becomes wet during the procedure. C. Remove the container cap and lay it with the inside facing down on the sterile field. D. Hold the container high and pour the solution into a receptacle at the back of the sterile field.

Wet or damp areas on a sterile field allow organisms to wick from the table surface and permeate into the sterile area, so the field is considered contaminated if it becomes wet (B). Outdated liquids may be contaminated and should be discarded, not used (A). The container's cap should be removed, placed facing up, and off the sterile field, not (C). To prevent contamination of the sterile field, liquids should be held close (6 inches) to the receptacle when pouring to prevent splashing, and the receptacle should be placed near the front edge to avoid reaching over or across the sterile field (D). Correct Answer: B

82.While the nurse is administering a bolus feeding to a client via nasogastric tube, the client begins to vomit. What action should the nurse implement first? A. Discontinue the administration of the bolus feeding. B. Auscultate the client's breath sounds bilaterally. C. Elevate the head of the bed to a high Fowler's position. D. Administer a PRN dose of a prescribed antiemetic.

When a client receiving a tube feeding begins to vomit, the nurse should first stop the feeding (A) to prevent further vomiting. (C) should then be implemented to reduce the risk of aspiration. After that, (B and D) can be implemented as indicated. Correct Answer: A

66.A 75-year-old client who has a history of end stage renal failure and advanced lung cancer, recently had a stroke. Two days ago the healthcare provider discontinued the client's dialysis treatments, stating that death is inevitable, but the client is disoriented and will not sign a DNR directive. What is the priority nursing intervention? A. Review the client's most recent laboratory reports. B. Refer the client and family members for hospice care. C. Notify the hospital ethics committee of the client situation. D. Determine who is legally empowered to make decisions.

When death is impending, it is essential for the nurse to determine who is legally empowered to make decisions regarding the use of life-saving measures for the client (D). (A) will be abnormal and will worsen without dialysis, so are not of immediate concern. (B) may help improve the client's quality of life prior to death, but is of less immediacy than determining whether actions should be taken to save a client's life. If the nurse remains unable to determine who is empowered to make decisions in this situation, the nurse may choose to contact the ethics committee (C) for a resolution. Correct Answer: D

60.A male client with venous incompetence stands up and his blood pressure subsequently drops. Which finding should the nurse identify as a compensatory response? A. Bradycardia. B. Increase in pulse rate. C. Peripheral vasodilation. D. Increase in cardiac output.

When postural hypotension occurs, the body attempts to restore arterial pressure by stimulating the baro-receptors to increase the heart rate (B), not decrease it (A). Peripheral vasoconstriction, not dilation (C), of the veins and arterioles occurs with venous incompetence through the baro-receptor reflex. A decrease in cardiac output, not an increase (D), occurs when orthostatic hypotension occurs. Correct Answer: B

An older male client who is incontinent receives a prescription for a condom catheter. Which step(s) should the practical nurse implement when applying the external catheter? (select all that apply)

Wrap the adhesive strip in a spiral around the penis. Apply skin prep to the penile shaft and allow to dry. Leave 1 to 2 inches between the tip of the penis and condom catheter.

75.A male client arrives at the outpatient surgery center for a scheduled needle aspiration of the knee. He tells the nurse that he has already given verbal consent for the procedure to the healthcare provider. What action should the nurse implement? A. Witness the client's signature on the consent form. B. Verify the client's consent with the healthcare provider. C. Notify the healthcare provider that the client is ready for the procedure. D. Document that the client has given consent for the needle aspiration.

Written informed consent is required prior to any invasive procedure. The healthcare provider must explain the procedure to the client, but the nurse can witness the client's signature on a consent form (A). (B) is not necessary since written consent must be obtained. (C) is not correct because written consent has not been obtained. (D) must occur after written consent is obtained. Correct Answer: A

In developing a plan of care for a client with dementia, the nurse should remember that confusion in the elderly

often follows relocation to new surroundings.

Which action should the practical nurse (PN) implement when administering a subcutaneous injection to a client who weighs 325 pounds?

select a needle with a longer shaft.

A client has a nursing diagnosis of Altered sleep patterns related to nocturia. Which client instruction is important for the nurse to provide? A. Decrease intake of fluids after the evening meal. B. Drink a glass of cranberry juice every day. C. Drink a glass of warm decaffeinated beverage at bedtime. D. Consult the health care provider about a sleeping pill.

Answer: A Nocturia is urination during the night. (A) is helpful to decrease the production of urine, thus decreasing the need to void at night. (B) helps prevent bladder infections. (C) may promote sleep, but the fluid will contribute to nocturia. (D) may result in urinary incontinence if the client is sedated and does not awaken to void.

An elderly male client who suffered a cerebral vascular accident is receiving tube feedings via a gastrostomy tube. The nurse knows that the best position for this client during administration of the feedings is A) prone. B) Fowler's. C) Sims'. D) supine

B) Fowler's The client should be positioned in a semi-sitting (Fowler's) (B) position during feeding to decrease the occurrence of aspiration. A gastrostomy tube, known as a PEG tube, due to placement by a percutaneous endoscopic gastrostomy procedure, is inserted directly into the stomach through an incision in the abdomen for long-term administration of nutrition and hydration in the debilitated client. In (A and/or C), the client is placed on the abdomen, an unsafe position for feeding. Placing the client in (D) increases the risk of aspiration

When assisting an 82-year-old client to ambulate, it is important for the nurse to realize that the center of gravity for an elderly person is the A) Arms. B) Upper torso. C) Head. D) Feet

B) Upper torso The center of gravity for adults is the hips. However, as the person grows older, a stooped posture is common because of the changes from osteoporosis and normal bone degeneration, and the knees, hips, and elbows flex. This stooped posture results in the upper torso (B) becoming the center of gravity for older persons. Although (A) is a part, or an extension of the upper torso, this is not the best and most complete answer.

An older female states that the medication tablet brought in a cup looks different from the tablet that she takes at home. Which action should the practical nurse (PN) take?

Check the written prescription to verify the medication.

Which intervention should the practical nurse (PN) implement to reduce the incidence of urinary tract infections in a client with an indwelling catheter?

Cleanse perineum area with soap and water BID and PRN.

A client whose diet is low in fiber is at risk for which condition?

Colon cancer.

9.Which statement correctly identifies a written learning objective for a client with peripheral vascular disease? A. The nurse will provide client instruction for daily foot care. B. The client will demonstrate proper trimming toenail technique. C. Upon discharge, the client will list three ways to protect the feet from injury. D. After instruction, the nurse will ensure the client understands foot care rationale.

Correct Answer: C

17.To obtain the most complete assessment data for a client with chronic pain, which information should the nurse obtain? A. Can you describe where your pain is the most severe? B. What is your pain intensity on a scale of 1 to 10? C. Is your pain best described as aching, throbbing, or sharp? D. Which activities during a routine day are impacted by your pain?

Correct Answer: D

19.The nurse is discussing dietary preferences with a client who adheres to a vegan diet. Which dietary supplement should the nurse encourage the client to include the dietary plan? A. Fiber. B. Folate. C. Ascorbic acid. D. Vitamin B12.

Correct Answer: D

2.What activity should the nurse use in the evaluation phase of the nursing process? A. Ask a client to evaluate the nursing care provided. B. Document the nursing care plan in the progress notes. C. Determine whether a client's health problems have been alleviated. D. Examine the effectiveness of nursing interventions toward meeting client outcomes.

Correct Answer: D

42.The nurse notes that a client consistently coughs while eating and drinking. Which nursing diagnosis is most important for the nurse include in this client's plan of care? A. Ineffective breathing pattern. B. Impaired gas exchange. C. Risk for aspiration. D. Ineffective airway clearance.

Coughing during or after meals is a manifestation of dysphagia, or difficulty swallowing, which places the client at risk for aspiration (C). Dysphagia can lead to aspiration pneumonia, but the client is not currently exhibiting any symptoms of breathing difficulty (A) or impaired gas exchange (B). Although (D) may be related to an ineffective cough, the client's coughing is an effective response when solids or liquids are taken orally. Correct Answer: C

At the beginning of the shift, the nurse assesses a client who is admitted from the post-anesthesia care unit (PACU). When should the nurse document the client's findings? A) At the beginning, middle, and end of the shift. B) After client priorities are identified for the development of the nursing care plan. C) At the end of the shift so full attention can be given to the client's needs. D) Immediately after the assessments are completed

D) Immediately after the assessments are completed Documentation should occur immediately after any component of the nursing process, so assessments should be entered in the client's medical record as readily as findings are obtained (D). (A, B, and C) do not address the concepts of legal recommendations for information management and informatics.

The nurse notices that the Hispanic parents of a toddler who returns from surgery offer the child only the broth that comes on the clear liquid tray. Other liquids, including gelatin, popsicles, and juices, remain untouched. What explanation is most appropriate for this behavior? A) The belief is held that the "evil eye" enters the child if anything cold is ingested. B) After surgery the child probably has refused all foods except broth. C) Eating broth strengthens the child's innate energy called "chi." D) Hot remedies restore balance after surgery, which is considered a "cold" condition.

D) Hot remedies restore balance after surgery, which is considered a "cold" condition Common parental practices and health beliefs among Hispanic, Chinese, Filipino, and Arab cultures classify diseases, areas of the body, and illnesses as "hot" or "cold" and must be balanced to maintain health and prevent illness. The perception that surgery is a "cold" condition implies that only "hot" remedies, such as soup, should be used to restore the healthy balance within the body, so (D) is the correct interpretation. (A, B, and C) are not correct interpretations of the noted behavior. "Chi" is a Chinese belief that an innate energy enters and leaves the body via certain locations and pathways and maintains health. The "evil eye," or "mal ojo," is believed by many cultures to be related to the balance of health and illness but is unrelated to dietary practice.

A male client tells the nurse that he does not know where he is or what year it is. What data should the nurse document that is most accurate? A) demonstrates loss of remote memory. B) exhibits expressive dysphasia. C) has a diminished attention span. D) is disoriented to place and time.

D) is disoriented to place and time The client is exhibiting disorientation (D). (A) refers to memory of the distant past. The client is able to express himself without difficulty (B), and does not demonstrate a diminished attention span (C).

Which assessment should the practical nurse (PN) make to best evaluate a client's fluid status?

Daily body weight.

The nurse is caring for a client who is unable to void. The plan of care establishes an objective for the client to ingest 1000ml of fluid between 7am and 3pm. Which client response should the nurse document that indicates a sucessful outcome?

Drinks 240ml of fluid five times during the shift.

A family member of a dying client asks the practical nurse (PN) if the client knows the family is at the bedside. The PN explains that which of the five senses persists the longest during the dying process?

Hearing

The nurse is preparing to administer a high volume saline enema to a client. Which information is most important for the nurse to obtain prior to administering the enema?

History of inflammatory bowel disorder scrymptoms: diarhhea, hematuria, perforation

Which action should the practical nurse (PN) implement to help a male client cope with his fear as he approaches death?

Hold the client's hand and tell him he is not alone.

84.Which client care requires the nurse to wear barrier gloves as required by the protocol for Standard Precautions? A. Removing the empty food tray from a client with a urinary catheter. B. Washing and combing the hair of a client with a fractured leg in traction. C. Administering oral medications to a cooperative client with a wound infection. D. Emptying the urinary catheter drainage bag for a client with Alzheimer's disease.

Possible contact with body secretions, excretions, or broken skin is an indication for wearing barrier (nonsterile) gloves. Emptying a urine drainage bag requires the use of gloves (D). (A, B, and C) do not require gloves. Correct Answer: D

An 80 year old male client who has arthritis and is having difficulty walking, tells the practical nurse (PN), "It's awful to be old, It seems as thought every day is a struggle. No one cares about an old person." What is the best response for the PN to provide?

It sounds as though you're having a difficult time. Tell me about it.

A client is taking lithium sodium (Lithium). The nurse should notify the health care provider for which of the following laboratory values? 1 White blood cell (WBC) count of 15,000 mm3 2 Negative protein in the urine 3 Blood urea nitrogen (BUN) of 20 mg/dL 4 Prothrombin of 12.0 seconds

1 White cell counts can increase with this drug. The expected range of the WBC count is 5000 to 10,000 mm3 for a healthy adult. Urinalysis, BUN, and prothrombin are not necessary and these are normal values.

The practical nurse (PN) is preparing an intramuscular injection for a client who is 5 feet tall and weighs 90 pounds. Which needle size should the PN select for a 3 mL syringe when using the IM ventrogluteal injection site?

1-inch.

Which technique should the practical nurse (PN) use to most accurately assess a client's baseline blood pressure during a routine health examination?

Measure the pressure in each arm while the client sits with the arm supported at heart level.

A health care provider prescribes 500 mg of an antibiotic intravenous piggyback (IVPB) every 12 hours. The vial of antibiotic contains 1 g and indicates that the addition of 2.5 mL of sterile water will yield 3 mL of reconstituted solution. How many milliliters of the antibiotic should be added to the 50 mL IVPB bag? Record your answer using one decimal place. __ mL

1.5

When evaluating a client's plan of care, the nurse determines that a desired outcome was not achieved. Which action will the nurse implement first?

Note which actions were not implemented.

To ensure the safety of a client who is receiving a continuous intravenous normal saline infusion, the nurse should change the administration set every: 1 4 to 8 hours 2 12 to 24 hours 3 24 to 48 hours 4 72 to 96 hours

4 Best practice guidelines recommend replacing administration sets no more frequently than 72 to 96 hours after initiation of use in patients not receiving blood, blood products, or fat emulsions. This evidence-based practice is safe and cost effective. Changing the administration set every 4 to 48 hours is not a cost-effective practice

A dying client is coping with feelings regarding impending death. The nurse bases care on the theory of death and dying by Kübler-Ross. During which stage of grieving should the nurse primarily use nonverbal interventions? 1 Anger 2 Denial 3 Bargaining 4 Acceptance

4 Communication and interventions during the acceptance stage are mainly nonverbal (e.g., holding the client's hand). The nurse should be quiet but available. During the anger stage the nurse should accept that the client is angry. The anger stage requires verbal communication. During the denial stage the nurse should accept the client's behavior but not reinforce the denial. The denial stage requires verbal communication. During the bargaining stage the nurse should listen intently but not provide false reassurance. The bargaining stage requires verbal communication.

An intravenous piggyback (IVPB) of cefazolin (Kefzol) 500 mg in 50 mL of 5% dextrose in water is to be administered over a 20-minute period. The tubing has a drop factor of 15 drops/mL. At what rate per minute should the nurse regulate the infusion to run? Record the answer using a whole number. ______ gtts/min Solve the problem by using the following formula: Drops per minute = total number of drops / total time in minutes Drops per minute = 50 mL x 15 (drop factor) / 20 mintes = 750 / 20 = 37.5. Round the answer to 38 drops per minute.

38 Solve the problem by using the following formula: Drops per minute = total number of drops / total time in minutes Drops per minute = 50 mL x 15 (drop factor) / 20 mintes = 750 / 20 = 37.5. Round the answer to 38 drops per minute

The spouse of a comatose client who has severe internal bleeding refuses to allow transfusions of whole blood because they are Jehovah's Witnesses. The client does not have a Durable Power of Attorney for Healthcare. What action should the nurse take? 1 Institute the prescribed blood transfusion because the client's survival depends on volume replacement. 2 Clarify the reason why the transfusion is necessary and explain the implications if there is no transfusion. 3 Phone the health care provider for an administrative prescription to give the transfusion under these circumstances. 4 Give the spouse a treatment refusal form to sign and notify the health care provider that a court order now can be sought

4 The client is unconscious. Although the spouse can give consent, there is no legal power to refuse a treatment for the client unless previously authorized to do so by a power of attorney or a health care proxy; the court can make a decision for the client. Explanations will not be effective at this time and will not meet the client's needs. Instituting the prescribed blood transfusion and phoning the health care provider for an administrative prescription are without legal basis, and the nurse may be held liable.

Which nursing activities are examples of primary prevention? Select all that apply. 1 Preventing disabilities 2 Correcting dietary deficiencies 3 Establishing goals for rehabilitation 4 Assisting with immunization programs 5 t

4,5 Immunization programs prevent the occurrence of disease and are considered primary interventions. Stopping smoking prevents the occurrence of disease and is considered a primary intervention. Preventing disabilities is a tertiary intervention. Correcting dietary deficiencies is a secondary intervention. Establishing goals for rehabilitation is a tertiary intervention.

An older male client tells the practical nurse (PN) that his religion does not permit him to bathe daily. How should the PN respond?

Request that the client clarify his religious beliefs about bathing.

After completing an assessment and determining that a client has a problem, which action should the nurse perform next? A) Determine the etiology of the problem. B) Prioritize nursing care interventions. C) Plan appropriate interventions. D) Collaborate with the client to set goals.

A) Determine the etiology of the problem Before planning care, the nurse should determine the etiology, or cause, of the problem (A), because this will help determine (B, C, and D).

A client's indwelling urinary catheter is removed at 9:30 AM. The practical nurse (PN) assesses the client every two hours for the desire to void. Which documented assessment requires further intervention by the PN?

5:30 pm: unable to void.

A male client being discharged with a prescription for the bronchodilator theophylline tells the nurse that he understands he is to take three doses of the medication each day. Since, at the time of discharge, timed-release capsules are not available, which dosing schedule should the nurse advise the client to follow?

8am, 4pm, 1200 midnight. q 8hrs

67.The charge nurse assigns a nursing procedure to a new staff nurse who has not previously performed the procedure. What action is most important for the new staff nurse to take? A. Review the steps in the procedure manual. B. Ask another nurse to assist while implementing the procedure. C. Follow the agency's policy and procedure. D. Refuse to perform the task that is beyond the nurse's experience.

According to states' nurse practice acts, it is the responsibility of the nurse to function within the scope of competency (D), and in this case safe nursing practice constitutes refusal to perform the procedure because of a lack of experience. Although state mandates, agency policies, and continued education and experience identify tasks that are within the scope of nursing practice, nurses should first refuse to perform tasks that are beyond their proficiency, and then pursue opportunities to enhance their competency (A, B, and C). Correct Answer: D

A client who has a pressure-relieving mattress overlay is mobilized to a chair and imprints of the clients buttocks, heels, and scapula are evident on the mattress overlay. What action should the practical nurse implement?

Apply a different pressure relieving device and assess its effectiveness for this client.

Seconal 0.1 gram PRN at bedtime is prescribed to a client for rest. The scored tablets are labeled grain 1.5 per tablet. How many tablets should the nurse plan to administer? A) 0.5 tablet. B) 1 tablet. C) 1.5 tablets. D) 2 tablets.

B) 1 tablet 15 gr=1 Gm. Converting the prescribed dose of 0.1 grams to grains requires multiplying 0.1 × 15 = 1.5 grains. The tablets come in 1.5 grains, so the nurse should plan to administer 1 tablet (B).

The healthcare provider prescribes furosemide (Lasix) 15 mg IV stat. On hand is Lasix 20 mg/2 ml. How many milliliters should the nurse administer? A) 1 ml. B) 1.5 ml. C) 1.75 ml. D) 2 ml.

B) 1.5 ml

The nurse is caring for a client who is the daughter of a local politician. When the nurse approaches a man who is reading the names on the hall doors, he identifies himself as a reporter for the local newspaper and requests information about the client's status. Which standard of nursing practice should the nurse use to respond?

Confidentiality

The practical nurse (PN) identifies a client's need for spiritual support. What is the first action the PN should take?

Determine the client's perceptions and belief system.

80.While preparing to insert a rectal suppository in a male adult client, the nurse observes that the client is holding his breath while bearing down. What action should the nurse implement? A. Advise the client to continue to bear down without holding his breath. B. Gently insert the lubricated suppository four inches into the rectum. C. Perform a digital exam to determine if a fecal impaction is present. D. Instruct the client to take slow deep breaths and stop bearing down.

During administration of a rectal suppository, the client is asked to take slow deep breaths through the mouth to relax the anal sphincter (D). Bearing down (A) will push the suppository out of the rectum, so the suppository should not be inserted while the client is bearing down (B). Further data is needed before performing an invasive digital exam to check for fecal impaction (C). Correct Answer: D

In planning care for an older client on bed rest, which intervention should the practical nurse include in the prevention of pressure ulcers?

Elevate the head of the bed less that 30 degrees.

Which intervention should the practical nurse (PN) implement to help a client cope effectively with chronic pain?

Encourage using relaxation techniques.

A client with acute hemorrhagic anemia is to receive four units of packed RBC's (red blood cells) as rapidly as possible. Which intervention is most important for the nurse to implement?

Ensure the accuracy of the blood type match.

An older client who is admitted to the hospital with dehydration and electrolyte imbalance is confused and incontinent of urine. Which action provides the best strategy for the practical nurse (PN) to implement for the client's incontinence?

Establish a 2-hour voiding schedule.

When irrigating the external ear canals of an older adult client, which action should the practical nurse (PN) use to soften dry cerumen for removal?

Instill mineral oil in the external auditory canal overnight before irrigation.

The practical nurse (PN) is providing wound care for a client with a stage III pressure ulcer on the left heel. To achieve the goal, and increase in granulation tissue development within two weeks, which intervention should the PN implement?

Irrigate wound with sterile normal saline.

23.Which client assessment data is most important for the nurse to consider before ambulating a postoperative client? A. Respiratory rate. B. Wound location. C. Pedal pulses. D. Pain rating.

Mobilization and ambulation increase oxygen use, so it is most important to assess the client's respiratory rate (A)before ambulation to determine tolerance for activity. (B, C, and D) are also important, but are of lower priority than (A). Correct Answer: A

71.After a client has been premedicated for surgery with an opioid analgesic, the nurse discovers that the operative permit has not been signed. What action should the nurse implement? A. Notify the surgeon that the consent form has not been signed. B. Read the consent form to the client before witnessing the client's signature. C. Determine if the client's spouse is willing to sign the consent form. D. Administer an opioid antagonist prior to obtaining the client's signature.

Once a client has been premedicated for surgery with any type of sedative, legal informed consent is not possible, so the nurse must notify the surgeon (A). (B, C, and D) are not legally viable options for ensuring informed consent. Correct Answer: A

64.A low-sodium, low-protein diet is prescribed for a 45-year-old client with renal insufficiency and hypertension, who gained 3 pounds in the last month. The nurse determines that the client has been noncompliant with the diet, based on which report from the 24-hour dietary recall? (Select all that apply.) A. Snack of potato chips, and diet soda. B. Lunch of tuna fish sandwich, carrot sticks, fresh fruit, and coffee. C. Breakfast of eggs, bacon, toast, and coffee. D. Dinner of vegetable lasagna, tossed salad, sherbet, and iced tea. E. Bedtime snack of crackers and milk.

Potato chips (A) are high in sodium. Tuna (B) is high in protein. Bacon (C) and crackers (E) are high in sodium. Only (D) is a meal that is in compliance with a low sodium, low protein diet. Correct Answer: A, B, C, E

The nurse observes an unlicensed personnel (UAP) taking a client's blood pressure with a cuff that is too small, but the blood pressure reading obtained is within the client's usage range. What action is most important for the nurse to implement?

Reassess the client's blood pressure using a larger cuff.

Acetaminophen is prescribed for an unconscious client with a temperature of 104 F. Which route should the practical nurse (PN) plan to administer this medication?

Rectal.

65.What intervention should the nurse include in the plan of care for a client who is being treated with an Unna's paste boot for leg ulcers due to chronic venous insufficiency? A. Check capillary refill of toes on lower extremity with Unna's paste boot. B. Apply dressing to wound area before applying the Unna's paste boot. C. Wrap the leg from the knee down towards the foot. D. Remove the Unna's paste boot q8h to assess wound healing.

The Unna's paste boot becomes rigid after it dries, so it is important to check distally for adequate circulation (A). Kerlix is often wrapped around the outside of the boot and an ace bandage may be used to cover both, but no bandage should be put under it (B). The Unna's paste boot should be applied from the foot and wrapped towards the knee (C). The Unna's paste boot acts as a sterile dressing, and should not be removed q8h. Weekly removal is reasonable (D). Correct Answer: A

36.In providing care for a terminally ill resident of a long-term care facility, the nurse determines that the resident is exhibiting signs of impending death and has a "do not resuscitate" or DNR status. What intervention should the nurse implement first? A. Request hospice care for the client. B. Report the client's acuity level to the nursing supervisor. C. Notify family members of the client's condition. D. Inform the chaplain that the client's death is imminent.

The nurse's first priority is to notify the family of the resident's impending death (C). The family may request that hospice care is initiated (A). Reporting the client's acuity level (B) does not have the priority of informing the family of the client's condition. Once the family is contacted, the nurse can also contact the chaplain (D). Correct Answer: C

77.A nurse is preparing to insert a rectal suppository and observes a small amount of rectal bleeding. What action should the nurse implement? A. Administer the medication as scheduled after assessing the client's vital signs. B. Ask the pharmacist to send an alternate form of the prescribed medication to the unit. C. Withhold the administration of the suppository until contacting the healthcare provider. D. Insert the suppository very gently being careful not to further injure the rectal mucosa.

The presence of rectal bleeding is generally a contraindication for the insertion of a rectal suppository, so the nurse should withhold the medication and notify the healthcare provider (C). (A and D) may cause increased rectal bleeding. Prior to asking the pharmacist for another form of the medication, the nurse must have a new prescription from the healthcare provider (B). Correct Answer: C

78.The nurse is preparing to irrigate a client's indwelling urinary catheter using an open technique. What action should the nurse take after applying gloves? A. Empty the client's urinary drainage bag. B. Draw up the irrigating solution into the syringe. C. Secure the client's catheter to the drainage tubing. D. Use aseptic technique to instill the irrigating solution.

To irrigate an indwelling urinary catheter, the nurse should first apply gloves, then draw up the irrigating solution into the syringe (B). The syringe is then attached to the catheter and the fluid instilled, using aseptic technique (D). Once the irrigating solution is instilled, the client's catheter should be secured to the drainage tubing (C). The urinary drainage bag can be emptied (A) whenever intake and output measurement is indicated, and the instilled irrigating fluid can be subtracted from the output at that time. Correct Answer: B

The practical nurse (PN) is applying a dry, sterile dressing to a client's abdominal wound. Which allergy should the PN verify with the client?

tape.

The nurse is interviewing a female client whose spouse is present. During the nterview, the spouse answers most of the questions for the client. Which action is best for the nurse to implement?

Ask the spouse to step out for a few minutes.

Which action should the practical nurse (PN) take when drawing medication from an ampule?

Aspirate with a filter needle and syringe.

The practical nurse (PN) is irrigation a client's indwelling urinary catheter, After injection normal saline as prescribed, what action should the PN implement?

Unclamp the tubing and lower the collection bag.

What is most important for the practical nurse (PN) to include when performing pain assessment after giving an analgesic?

Use a pain scale to describe the intensity.

The healthcare provider prescribes the diuretic metolazone (Zaroxolyn) 7.5 mg PO. Zaroxolyn is available in 5 mg tablets. How much should the nurse plan to administer? A) ½ tablet. B) 1 tablet. C) 1½ tablets. D) 2 tablets.

C) 1½ tablets

The practical nurse (PN) is caring for a client who is admitted with influenza and vomiting for 3 days. The client's skin turgor is poor and oral mucous membranes are dry. Which finding is most important for the practical nurse (PN) to report to the charge nurse?

Hypotension and tachycardia

53.A medication is prescribed to be given QID. What schedule should the nurse use to administer this prescription? A. 0800, 1200, 1600, 2000. B. 800. C. Every other day at 0800. D. 0800, 1200, 1600, 2000, 0000, 0400.

(A) provides the best schedule, because QID means four times per day. (B, C, and D) provide incorrect dosages. Correct Answer: A

An obese male client discusses with the nurse his plans to begin a long-term weight loss regimen. In addition to dietary changes, he plans to begin an intendive aerobic exercise program 3 to 4 times a week and to take stress managment classes. After praising the client for his decision, which instruction is most important for the nurse to provide?

Be sure to have a complter physical exam before beginning your planned exercise program.

The healthcare provider prescribes 1,000 ml of Ringer's Lactate with 30 Units of Pitocin to run in over 4 hours for a client who has just delivered a 10 pound infant by cesarean section. The tubing has been changed to a 20 gtt/ml administration set. The nurse plans to set the flow rate at how many gtt/min? A) 42 gtt/min. B) 83 gtt/min. C) 125 gtt/min. D) 250 gtt/min

B. 83 gtt/min

The nurse assigns a UAP to obtain vital signs from a very anxious client. What instructions should the nurse give the UAP?

Report the vital signs to the nurse.

A client who is 5'5 tall and weighs 200lbs is scheduled for surgery the next day. What question is most important for the nurse to include during the preoperative assessment?

What vitamin and mineral supplements do you take? Vitamins affect meds.

50.The nurse assesses an immobile, elderly male client and determines that his blood pressure is 138/60, his temperature is 95.8° F, and his output is 100 ml of concentrated urine during the last hour. He has wet-sounding lung sounds, and increased respiratory secretions. Based on these assessment findings, what nursing action is most important for the nurse to implement? A. Administer a PRN antihypertensive prescription. B. Provide the client with an additional blanket. C. Encourage additional fluid intake. D. Turn the client q2h.

(D) will help to move and drain respiratory secretions and prevent pneumonia from occurring, so this intervention has the highest priority. Older adults often have an increased BP, and a PRN antihypertensive medication is usually prescribed for a BP over 140 systolic and 90 diastolic (A). Older adults often run a lower temperature, particularly in the morning, and (B) does not have the priority of (D). Even though the client has adequate output, (C) might be encouraged because the urine is concentrated, but this intervention does not have the priority of (D). Correct Answer: D

What is the maximum length of time a nurse should allow an intravenous (IV) bag of solution to infuse? 1 6 hours 2 12 hours 3 18 hours 4 24 hours

4 After 24 hours there is increased risk for contamination of the solution and the bag should be changed. It is unnecessary to change the bag any less often.

A nurse administers an intravenous solution of 0.45% sodium chloride. In what category of fluids does this solution belong? 1 Isotonic 2 Isomeric 3 Hypotonic 4 Hypertonic

1 Hypotonic solutions are less concentrated (contain less than 0.85 g of sodium chloride in each 100 mL) than body fluids. Isotonic solutions are those that cause no change in the cellular volume or pressure, because their concentration is equivalent to that of body fluid. This relates to two compounds that possess the same molecular formula but that differ in their properties or in the position of atoms in the molecules (isomers). Hypertonic solutions contain more than 0.85 g of solute in each 100 mL.

An arterial blood gas report indicates the client's pH is 7.25, PCO2 is 35 mm Hg, and HCO3 is 20 mEq/L. Which disturbance should the nurse identify based on these results? 1 Metabolic acidosis 2 Metabolic alkalosis 3 Respiratory acidosis 4 Respiratory alkalosis A low pH and low bicarbonate level are consistent with metabolic acidosis. The pH indicates acidosis. The CO2 concentration is within normal limits, which is inconsistent with respiratory acidosis; it is elevated with respiratory acidosis.

1 A low pH and low bicarbonate level are consistent with metabolic acidosis. The pH indicates acidosis. The CO2 concentration is within normal limits, which is inconsistent with respiratory acidosis; it is elevated with respiratory acidosis. Ph-7.35-7.45 PCO2 - 35-45 HCO3 - 22-30

What should the nurse consider when obtaining an informed consent from a 17-year-old adolescent? 1 If the client is allowed to give consent 2 The client cannot make informed decisions about health care. 3 If the client is permitted to give voluntary consent when parents are not available 4 The client probably will be unable to choose between alternatives when asked to consent

1 A person is legally unable to sign a consent until the age of 18 years unless the client is an emancipated minor or married. The nurse must determine the legal status of the adolescent. Although the adolescent may be capable of intelligent choices, 18 is the legal age of consent unless the client is emancipated or married. Parents or guardians are legally responsible under all circumstances unless the adolescent is an emancipated minor or married. Adolescents have the capacity to choose, but not the legal right in this situation unless they are legally emancipated or married.

Health promotion efforts with the chronically ill client should include interventions related to primary prevention. What should this include? 1 Encouraging daily physical exercise 2 Performing yearly physical examinations 3 Providing hypertension screening programs 4 Teaching a person with diabetes how to prevent complications

1 Primary prevention activities are directed toward promoting healthful lifestyles and increasing the level of well-being. Performing yearly physical examinations is a secondary prevention. Emphasis is on early detection of disease, prompt intervention, and health maintenance for those experiencing health problems. Providing hypertension screening programs is a secondary prevention. Emphasis is on early detection of disease, prompt intervention, and health maintenance for those experiencing health problems. Teaching a person with diabetes how to prevent complications is a tertiary prevention. Emphasis is on rehabilitating individuals and restoring them to an optimum level of functioning.

The nurse is caring for a client with a temperature of 104.5 degrees Fahrenheit. The nurse applies a cooling blanket and administers an antipyretic medication. The nurse explains that the rationale for these interventions is to: 1 Promote equalization of osmotic pressures. 2 Prevent hypoxia associated with diaphoresis. 3 Promote integrity of intracerebral neurons. 4 Reduce brain metabolism and limit hypoxia.

4

What is a nurse's responsibility when administering prescribed opioid analgesics? Select all that apply. 1 Count the client's respirations. 2 Document the intensity of the client's pain. 3 Withhold the medication if the client reports pruritus. 4 Verify the number of doses in the locked cabinet before administering the prescribed dose.

1,2,4 Opioid analgesics can cause respiratory depression; the nurse must monitor respirations. The intensity of pain must be documented before and after administering an analgesic to evaluate its effectiveness. Because of the potential for abuse, the nurse is legally required to verify an accurate count of doses before taking a dose from the locked source and at the change of the shift. Pruritus is a common side effect that can be managed with antihistamines. It is not an allergic response, so it does not preclude administration. The nurse should not discard an opioid in a client's room. Any waste of an opioid must be witnessed by another nurse.

The client asks the nurse to recommend foods that might be included in a diet for diverticular disease. Which foods would be appropriate to include in the teaching plan? Select all that apply. 1 Whole grains 2 Cooked fruit and vegetables 3 Nuts and seeds 4 Lean red meats 5 Milk and eggs

1,2,5 With diverticular disease the patient should avoid foods that may obstruct the diverticuli. Therefore the fiber should be digestible, such as whole grains, and cooked fruits and vegetables. Milk and eggs have no fiber content but are good sources of protein. In clients with diverticular disease, nuts and seeds are contraindicated as they may be retained and cause inflammation and infection, which is known as diverticulitis. The client should also decrease intake of fats and red meats.

An older client who is receiving chemotherapy for cancer has severe nausea and vomiting and becomes dehydrated. The client is admitted to the hospital for rehydration therapy. Which interventions have specific gerontologic implications the nurse must consider? Select all that apply. 1 Assessment of skin turgor 2 Documentation of vital signs 3 Assessment of intake and output 4 Administration of antiemetic drugs 5 Replacement of fluid and electrolytes

1,4,5 When skin turgor is assessed, the presence of tenting may be related to loss of subcutaneous tissue associated with aging rather than to dehydration; skin over the sternum should be used instead of skin on the arm for checking turgor. Older adults are susceptible to central nervous system side effects, such as confusion, associated with antiemetic drugs; dosages must be reduced, and responses must be evaluated closely. Because many older adults have delicate fluid balance and may have cardiac and renal disease, replacement of fluid and electrolytes may result in adverse consequences, such as hypervolemia, pulmonary edema, and electrolyte imbalance. Vital signs can be obtained as with any other adult. Intake and output can be measured accurately in older adults.

The nurse is caring for a non-ambulatory client with a reddened sacrum that is unrelieved by repositioning. What nursing diagnosis should be included on the client's plan of care? 1 Risk for pressure ulcer 2 Risk for impaired skin integrity 3 Impaired skin integrity, related to infrequent turning and repositioning 4 Impaired skin integrity, related to the effects of pressure and shearing force

4

A client is receiving a Mantouz test for tuberculosis screening. Which angle should the practical nurse (PN) insert the needle for injection?

15 degrees.

While undergoing a soapsuds enema, the client reports abdominal cramping. What action should the nurse take? 1 Immediately stop the infusion. 2 Lower the height of the enema bag. 3 Advance the enema tubing 2 to 3 inches. 4 Clamp the tube for 2 minutes, then restart the infusion.

2 Abdominal cramping during a soapsuds enema may be due to too rapid administration of the enema solution. Lowering the height of the enema bag slows the flow and allows the bowel time to adapt to the distention without causing excessive discomfort. Stopping the infusion is not necessary. Advancing the enema tubing is not appropriate. Clamping the tube for several minutes then restarting the infusion may be attempted if slowing the infusion does not relieve the cramps.

During the initial physical assessment of a newly admitted client with a pressure ulcer, a nurse observes that the client's skin is dry and scaly. The nurse applies emollients and reinforces the dressing on the pressure ulcer. Legally, were the nurse's actions adequate? 1 The nurse also should have instituted a plan to increase activity. 2 The nurse provided supportive nursing care for the well-being of the client. 3 Debridement of the pressure ulcer should have been done before the dressing was applied. 4 Treatment should not have been instituted until the health care provider's prescriptions were received.

2 According to the Nurse Practice Act, a nurse may independently treat human responses to actual or potential health problems. An activity level is prescribed by a health care provider; this is a dependent function of the nurse. There is not enough information to come to the conclusion that debridement should have been done before the dressing was applied. Application of an emollient and reinforcing a dressing are independent nursing functions.

A client is receiving an intravenous (IV) infusion of 5% dextrose in water. The client loses weight and develops a negative nitrogen balance. The nurse concludes that what likely contributed to this client's weight loss? 1 Excessive carbohydrate intake 2 Lack of protein supplementation 3 Insufficient intake of water-soluble vitamins 4 Increased concentration of electrolytes in cells

2 An infusion of dextrose in water does not provide proteins required for tissue growth, repair, and maintenance; therefore, tissue breakdown occurs to supply the essential amino acids. Each liter provides approximately 170 calories, which is insufficient to meet minimal energy requirements; tissue breakdown will result. Weight loss is caused by insufficient nutrient intake; vitamins do not prevent weight loss. An infusion of 5% dextrose in water may decrease electrolyte concentration.

In what position should the nurse place a client recovering from general anesthesia? 1 Supine Correct2 Side-lying 3 High Fowler 4 Trendelenburg

2 Turning the client to the side promotes drainage of secretions and prevents aspiration, especially when the gag reflex is not intact. This position also brings the tongue forward, preventing it from occluding the airway when it is in the relaxed state. The risk for aspiration is increased when the supine position is assumed by a semi-alert client. High Fowler position may cause the neck to flex in a client who is not alert, interfering with respirations. Trendelenburg position is not used for a postoperative client because it interferes with breathing.

A client is being admitted for a total hip replacement. When is it necessary for the nurse to ensure that a medication reconciliation is completed? Select all that apply. 1 After reporting severe pain 2 On admission to the hospital 3 Upon entering the operating room 4 Before transfer to a rehabilitation facility 5 At time of scheduling for the surgical procedure

2, 4 Medication reconciliation involves the creation of a list of all medications the client is taking and comparing it to the health care provider's prescriptions on admission or when there is a transfer to a different setting or service, or discharge. A change in status does not require medication reconciliation. A medication reconciliation should be completed long before entering the operating room. Total hip replacement is elective surgery, and scheduling takes place before admission; medication reconciliation takes place when the client is admitted.

The nurse expects a client with an elevated temperature to exhibit what indicators of pyrexia? Select all that apply. Incorrect 1 Dyspnea 2 Flushed face 3 Precordial pain 4 Increased pulse rate 5 Increased blood pressure

2,4 Increased body heat dilates blood vessels, causing a flushed face. The pulse rate increases to meet increased tissue demands for oxygen in the febrile state. Fever may not cause difficult breathing. Pain is not related to fever. Blood pressure is not expected to increase with fever.

To minimize the side effects of the vincristine (Oncovin) that a client is receiving, what does the nurse expect the dietary plan to include? 1 Low in fat 2 High in iron 3 High in fluids 4 Low in residue

3 A common side effect of vincristine is a paralytic ileus that results in constipation. Preventative measures include high-fiber foods and fluids that exceed minimum requirements. These will keep the stool bulky and soft, thereby promoting evacuation. Low in fat, high in iron, and low in residue dietary plans will not provide the roughage and fluids needed to minimize the constipation associated with vincristine.

A nurse is providing care to a client eight hours after the client had surgery to correct an upper urinary tract obstruction. Which assessment finding should the nurse report to the surgeon? 1 Incisional pain 2 Absent bowel sounds 3 Urine output of 20 mL/hour 4 Serosanguineous drainage on the dressing .

3 A urinary output of 50 mL/hr or greater is necessary to prevent stasis and consequent infections after this type of surgery. The nurse should notify the surgeon of the assessment findings, since this may indicate a urinary tract obstruction. Incisional pain, absent bowel sounds, and serosanguineous drainage are acceptable assessment findings for this client after this procedure and require continued monitoring but do not necessarily require reporting to the surgeon

A client has an anaphylactic reaction after receiving intravenous penicillin. What does the nurse conclude is the cause of this reaction? 1 An acquired atopic sensitization occurred. 2 There was passive immunity to the penicillin allergen. 3 Antibodies to penicillin developed after a previous exposure. 4 Potent antibodies were produced when the infusion was instituted

3 Hypersensitivity results from the production of antibodies in response to exposure to certain foreign substances (allergens). Earlier exposure is necessary for the development of these antibodies. This is not a sensitivity reaction to penicillin; hay fever and asthma are atopic conditions. It is an active, not passive, immune response. Antibodies developed when there was a previous, not current, exposure to penicillin.

A nurse is preparing a community health program for senior citizens. The nurse teaches the group that the physical findings that are typical in older people include: 1 A loss of skin elasticity and a decrease in libido 2 Impaired fat digestion and increased salivary secretions 3 Increased blood pressure and decreased hormone production 4 An increase in body warmth and some swallowing difficulties

3 With aging, narrowing of the arteries causes some increase in the systolic and diastolic blood pressures; hormone production decreases after menopause. There may or may not be changes in libido; there is a loss of skin elasticity. Salivary secretions decrease, not increase, causing more difficulty with swallowing; there is some impairment of fat digestion. There may be a decrease in subcutaneous fat and decreasing body warmth; some swallowing difficulties occur because of decreased oral secretions.

Which age-related change should the nurse consider when formulating a plan of care for an older adult? Select all that apply. Incorrect 1 Difficulty in swallowing 2 Increased sensitivity to heat 3 Increased sensitivity to glare 4 Diminished sensation of pain 5 Heightened response to stimuli .

3,4 Changes in the ciliary muscles, decrease in pupil size, and a more rigid pupil sphincter contribute to an increased sensitivity to glare. Diminished sensation of pain may make an older individual unaware of a serious illness, thermal extremes, or excessive pressure. There should be no interference with swallowing in older individuals. Older individuals tend to feel the cold and rarely complain of the heat. There is a decreased response to stimuli in the older individual

What clinical indicators should the nurse expect a client with hyperkalemia to exhibit? Select all that apply. 1 Tetany 2 Seizures 3 Diarrhea 4 Weakness 5 Dysrhythmias

3,4,5 Tetany is caused by hypocalcemia. Seizures caused by electrolyte imbalances are associated with low calcium or sodium levels. Because of potassium's role in the sodium/potassium pump, hyperkalemia will cause diarrhea, weakness, and cardiac dysrhythmias.

A client who was exposed to hepatitis A asks why an injection of gamma globulin is needed. Before responding, what should the nurse consider about how gamma globulin provides passive immunity? 1 It increases production of short-lived antibodies. 2 It accelerates antigen-antibody union at the hepatic sites. 3 The lymphatic system is stimulated to produce antibodies. 4 The antigen is neutralized by the antibodies that it supplies

4 Gamma globulin, which is an immune globulin, contains most of the antibodies circulating in the blood. When injected into an individual, it prevents a specific antigen from entering a host cell. Gamma globulin does not stimulate antibody production. It does not affect antigen-antibody function.

A health care provider prescribes 10 mL of a 10% solution of calcium gluconate for a client with a severely depressed serum calcium level. The client also is receiving digoxin (Lanoxin) 0.25 mg daily and an intravenous (IV) solution of D5W. The nurse's next action is based on the fact that calcium gluconate: 1 Can be added to any IV solution Incorrect2 Must be administered via an intravenous piggyback (IVPB) 3 Is non-irritating to surrounding tissues Correct4 Potentiates the action of the digoxin preparation

4 Toxicity can result because the action of calcium ions is similar to that of digoxin. Calcium gluconate cannot be added to a solution containing carbonate or phosphate because a dangerous precipitation will occur. Calcium gluconate can be added to the IV solution the client is receiving. If calcium infiltrates, sloughing of tissue will result.

A client has been diagnosed as brain dead. The nurse understands that this means that the client has: 1 No spontaneous reflexes 2 Shallow and slow breathing 3 No cortical functioning with some reflex breathing 4 Deep tendon reflexes only and no independent breathing

4 A client who is declared as being brain dead has no function of the cerebral cortex and a flat EEG. The client may have some spontaneous breathing and a heartbeat. The guidelines established by the American Association of Neurology include coma or unresponsiveness, absence of brainstem reflexes, and apnea. There are specific assessments to validate the findings. The other answer options do not fit the definition of brain dead.

A client has a pressure ulcer that is full thickness with necrosis into the subcutaneous tissue down to the underlying fascia. The nurse should document the assessment finding as which stage of pressure ulcer? 1 Stage I 2 Stage II 3 Stage III 4 Unstageable

4 A pressure ulcer with necrotic tissue is unstageable. The necrotic tissue must be removed before the wound can be staged. A stage I pressure ulcer is defined as an area of persistent redness with no break in skin integrity. A stage II pressure ulcer is a partial-thickness wound with skin loss involving the epidermis, dermis, or both; the ulcer is superficial and may present as an abrasion, blister, or shallow crater. A stage III pressure ulcer involves full thickness tissue loss with visible subcutaneous fat. Bone, tendon, and muscle are not exposed.

A nurse is reviewing a plan of care for a client who was admitted with dehydration as a result of prolonged watery diarrhea. Which prescription should the nurse question? 1 Oral psyllium (Metamucil) 2 Oral potassium supplement 3 Parenteral half normal saline 4 Parenteral albumin (Albuminar)

4 Albumin is hypertonic and will draw additional fluid from the tissues into the intravascular space. Oral psyllium will absorb the watery diarrhea, giving more bulk to the stool. An oral potassium supplement is appropriate because diarrhea causes potassium loss. Parenteral half normal saline is a hypotonic solution, which can correct dehydration.

A health care provider has prescribed isoniazid (Laniazid) for a client. Which instruction should the nurse give the client about this medication? 1 Prolonged use can cause dark concentrated urine. 2 The medication is best absorbed when taken on an empty stomach. 3 Take the medication with aluminum hydroxide to minimize GI upset. 4 Drinking alcohol daily can cause drug-induced hepatitis

4 Daily alcohol intake can cause drug induced hepatitis. Prolonged use does not cause dark concentrated urine. The client should take isoniazid with meals to decrease GI upset. Clients should avoid taking aluminum antacids at the same time as this medication because it impairs absorption.

When being interviewed for a position as a registered professional nurse, the applicant is asked to identify an example of an intentional tort. What is the appropriate response? 1 Negligence 2 Malpractice 3 Breach of duty 4 False imprisonment

4 False imprisonment is a wrong committed by one person against another in a willful, intentional way without just cause or excuse. Negligence is an unintentional tort. Malpractice, which is professional negligence, is classified as an unintentional tort. Breach of duty is an unintentional tort.

Often when a family member is dying, the client and the family are at different stages of grieving. During which stage of a client's grieving is the family likely to require more emotional nursing care than the client? 1 Anger 2 Denial 3 Depression 4 Acceptance

4 In the stage of acceptance, the client frequently detaches from the environment and may become indifferent to family members. In addition, the family may take longer to accept the inevitable death than does the client. Although the family may not understand the anger, dealing with the resultant behavior may serve as a diversion. Denial often is exhibited by the client and family members at the same time. During depression, the family often is able to offer emotional support, which meets their needs.

A postoperative client says to the nurse, "My neighbor, I mean the person in the next room, sings all night and keeps me awake." The neighboring client has dementia and is awaiting transfer to a nursing home. How can the nurse best handle this situation? 1 Tell the neighboring client to stop singing. 2 Close the doors to both clients' rooms at night. 3 Give the complaining client the prescribed as needed sedative. 4 Move the neighboring client to a room at the end of the hall

4 Moving the client who is singing away from the other clients diminishes the disturbance. A client with dementia will not remember instructions. It is unsafe to close the doors of clients' rooms because they need to be monitored. The use of a sedative should not be the initial intervention

A visitor comes to the nursing station and tells the nurse that a client and his relative had a fight and that the client is now lying unconscious on the floor. What is the most important action the nurse needs to take? 1 Ask the client if he is okay. 2 Call security from the room. 3 Find out if there is anyone else in the room. 4 Ask security to make sure the room is safe

4 Safety is the first priority when responding to a presumably violent situation. The nurse needs to have security enter the room to ensure it is safe. Then it can be determined if the client is okay and make sure that any other people in the room are safe

A nurse assesses a client's serum electrolyte levels in the laboratory report. What electrolyte in intracellular fluid should the nurse consider most important? 1 Sodium 2 Calcium 3 Chloride 4 Potassium

4 The concentration of potassium is greater inside the cell and is important in establishing a membrane potential, a critical factor in the cell's ability to function. Sodium is the most abundant cation of the extracellular compartment, not the intracellular compartment. Calcium is the most abundant electrolyte in the body; 99% is concentrated in the teeth and bones, and only 1% is available for bodily functions. Chloride is an extracellular, not intracellular, anion.

The practical nurse (PN) hears breath sounds that are short, popping, and discontinuous on inspiration when auscultating a client's lungs. Which description should the PN document in the client's record?

Crackles auscultated.

A male client who had abdominal surgery has a nasogastric tube to suction, oxygen per nasal cannula, and complains of dry mouth. Which action should the nurse implement?

Apply a water soluble lubricant to the lips, oral mucosa, and nares. Petroleum based products are flammable.

A postoperative client will need to perform daily dressing changes after discharge. Which outcome statement best demonstrates the client's readiness to manage his wound care after discharge? The client

Demonstrates the wound care procedure correctly

An older male client who is sedentary complains of not having a formed bowel movement in four days and tells the practical nurse (PN) that he feels rectal pressure and has a constant headache. The PN determines the client is having frequent small, liquid stools. Which nursing action should the PN take first?

Digitally assess for impacted stool.

Place each step of the nursing process in the order that it should be used. Correct 1. Obtain client's nursing history. Correct 2. State client's nursing needs. Correct 3. Identify goals for care. Correct 4. Develop a plan of care. Correct 5. Implement nursing interventions.

First the nurse should gather data. Based on the data, the client's needs are assessed. After the needs have been determined, the goals for care are established. The next step is planning care based on the knowledge gained from the previous steps. Implementation follows the development of the plan of care.

Which intervention provides confirmation of nasogastric tube (NGT) placement before NGT feedings are started?

Flat plate x-ray of the abdomen.

An elderly male client who is unresponsive following a cerebral vascular accident (CVA) is receiving bolus enteral feedings though a gastrostomy tube. What is the best client position for administration of the bolus tube feedings?

Fowlers' (Semi-sitting)

The practical nurse (PN) is checking the surgical dressing for a client who arrived on the postoperative unit an hour ago. The dressing has an increase in the accumulation of serosanguinous drainage. what nursing action should the PN take?

Mark the outlined area of drainage with date, time and initials.

Alternative therapy measures have become increasingly accepted within the past decade, especially in the relief of pain. Which methods qualify as alternative therapies for pain? Select all that apply. 1 Prayer 2 Hypnosis 3 Medication 4 Aromatherapy 5 Guided imagery

Prayer is an alternative therapy that may relax the client and provide strength, solace, or acceptance. The relief of pain through hypnosis is based on suggestion; also, it focuses attention away from the pain. Some clients learn to hypnotize themselves. Aromatherapy can help relax and distract the individual and thus increase tolerance for pain, as well as relieve pain. Guided imagery can help relax and distract the individual and thus increase tolerance for pain, as well as relieve pain. Analgesics, both opioid and nonopioid, long have been part of the standard medical regimen for pain relief, so they are not considered an alternative therapy.

46.A client with chronic renal disease is admitted to the hospital for evaluation prior to a surgical procedure. Which laboratory test indicates the client's protein status for the longest length of time? A. Transferrin. B. Prealbumin. C. Serum albumin. D. Urine urea nitrogen.

Serum albumin has a long half-life and is the best long-term indicator of the body's entry into a catabolic state following protein depletion from malnutrition or stress of chronic illness (C). While (A) is a good indicator of iron-binding capacity in a healthy adult, it is an unreliable measure in the client with a chronic illness. (B) has a short half-life, and is a sensitive indicator of recent catabolic changes, but it is not as effective as (C) in indicating long-term protein depletion. While (D) is a good indicator of a negative nitrogen balance, it is not as good an indicator of long-term protein catabolism as is (C). Correct Answer: C

81.The nurse is completing the plan of care for a client who is admitted for benign prostatic hypertrophy. Which data should the nurse document as a subjective findings? A. Complains of inability to empty bladder. B. Temperature of 99.8° F and pulse of 108. C. Post-voided residual volume of 750 ml. D. Specimen collection for culture and sensitivity.

The nurse should document the client's complaints (A) as subjective data--symptoms only the client can describe. (B) should be documented as objective data, which is collected via the nurse's observation. (C and D) are documented as intervention results. Correct Answer: A

The practical nurse (PN) contacts the healthcare provider about an older client who is agitated and aggressive with the staff. Which reason should the PN use to request a prescription for wrist restraints?

To ensure the client's safety when the benefits outweigh the risk.

During insertion of a nasogastric tube (NGT) into the right nares, the client starts to cough. Which action should the practical nurse (PN) implement?

Withdraw the NGT to the oral pharynx, repostion client's head and reinsert.