Fundamentals

A parent brings a 5-month-old infant to the clinic for a well-infant check. The infant weighed 3.2 kg (7 lb) at birth. If the infant has followed the usual pattern of growth for 5 months, how much should the infant weigh? (Round the answer to the nearest tenth) ___ lb

14.5 lb Rationale: The infant should gain 0.7 kg (1.5 lb) per month in the first 6 months. 1.5 lb x age 5 months + birthweight 7 lb = 14.5 lb

A nurse is performing an admission assessment on a client. When measuring her vital signs, the nurse finds that her radial pulse rate is 68/min and her simultaneous apical pulse rate is 84/min. What is the client's pulse deficit?

16/min Rationale: The pulse deficit is the difference between the apical and radial pulse rates. It reflects the number of ineffective or non perfusing heartbeats that do not transmit pulsations to peripheral pulse points. 84 - 68 = 16

A nurse is caring for a client who is 24 hr postoperative following an inguinal hernia repair. The client is tolerating clear liquids well, has active bowel sounds, and is expressing a desire for "real food." The nurse tells the client that she will call the surgeon and ask. The surgeon hears the nurse's report and prescribes a full liquid diet. The nurse used which of the following levels of critical thinking? A) Basic B) Commitment C) Complex D) Integrity

A Rationale: At the basic level, thinking is concrete and based on a set of rules, such as obtaining the prescription for diet progression.

A nurse observes an assistive personnel (AP) reprimanding a client for not using the urinal properly. The AP tells him she will put a diaper on him if he does not use the urinal more carefully next time. Which of the following torts is the AP committing? A) Assault B) Battery C) False imprisonment D) Invasion of privacy

A Rationale: By threatening the client, the AP is committing assault. Her threats could make the client become fearful and apprehensive.

A nurse is caring for a client who has a new prescription for antihypertensive medication. Prior to administering the medication, the nurse uses an electronic database to gather information about the medication and the effects it might have on this client. Which of the following components of critical thinking is the nurse using when he reviews the medication information? A) Knowledge B) Experience C) Intuition D) Competence

A Rationale: By using the electronic database, the nurse takes the initiative to increase his knowledge base, which is the first component of critical thinking.

A nurse educator is presenting a module on basic first aid for newly licensed home health nurses. The nurse educator evaluates the teaching as effective when the newly licensed nurse states the client who has heat stroke will have which of the following? A) Hypotension B) Bradycardia C) Clammy skin D) Bradypnea

A Rationale: Clinical manifestations of heat stroke include hypotension, tachycardia, hot and dry skin, and tachypnea.

During evaluation, the nurse must gather information about the client to A) identify whether the client outcomes have been met. B) organize resources to proceed with implementing interventions. C) establish client-centered outcomes that are measurable and realistic D) determine the priority of care and appropriate interventions

A Rationale: Evaluation involves gathering information about the client to determine whether the outcomes have been met.

A nurse is cautioning the mother of an 8-month-old infant about safety. Which of the following statements by the mother indicates an understanding of safety for the infant? A) "My baby loved to play with his crib gym, but I took it away from him." B) "I just bought a soft mattress so my baby will sleep better." C) "My baby really likes sleeping on the fluffy pillow we just got for him." D) "I just bought a child-safety gate that folds like an accordion."

A Rationale: Parents should remove gyms and mobiles by 4 months because injury can occur from choking or strangulation.

A nurse in a health clinic is caring for a 21-year-old client who reports a sore throat. The client tells the nurse that he has not seen a doctor since high school Which of the following health screenings should the nurse expect the provider to perform for this client? A) Testicular examination B) Blood glucose C) Fecal occult blood D) Prostate-specific antigen

A Rationale: Starting at age 20, examinations for testicular cancer are appropriate, along with blood pressure and BMI measurements and cholesterol determinations.

A nurse is caring for a client who has a left-sided hemiplegia resulting from a cerebrovascular accident. The client works as a carpenter and is now experiencing a situational role change based on physical limitations. The client is the primary wage earner in the family. Which of the following best describes the client's role program? A) Role conflict B) Role overload C) Role ambiguity D) Role strain

A Rationale: The client is experiencing role conflict because his career is extremely physical, and he can no longer perform his job duties. However, the client is the primary wage earner in the family.

A client asks the nurse what her Snellen eye test results mean. Her visual acuity is 20/30. Which of the following responses is appropriate? A) "Your eyes see at 20 feet what visually unimpaired eyes see at 30 feet." B) "Your right eye can see the chart clearly at 20 feet, and your left eye can see the chart clearly at 30 feet." C) "Your eyes see at 30 feet what visually unimpaired eyes see at 20 feet." D) "Your left eye can see the chart clearly at 20 feet, and your right eye can see the chart clearly at 30 feet."

A Rationale: The first number is the distance (in feet) the client stands from the chart. The second number is the distance at which a visually unimpaired eyes can see the line clearly.

A nurse is instructing an assistive personnel (AP) in caring for a client who has a low platelet count as a result of chemotherapy. Which of the following is the nurse's priority instruction for measuring vital signs for this client? A) "Do not measure the client's temperature rectally." B) "Count the client's radial pulse for 30 seconds." C) "Do not let the client know you are counting her respirations." D) "Let the client rest for 5 minutes before you measure her blood pressure."

A Rationale: The greatest risk to a client with a low platelet count is an injury to the rectal mucosa; therefore, the low platelet count contraindicates the use of the rectal route for this client. Of these instructions, this is the nurse's priority.

A nurse is caring for a newly admitted client who has a documented history of falls. Which of the following is the priority action by the nurse? A) Complete a fall-risk assessment B) Educate the client and family on fall risks C) Complete a physical assessment D) Survey the client's belongings

A Rationale: The greatest risk to this client is injury due to a fall. Therefore, the priority action is to determine the client's fall risk. This will guide the nurse in implementing appropriate safety measures.

A nurse is performing an admission assessment for an older adult client. After gathering the assessment data and performing the review of systems, which of the following actions is a priority for the nurse? A) Orient the client to his room. B) Conduct a client care conference. C) Review the client's medical orders. D) Develop a plan of care.

A Rationale: The greatest risk to this client is injury from unfamiliar surroundings. Therefore, the priority action is to orient the client to the room. Before the nurse leaves the room, the client should know how to use the call light and other equipment at the bedside.

A nurse educator is teaching a module on proper body mechanics during employee orientation. Which of the following statements by a newly hired nurse indicated the need for further teaching? A) "My line of gravity should fall outside my base of support" B) "The lower my center of gravity, the more stability I have." C) "To broaden my base of support, I should spread my feet apart." D) "When I lift an object, I should hold it as close to my body as possible."

A Rationale: The line of gravity should fall within the base of support, not outside, which increases the risk of falling.

By the second postoperative day, a client has not achieved satisfactory pain relief. Based on this evaluation, what should the nurse do next according to the nursing process? A) Reassess the client to determine the reasons for unsatisfactory pain relief. B) See whether the pain lessens during the next 24 hr. C) Change the plan to ensure that the client achieves adequate pain relief. D) Teach the client about the plan of care for managing his pain.

A Rationale: The nurse should reassess the client to determine why he has not achieved satisfactory pain relief. Various factors may be influencing the lack of pain relief.

A nursing student is reporting to the clinical instructor about the care she gave to a client. She states: "The client said his leg pain was back, so I checked his medical record, and he last received his pain medication 6 hr ago. The prescription reads every 4 hr PRN for pain, so I decided he needs it. I asked the unit nurse to observe me preparing and administering it. I checked with the client 40 min later, and he said his pain is going away." The instructor should inform the student that she left out which of the following steps of the nursing process? A) Assessment B) Planning C) Intervention D) Evaluation

A Rationale: The nursing student should have used the assessment step of the nursing process by asking the client to evaluate the severity of his pain on a 0 to 10 scale. She also should have asked about the characteristics of his pain and assessed for any changes that might have contributed to the worsening of the pain.

A mother tells the nurse that her 2-year-old child has temper tantrums. The child says "no" every time the mother tries to help her get dressed. The nurse explains that, developmentally, the toddler is A) trying to increase her independence. B) developing a sense of trust. C) manifesting an anger management problem. D) attempting to finish a project she started.

A Rationale: Toddler express a drive for independence by opposing the desires of those in authority and attempting to do everything themselves.

A nurse is talking with the parents of a toddler. Which of the following should the nurse suggest regarding discipline? A) Establish consistent boundaries. B) Place him in a room with the door closed. C) Have him learn by trial and error. D) Use favorite snacks as rewards.

A Rationale: Toddlers need to have consistent boundaries for discipline to be effective.

A nurse is talking with parents of a school-age child who describe several issues that concern them. Which of the following problems the parents verbalized should the nurse identify as the priority for further assessment and intervention? A) "We just don't understand why our son can't keep up with the other kids in simple activities like running and jumping." B) "Our son keeps trying to find ways around our household rules. He always wants to make deals with us." C) "We think our son is trying too hard to excel in math just to get the top grades in his class." D) "Our son is always afraid the kids in school will laugh at him because he likes to sing and write little poems."

A Rationale: When using the urgent vs. non urgent approach to client care, the priority issue is the problem that reflects a lack of completion of the previous stage of development and progression to the current stage of development. According to Erikson, it is a task of the preschool stage to develop initiative vs. guilt. This school-age child is still trying to develop the physical abilities he needs to feel a sense of accomplishment. He is still struggling with this task and needs assistance with motor skills and agility.

A nurse is performing a neurosensory examination for a client. Which of the following tests should the nurse perform to test the clients balance? (Select all that apply) A) Romberg test B) Heel-to-toe walk C) Snellen test D) Spinal accessory function E) Rosenbaum test

A, B Rationale: For the Romberg test, the client stands with his eyes closed, arms at his side, and feet together. The nurse verifies balance if he can stand with minimal swaying for at least 5 seconds. For the heel-to-toe walk, the client places the heel of one foot in front of the toes of the other foot as he walks in a straight line. The nurse verifies balance if he can walk in a straight line without losing his balance.

A client is about to undergo an elective surgical procedure. Which of the following actions are appropriate for the nurse who is providing preoperative care regarding informed consent? (Select all that apply) A) Make sure the surgeon obtained the client's consent. B) Witness the client's signature on the consent form. C) Explain the risks and benefits of the procedure. D) Describe the consequences of choosing not to have the surgery. E) Tell the client about alternatives to having the surgery.

A, B Rationale: It is the nurse's responsibility to verify that the surgeon obtained the client's consent and that he understands the information the surgeon gave him. It is also the nurse's responsibility to witness the client's signing of the consent form, and to verify that he is consenting voluntarily and appears to be competent to do so. The nurse should verify that he understands the information the surgeon has given him.

A nurse in a provider's office is preparing to auscultate and percuss a client's abdomen as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply) A) Tympany B) High-pitched clicks C) Borborygmi D) Friction rubs E) Bruits

A, B Rationale: Tympany is the expected dreamlike percussion sound over the abdomen. It indicates air in the stomach. Typical bowel sounds are high-pitched clicks and gurgles occurring about 35 times/min.

A nurse is instructing a group of nursing students in measuring a client's respiratory rate. Which of the following guidelines should the nurse include? (Select all that apply) A) Place the client in semi-Fowler's position. B) Have the client rest an arm across the abdomen. C) Observe one full respiratory cycle before counting the rate. D) Count the rate for 1 min if it is regular. E) Count and report any sighs the client demonstrates.

A, B, C Rationale: Having the client sit upright facilitates full ventilation and gives the students a clear view of the chest and abdominal movements. With the client's arm across the abdomen or lower chest, it is easier for the student to see respiratory movements. Observing for one full respiratory cycle before starting to count assists the students in obtaining an accurate count.

A nurse in a provider's office is documenting his findings following an assessment he performed for a client new to the practice. Which of the following parameters should he include as part of the general survey? (Select all that apply) A) Posture B) Skin lesions C) Speech D) Allergies E) Immunization

A, B, C Rationale: Posture and skin lesions are part of the body structure or general appearance portion of the general survey. Speech is part of the behavior portion of the general survey.

A nursing instructor is explaining the various levels of health care services to a group of nursing students. Which of the following examples of care or care settings should the nurse classify as tertiary care? (Select all that apply) A) Intensive care unit B) Oncology treatment center C) Burn center D) Cardiac Rehabilitation E) Home health care

A, B, C Rationale: Tertiary health care involves the provision of specialized and highly technical care.

A nurse is reviewing the Centers for Disease Control and Prevention's (CDC's) immunization recommendations with a young adult client. Which of the following recommendations should the nurse include in this discussion? (Select all that apply) A) Human papillomavirus B) Measles, mumps, rubella C) Varicella D) Haemophilus influenzae type b E) Polio

A, B, C Rationale: The CDC recommends HPV immunizations, MMR immunizations, and varicella (chickenpox) immunizations during adulthood.

A nurse is receiving a provider's prescription by telephone for morphine for a client who is reporting moderate to severe pain. Which of the following nursing actions are appropriate? (Select all that apply) A) Repeat the details of the prescription back to the provider. B) Have another nurse listen to the telephone prescription. C) Obtain the prescriber's signature on the prescription within 24 hr. D) Decline the verbal prescription because it is not an emergency situation. E) Tell the charge nurse that the provider has prescribed.

A, B, C Rationale: The nurse should repeat the medication's name, dosage, time or interval, route, and any other pertinent information back to the provider and receive and document confirmation. Having another nurse listen to the telephone prescription is a safety precaution that helps prevent medication errors due to miscommunication. The provider must sign the prescription within the time frame the facility specifies in its policies (generally 24 hr).

A nurse is planning diversionary activities for children on an inpatient pediatric unit. Which of the following should the nurse incorporate as appropriate play activities for school-age children? (Select all that apply) A) Building models B) Playing video games C) Reading books D) Using toy carpentry tools E) Shaping modeling clay

A, B, C Rationale: These activities are appropriate for school-age children and help develop fine motor skills, cognitive skills, and communication skills.

A nursing instructor is acquainting a group of nursing students with the roles of the various members of the health care team they will encounter on a medical-surgical unit. When she gives examples of the types of tasks certified nursing assistants (CNAs) may perform, which of the following client activities should she include? (Select all that apply) A) Bathing B) Ambulating C) Toiling D) Determining pain level E) Measuring vital signs

A, B, C, D Rationale: It is within the scope of a CNA's duties to provide basic care to clients.

A nurse at an elementary school is planning a health promotion and primary prevention class. Which of the following topics are appropriate to include for the parents of school-age children? (Select all that apply) A) Childhood obesity B) Substance use disorders C) Scoliosis screening D) Front-seat seatbelt use E) Stranger awareness

A, B, C, E Rationale: Parents of school-age children need to be aware of nutritional strategies for preventing childhood obesity. Parents of school-age children need to know how to teach children to say no to illegal drugs, alcohol, and all other harmful or additive substances. School-age children and adolescents require screening for scoliosis. Parents need to reinforce stranger safety as soon as their children are old enough to understand it, and throughout all stages of childhood.

A nurse is admitting a client who has acute cholecystitis to a medical-surgical unit. Which of the following actions are essential steps of the admission procedure? (Select all that apply) A) Explain the roles of other care delivery staff. B) Begin discharge planning. C) Provide information about advance directives. D) Document the client's wishes about organ donation. E) Introduce the client to his roommate.

A, B, C, E Rationale: The client's hospitalization is likely to be more positive if the client understands who can perform which care activities for her. Unless the client is entering a LTC facility, discharge planning should begin on admission. The Patient Self-Determination Act requires asking clients if they have advance directives and providing information about them. Any action that can reduce the stress of hospitalization is therapeutic. Introductions to other clients and staff can encourage communication and physiological comfort.

A nurse in a clinic is caring for a client who has multiple risk factors for cardiovascular disease. When planning health promotion and disease prevention strategies for this client, which of the following interventions should the nurse include? (Select all that apply) A) Help the client see the benefits of her actions. B) Identify the client's support systems. C) Suggest and recommend community resources. D) Devise and set goals for the client E) Teach stress management strategies

A, B, C, E Rationale: The nurse should help the client recognize the benefits of her health-promoting actions while also overcoming barriers to taking implementing actions. Once the nurse has collected information about who can help the client change her unhealthful behaviors, she can suggest ways the client's supportive friends and family can get involved. The nurse should promote the client's use of any available community or online resources that can help her progress toward meeting her goals. Stress is a contributing factor to cardiovascular disease, as well as many other specific and systematic disorders.

A nurse is caring for a client diagnosed with severe acute respiratory syndrome (SARS). The nurse is aware that health care professionals are required to report communicable and infectious diseases. Which of the following illustrate the rationale for reporting? (Select all that apply) A) Planning and evaluating control and prevention strategies B) Determining public health priorities C) Ensuring proper medical treatment D) Identifying endemic disease E) Monitoring for common-source outbreaks

A, B, C, E Rationale: Reporting of communicable and infectious diseases assists with planning and evaluating control and prevention strategies, determining public health policies, ensuring proper medical treatment is available, and monitoring for common-source outbreaks.

A nurse manager is reviewing guidelines to prevent injury with staff nurses. Which of the following should the nurse manager include in the teaching? (Select all that apply) A) Request assistance when repositioning a client. B) Avoid twisting the spine or bending at the waist. C) Keep the knees slightly lower than the hips when sitting for long periods of time. D) Use smooth movements when lifting and moving clients. E) Take a break from repetitive movements every 2 to 3 hr to flex and stretch joints and muscles.

A, B, D Rationale: It is preferred that two or more personnel assist with any positioning in order to reduce the risk of injury. Twisting the spine or bending at the waist (flexion) increases the nurse's risk for injury. Using smooth movements instead of sudden or jerky muscle movements is recommended to prevent injury.

The skin barrier covering a client's intestinal fistula keeps falling off when she stands up to ambulate. The nurse has reapplied it twice during the current shift, but it remains intact only when the client is supine in bed. The nurse telephoned the physical therapist about the difficulties containing the drainage from the fistula, so the therapist did not ambulate the client today. The client sat in a chair during lunch with an absorbent pad over the fistula. The client ate all the food on her tray. The wound care nurse confirmed that she will see the client later today. The client states that she feels frustrated at not having physical therapy, but the nurse thinks the client welcomed having a day to rest. Which of the following information should the nurse include in the change-of-shift report? (Select all that apply) A) The physical therapist did not ambulate the client today. B) The skin barrier's seal stays on in bed but loosens when the client stands. C) The client seemed to welcome having a "day off" from physical therapy. D) The wound care nurse will see the client later today. E) The client ate all the food on her lunch tray.

A, B, D Rationale: The oncoming nurse needs to know about any changes in or deviations from the client's plan of care, such as missing a physical therapy session. The current problem about the adhesion of the skin barrier is important information the oncoming nurse needs to know and address. The oncoming nurse also needs to know about any consultations that will take place during the shift.

A nurse is talking with the parents of a 6-month-old infant about gross motor development. Which of the following gross motor skills are expected findings in the next 3 months? (Select all that apply) A) Rolls from back to front B) Bears weight on legs C) Walks holding onto furniture D) Sits unsupported E) Sits down from a standing position

A, B, D Rationale: The infant should be able to roll from back to front by 6 months. The infant should be able to bear weight on legs by 7 months. The infant should be able to sit unsupported by 8 months.

A nurse educator is reviewing with a newly hired nurse the difference in clinical manifestations of a localized versus a systemic infection. The nurse indicates understanding when she states that which of the following are clinical manifestations of a systemic infection? (Select all that apply) A) Fever B) Malaise C) Edema D) Pain or tenderness E) Increase in pulse and respiratory rate

A, B, E Rationale: Systemic infections affect the whole body.

A nurse is preparing a wellness presentation for families at a community center. When discussing health screenings for adolescents, which of the following information about scoliosis should the nurse include? (Select all that apply) A) Scoliosis is more common among girls than it is among boys. B) Loss of height is often the first sign of scoliosis. C) Scoliosis screening is essential during the adolescent growth spurt. D) Slouching is a common cause of scoliosis, especially in adolescents. E) Scoliosis is a forward curvature of the spine.

A, C Rationale: Girls are more likely than boys to have adolescent idiopathic scoliosis. Idiopathic scoliosis is most noticeable during the adolescent growth spurt.

A client who is postoperative following knee arthroplasty is concerned about the adverse effects of the medication he is receiving for pain management. Which of the following members of the interprofessional care team may assist the client in understanding the medication's effects. (Select all that apply) A) Provider B) Certified nursing assistant C) Pharmacist D) Registered nurse E) Respiratory therapist

A, C, D Rationale: All must be knowledgeable about any medication he or she prescribes for the client, including its actions, effects, and interactions.

A nurse is giving a presentation about accident prevention to a group of parents of toddlers. Which of the following accident-prevention strategies should the nurse include? (Select all that apply) A) Keep toxic agents in locked cabinets. B) Keep toilet seats up. C) Turn pot handles toward the back of the stove. D) Place safety gates across stairways. E) Make sure balloons are fully inflated.

A, C, D Rationale: Parents must prevent toddlers from accessing dangerous substances. If toddlers can reach a pot handle, they can pull the pot and its contents down no themselves and incur serious injuries. At the bottom of a staircase, they prevent toddlers from climbing stairs and falling backward. At the top of a staircase, they prevent toddlers from falling down the stairs.

A nurse is transferring a client from an acute-care hospital to a rehabilitation facility. Which of the following information about the client should the nurse include in the transfer report? (Select all that apply) A) Alert and oriented B) Refuses to eat spinach C) Has a selfish allergy D) Requests morphine every 4 hr E) Misses the two cats he has at home

A, C, D Rationale: The client's LOC is relevant for evaluating health status and maintaining safety and comfort. Information about the client's allergy is essential for maintaining his safety and comfort. It is essential to convert any information about medications or other therapies the client will need within the next few hours.

A nurse is admitting an older client who has lost 4.5 kg (9.9 lb) since his last admission 6 months ago. Which of the following questions should the nurse ask to investigate the source of his weight loss? (Select all that apply) A) "Do you eat alone or with someone?" B) "Do you watch television while eating your meals?" C) "Have you started any new medications in the past 6 months?" D) "What foods have you eaten within the past 24 hours?" E) "Are you on a fixed income?"

A, C, D, E Rationale: Clients who eat alone are more likely to skip or skimp on meals. Many medications affect the senses of taste and smell, as well as the abilities to tolerate food and to absorb nutrients. Asking about food the client ate within the last 24 hr will provide a basis to determine what he typically eats in a 24-hr period. Clients who receive a fixed income may not have enough money to buy food.

A nurse in a provider's office is preparing to assess a young adult male client's musculoskeletal system as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply) A) A concave thoracic spine posteriorly B) An exaggerated lumbar curvature C) A concave lumbar spine posteriorly D) An exaggerated thoracic curvature E) Muscles slightly larger on his dominant side

A, C, E Rationale: All of the above are expected findings.

Which of the following are behaviors of active listening? (Select all that apply) A) Maintaining an open posture B) Writing down what the client says so that details are not forgotten C) Establishing and maintaining eye contact D) Nodding in agreement with the client throughout the conversation E) Responding positively when giving feedback

A, C, E Rationale: Having an open posture and leaning forward, establishing and maintaining eye contact, and responding positively when giving feedback are ways the nurse can demonstrate active listening.

A nurse is collecting history and physical examination data from a middle adult. The nurse should expect to find decreases in which of the following physiologic functions? (Select all that apply) A) Metabolism B) Ability to hear low-pitched sounds C) Gastric secretion D) Far vision E) Glomerular filtration

A, C, E Rationale: In middle adulthood, metabolism declines and weight gain is likely. In middle adulthood, decreases in secretions of bicarbonate and gastric mucus begin and persist into older age. This increases the risk of peptic ulcer disease. Middle adults begin to lose nephron units, which results in a decline in glomerular filtration rates.

A nurse in a provider's office is preparing to test a client's cranial nerve function. Which of the following directions should she include when testing cranial nerve V? (Select all that apply) A) "Close your eyes." B) "Tell me what you can taste." C) "Clench your teeth." D) "Raise your eyebrows." E) "Tell me when you feel a touch."

A, C, E Rationale: Testing cranial nerve V, the trigeminal nerve, involves testing light touch by having the client tell the nurse when he feels a gentle touch on his face from a wisp of cotton. Testing the strength of muscle contraction involves asking the client to clench his teeth while the nurse palpates the master and temporal muscles, and then the temporomandibular joint. The first step of testing cranial nerve V is to have the client close his eyes.

A nurse is caring for an 82-year-old client in the emergency department who has an oral body temperature of 38.3 degrees celsius (101 degrees fahrenheit), a pulse rate of 114/min, and a respiratory rate of 22/min. He is restless and his skin is warm. Which of the following are appropriate nursing interventions for this client? (Select all that apply) A) Obtain a culture specimens before initiating antimicrobials. B) Restrict the client's oral fluid intake. C) Encourage the client to limit activity and rest. D) Allow the client to shiver to dispel excess heat. E) Assist the client with oral hygiene frequently.

A, C, E Rationale: The provider may prescribe cultures to identify any infectious organisms causing the fever. The nurse should obtain culture specimens before antimicrobial therapy to prevent interference with the detection of the infection. Rest helps conserve energy and decreases metabolic rate. Activity can increase heat production. Oral hygiene helps prevent cracking of dry mucous membranes of the mouth and lips.

A nurse is planning diversionary activities for children on an inpatient pediatric unit. Which of the following should the nurse incorporate as appropriate play activities for preschoolers? (Select all that apply) A) Assembling puzzles B) Pulling wheeled toys C) Using musical toys D) Using finger paints E) Coloring with crayons

A, C, E Rationale: These activities are appropriate for preschoolers and help develop fine motor skills, cognitive skills, and coordination.

A nurse in a provider's office is preparing to assess a client's skin as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply) A) Capillary refill in 2 seconds B) 1+ pitting edema in both feet C) Pale nail beds in both hands D) Thick skin on the soles of the feet E) Numerous light brown macule on the face

A, D, E Rationale: Capillary refill in less than 2 seconds is an expected finding. Thicker skin on the palms of the hands and the soles of the feet is an expected finding. Light brown macules on the face are likely to be freckles, which are an expected finding.

A nurse in a provider's office is preparing to perform a breast examination for an older adult who is postmenopausal. Which of the following findings should the nurse expect? (Select all that apply) A) Smaller nipples B) Less adipose tissue C) Nipple discharge D) More pendulous E) Nipple inversion

A, D, E Rationale: In older adulthood, the nipples become smaller and flatter and the breasts become softer and more pendulous. Nipple inversion is common among older adults, due to fibrotic changes and shrinkage.

A nurse is caring for a 5-year-old client whose parents report that she fears painful procedures, such as injections. Which of the following strategies should the nurse use to try to help ease the child's fear? (Select all that apply) A) Invite the child to assist with mealtime activities. B) Cluster invasive procedures whenever possible. C) Assign caregivers with whom the child is familiar. D) Have the parents bring in a favorite toy from home. E) Engage the child in pretend play with a toy medical kit.

A, D, E Rationale: Preschoolers enjoy mastering tasks they can perform independently. Assisting with routine, nonthreatening tasks can help improve their self-esteem during hospitalization. Having familiar and cherished objects nearby is therapeutic for children during their hospitalization. Pretend play helps children determine the difference between reality and fantasy (imagined fears), especially with the assistance of the nurse during hospitalization.

A nurse is assessing a client's thyroid gland as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply) A) Palpating the thyroid in the lower half of the neck B) Visualizing the thyroid on inspection of the neck C) Hearing a bruit when auscultating the thyroid D) Feeling the thyroid ascend as the client swallows E) Finding symmetric extension of the trachea on both sides of the midline

A, D, E Rationale: The thyroid gland lies in the anterior position of the lower half of the neck, just in front of the trachea. When the client swallows a sip of water, the nurse should feel the thyroid move upward with the trachea. The thyroid gland lies in front of the trachea and extends symmetrically to both sides of the midline.

A nursing instructor is reviewing the steps of the nursing process with a group of nursing students. The students should identify which of the following data as objective? (Select all that apply) A) Respiratory rate of 22/min with even, unlabored respirations B) "I can only walk three blocks before my legs start to hurt." C) Pain level 3 on a scale of 0 to 10 D) Skin pink, warm, and dry E) Urine output of 300 mL/8 hr F) Dressing clean, dry, and intact

A, D, E, F Rationale: Objective data are those nurses observe and measure.

A nurse manager of a medical-surgical unit is assigning care responsibilities for the oncoming shift. A client is awaiting transfer back to the unit from the PACU following thoracic surgery. To which staff member should the nurse assign to this client? A) Charge nurse B) RN C) Licensed practical nurse (LPN) D) Assistive personnel (AP)

B Rationale: A client returning from surgery requires assessment and establishment of a plan of care. RNs are responsible for assessment (especially when a client is potentially unstable), initiation of an individualized plan of care, and identification of expected client outcomes.

A hospital is conducting a community blood pressure screening in its lobby. This is an example of which of the following levels of care? A) Preventive B) Primary C) Secondary D) Tertiary

B Rationale: A screening is an attempt to detect an undiagnosed disease at its earliest stage, and it is an example of primary care.

A nurse is evaluating how well a client learned the information presented in an instructional session about following a heart-healthy diet. The client states that she understands what to do now. Which of the following actions by the nurse should assist the nurse in evaluating the client's learning? A) Encourage the client to ask questions. B) Ask the client to explain how to select of prepare meals. C) Encourage the client to fill out an evaluation form. D) Ask the client if she has resources for further instruction on this topic.

B Rationale: A useful strategy for evaluating learning is to ask the client to explain in her own words how she will implement what she learned.

A nurse in a provider's office is collecting data from the mother of a 1-year-old child. The client states that her child is old enough for toilet training. Following an educational session by the nurse, the client now states that her earlier ideas have changed. She is now willing to postpone toilet training until the child is older. Learning has occurred in which of the following domains? A) Cognitive B) Affective C) Psychomotor D) Kinesthetic

B Rationale: Affective learning has taken place, as evidenced by the client's changed ideas about toilet training.

A nurse educator is conducting a parenting class for new parents. Which of the following statements made by a participant indicated a need for further clarification and instruction? A) "I will begin swimming lessons as soon as my baby can close her mouth underwater." B) "Once my baby can sit up, he should be safe in the bathtub." C) "I will test the temperature of the water before placing my baby in the bath." D) "Once my infant starts to push up, I will remove the mobile from over the bed."

B Rationale: Although the baby can hold his head above the water by sitting up, this does not make the child safe in the bathtub. Parents should never leave an infant or toddler alone in the bathtub.

A nurse is collecting data for a client's comprehensive physical examination. After the nurse inspects the client's abdomen, which of the following skills of the physical examination process should she perform next? A) Olfaction B) Auscultation C) Palpation D) Percussion

B Rationale: Because palpation and percussion can alter the frequency and intensity of bowel sounds, the nurse should auscultate the abdomen next - and before using those two techniques.

A nurse at a provider's office is talking with a 45-year-old client who has no specific family history of cancer or diabetes mellitus about planning her routine screenings. Which of the following client statements indicated that the client understands how to proceed? A) "So I don't need the colon cancer procedure for another 2 or 3 years." B) "For now, I should continue to have a mammogram each year." C) "Because the doctor just did a Pap smear, I'll come back next year for another one." D) "I had my blood glucose test last year, so I won't need it again till next year."

B Rationale: Between the ages of 40 and 50, women should have a mammogram annually.

A nurse is caring for a client whose partner passed away 4 months ago and who has been recently diagnosed with diabetes mellitus. He is tearful and states, "How could you possibly understand what I am going through?" Which of the following is an appropriate response by the nurse? A) "It takes time to get over the loss of a loved one." B) "You are right; I cannot really understand. Perhaps you'd like to tell me more about what you're feeling." C) "Why don't you try something to take your mind off your troubles, like watching a funny movie." D) "I might not share your exact situation, but I do know what people go through when they deal with a loss."

B Rationale: By stating that she is not in his situation, the nurse is using the therapeutic communication technique of validation, whereby she shows sensitivity to the meaning behind his behavior. She is also creating a supportive and nonjudgmental environment, and inviting him to express his frustrations.

A nurse enters a client's room and finds him sitting in his chair. He states, "I fell in the shower, but I got myself back up and into my chair." How should the nurse document this in the client's chart? A) The client fell in the shower. B) The client states he fell in the shower and was able to get himself back into his chair. C) The nurse should not document this information in the chart because she did not witness the fall. D) The client fell in the shower but is now resting comfortably.

B Rationale: By writing what the client says, the information is subjective data.

When a nurse is observing a client drawing up and mixing insulin injections, which of the following best demonstrates that psychomotor learning has taken place? A) The client is able to discuss the appropriate technique. B) The client is able to demonstrate the appropriate technique. C) The client states that he understands. D) The client is able to write the steps on a piece of paper.

B Rationale: Demonstrating the appropriate technique indicates that psychomotor learning has taken place.

A nurse manager is reviewing care of a client who has had a seizure with nurses on the unit. Which of the following statements by a nurse requires further instruction? A) "I will place the client on his side." B) "I will go to the nurses' station for assistance." C) "I will administer medications as prescribed." D) "I will be prepared to insert an airway."

B Rationale: During a seizure, the client should not be left alone. The nurse remains with the client and calls for assistance using the call light.

A nurse is caring for a client receiving enteral tube feedings due to dysphagia. Which of the following bed positions is appropriate for safe care of this client? A) Supine B) Semi-Fowler's C) Semi-prone D) Trendelenburg

B Rationale: In the semi-Fowler's position, the client lies supine with the head of the bed elevated approximately 30 degrees. This position is frequently used to prevent regurgitation and aspiration in clients who have difficulty swallowing. This is the safest position for the client receiving a tube feeding.

A nurse is caring for a client who decides not to have surgery despite significant blockages in his coronary arteries. The nurse understands that this client's choice is an example of which of the following ethical principles? A) Fidelity B) Autonomy C) Justice D) Nonmaleficence

B Rationale: In this situation, the client is exercising his right to make his own personal decision about surgery, regardless of others' opinions of what is "best" for him. This is an example of autonomy.

A nurse is reviewing car-seat safety with parents of a 1-month-old infant. When reviewing car-seat use, which of the following instructions should the nurse include? A) Use a car seat that has a three-point harness system. B) Position the car seat so that the infant is rear facing. C) Secure the car seat in the front passenger seat of the vehicle. D) Put soft padding in the car seat behind the infant's back and neck.

B Rationale: Infants in a car seat should face the rear of the vehicle until age 2 or until they reach the maximum height and weight for the seat.

A nurse is talking with a client who recently attended a cholesterol screening event and a heart-healthy nutrition presentation at a neighborhood center. His total cholesterol result from the screening was 248 mg/dL, so he saw his provider and received a medication prescription to improve his cholesterol level. The client was later hospitalized for severe chest pain, and subsequently enrolled in a cardiac rehabilitation program. Which of the following activities of this client is an example of primary prevention? A) Cholesterol screening B) Nutrition presentation C) Medication therapy D) Cardiac rehabilitation

B Rationale: Primary prevention encompasses strategies that actually help prevent illness or injury. This level of prevention includes health information about nutrition, exercise, stress management, and protection from illness and injuries.

A nurse is caring for a client who states, "I have to check with my wife and see if she thinks I am ready to be discharged." The nurse replies, "How do you feel about going home today?" Which clarifying technique is the nurse displaying to enhance communication between the nurse and the client? A) Pacing B) Reflecting C) Paraphrasing D) Restating

B Rationale: Reflecting directs the focus of the conversation back to the client so that the client can further explore his own feelings.

A nurse in an ambulatory care clinic is caring for a client who had a mastectomy 6 months ago. The client tells the nurse that she has not had much desire for sexual relations since her surgery, stating, "My body is so different now." Which of the following is an appropriate response by the nurse? A) "Really, you look just fine to me. There's no need to feel undesirable." B) "I'm interested in finding out more about how your body feels to you." C) "Consider an afternoon at a spa. A facial will make you feel more attractive." D) "It's still too soon to expect to feel normal. Give it a little more time"

B Rationale: Showing interest in the client is applying the therapeutic communication technique of offering self; asking more about how the client feels is applying the therapeutic communication technique of encouraging a description of perception.

A nurse who admitting a client who has a fractured femur obtains a blood pressure (BP) reading of 140/94 mmHg. The client denies an history of HTN. Which of the following actions should the nurse take next? A) Request a prescription for an antihypertensive medication. B) Ask the client is she is having pain. C) Request a prescription for an anti-anxiety medication. D) Return in 30 min to recheck the client's BP.

B Rationale: The greatest risk to a client with a fracture is unrelieved pain, which can cause multiple complications, including elevated BP. Therefore, the nurse's priority is to perform a pain assessment. If the client's BP is still elevated after pain interventions, the nurse should report this finding to the provider. Of these instructions, this is the nurse's priority.

An adult client who is competent tells the nurse that he is thinking about leaving the hospital against medical advice. The nurse believes that this is not in the client's best interest, so she administers a PRN sedative medication the client has not requested along with his usual medication. Which of the following types of tort has the nurse committed? A) Assault B) False imprisonment C) Negligence D) Breach of confidentiality

B Rationale: The nurse gave the medication as a chemical restraint to keep the client from leaving the facility against medical advice. This is false imprisonment because the client neither requested nor consented to receiving the sedative.

A nurse receives a prescription for an antibiotic for a client who has cellulitis. The nurse checks the client's medical record, discovers that she is allergic to the antibiotic, and cells the provider to request a prescription for a different antibiotic. Which of the following critical thinking attitudes did the nurse demonstrate? A) Fairness B) Responsibility C) Risk taking D) Creativity

B Rationale: The nurse is responsible of administering medications in a safe manner and according to standards of practice. Checking the medical record for allergies helps ensure safety.

A nurse is caring for a school-age child who is seated. In order to facilitate effective communication, the nurse should A) touch the child. B) sit at eye level with the child. C) stand facing the child. D) stand with a relaxed posture.

B Rationale: The nurse should be at the same eye level as the child to facilitate communication.

A nurse is instructing a group of nursing students in the priorities of care in performing an integumentary assessment for their clients. Which of the following findings should the students recognize as requiring immediate intervention? A) Pallor B) Cyanosis C) Jaundice D) Erythema

B Rationale: The priority finding when using the airway, breathing, circulation (ABC) approach to care delivery is one that affects the client's airway. Cyanosis can reflect hypoxia (inadequate oxygenation), so nurses must take immediate action to report the finding and improve the client's oxygenation.

A nurse recognizes that a helping relationship is established with a client if the communication A) is equally reciprocal between the nurse and the client. B) encourages the client to express his thoughts and feelings. C) has no time limits. D) occurs spontaneously throughout the nurse-client relationship.

B Rationale: Therapeutic communication facilitates a helping relationship that maximizes the client's ability to openly express his thoughts and feelings.

A nurse is talking with parents of a preschooler who describe several issues that concern them. Which of the following problems the parents verbalized should the nurse identify as the priority for further assessment and intervention? A) "Our son will only eat a few things, like burgers and bananas, and pretty much refuses everything else." B) "Our son has these temper tantrums every time we tell him to do something he doesn't want to do." C) "We think our son truly believes that his toys have personalities and talk to him, especially at night." D) "We feel bad when we see our son trying so hard to button his shirt. We just tell him this is something he'll just have to learn to do."

B Rationale: When using the urgent vs. non urgent approach to client care, the nurse determines that the priority issue is the problem that reflects a lack of completion of the previous stage of development and progression to the current stage of development. According to Erikson, it is a task of toddler stage to develop autonomy vs. shame and doubt. The preschooler is still acting out with negativism, which is a persistent negative response to requests, often manifested in tantrums. He is still struggling with this task and needs assistance in working through that stage.

A nurse is counseling a middle adult who describes having difficulty dealing with several issues. Which of the following problems the client verbalized should the nurse identify as the priority for further assessment and intervention? A) "I am struggling to accept that my parents are aging and need so much help." B) "It's been so stressful for me to think about having intimate relationships." C) "I know I should volunteer my time for a good cause, but maybe I'm just selfish." D) "I love my grandchildren, but my son expects me to relive my parenting days."

B Rationale: When using the urgent vs. nonurgent approach to client care, the nurse determines that the counseling priority is the problem that reflects a lack of completion of the previous stage and progression to the current stage of development. According to Erikson, it is a task of young adulthood to develop intimacy vs. isolation. This middle adult is still struggling with this task and needs assistance in working through searching for and developing intimate relationships with others.

A nurse is teaching a young adult client about health promotion and illness prevention. Which of the following statements by the client indicates an understanding of the teaching? A) "I already had my immunizations as a child, so I'm protected in that area." B) "It is important to schedule routine health care visits even if I am feeling well." C) "If I am having any discomfort, I'll just go to an urgent care center." D) "If I am feeling stressed, I will remind myself that this is something I should expect."

B Rationale: Young adulthood is a time of relative health, but routine screenings and health care visits are still important.

A nursing instructor is reviewing documentation with a group of nursing students. Which of the following legal guidelines should they follow when documenting in a client's record? (Select all that apply) A) Covers errors with correction fluid, and write in the correct information. B) Put the date and time on all entries. C) Document objective data, leaving out opinions. D) Use as many abbreviations as possible. E) Wait until the end of the shift to document.

B, C Rationale: The day and time confirm the recording of the correct sequence of events. Documentation must be factual, descriptive, and objective, without opinions of criticism.

The mother of a 7-month-old infant tells the nurse at the pediatric clinic that her baby has been fussy with occasional loose stools since she started feeding him fruits and vegetables. Which of the following responses by the nurse are appropriate? (Select all that apply) A) "It might be good to add bananas, as they can help with loose stools." B) "Let's make a list of foods he is eating so we can spot any problems." C) "Did the changes begin after you started one particular food?" D) "Has he been vomiting since he started these new foods?" E) "Most babies react with a little indigestion when you start new foods."

B, C, D Rationale: Before the nurse can determine that there is a problem, such as food allergy or intolerance, she should determine the components of the child's diet. Fussiness and diarrhea, as well as a rash and vomiting or constipation, can all be signs of a food allergy or intolerance. Before the nurse can intervene, she has to collect data that can help her plan the appropriate interventions. Vomiting and constipation can also be signs of a food allergy or intolerance. Before the nurse can intervene, she has to collect data that can help her plan the appropriate interventions.

A nurse has prepared a sterile field for assisting a provider with a chest tube insertion. Which of the following events should the nurse recognize as contaminating the sterile filed? (Select all that apply) A) The provider drops a sterile instrument onto the near side of the sterile field. B) The nurse moistens a cotton ball with sterile normal saline and places it on the sterile field. C) The procedure is delayed 1 hr because the provider receives an emergency call. D) The nurse turns to speak to someone who enters through the door behind the nurse. E) The client's hand brushes against the outer edge of the sterile field.

B, C, D Rationale: Fluid permeation of the sterile drape or barrier contaminates the field. Prolonged exposure to air contaminates a sterile field. Turing away from a sterile field contaminates the field because the nurse cannot see if a piece of clothing or hair made contact with the field.

A nurse educator is discussing the facility protocol in the event of a tornado with the staff. Which of the following should the nurse include in the instructions? (Select all that apply) A) Open doors to client rooms. B) Place blankets over clients who are confined to beds. C) Move beds away from the windows. D) Draw shades and close drapes. E) Relocate ambulatory clients in the hallways back into their rooms.

B, C, D Rationale: In the event of a tornado, placing blankets over clients protects them from shattering glass or flying debris. The nurse should move all beds away from windows to protect clients from shattering glass or flying debris. The nurse should draw shades and close drapes to protect clients against shattering glass.

A nurse's assessment of an older adult client identifies significant tenting of the skin over his forearm. Which of the following can explain this finding? (Select all that apply) A) Thin, parchment-like skin B) Loss of adipose tissue C) Dehydration D) Diminished skin elasticity E) Excessive dryness and wrinkling

B, C, D Rationale: Tenting is a delay in the skin returning to its normal place after pinching. It can be a sign of aging skin and loss of subcutaneous tissue that provides recoil in younger skin. It can be a sign of dehydration, which easily develops in older adult clients for many reasons. It can be a sign of aging skin and its loss of elasticity.

A nurse is delegating the ambulation of a client who has had knee arthroplasty 5 days ago to an AP. Which of the following information should the nurse share with the AP? (Select all that apply) A) The roommate is up independently. B) The client ambulated with his slippers on over his antiemobolic stockings. C) The client uses a front-wheeled walker when ambulating. D) The client had pain medication 30 min ago. E) The client is allergic to codeine. F) The client ate 50% of his breakfast this morning.

B, C, D Rationale: The AP should make sure the client wears stockings and slippers, uses a front-wheeled walker, and feels the effects of the pain medication.

A nurse is reviewing safety precautions with a group of young adults at a community health fair. Which of the following recommendations should the nurse include specifically for this age group? (Select all that apply) A) Install bath rails and grab bars in bathrooms. B) Wear a helmet while skiing. C) Install a carbon monoxide detector. D) Secure firearms in a safe location. E) Remove throw rugs from the home.

B, C, D Rationale: Wearing a helmet while skiing helps reduce the risk of head injury. Although it applies to other age groups, many young adults engage in winter sports, so this is an age-appropriate recommendation for this developmental group. Having a carbon monoxide detector in the home is an essential safety precaution for young adults as well as for all other developmental stages. Securing firearms in a safe location helps reduce the risk of accidental gunshot injuries. Although it applies to all age groups, many young adults own firearms, so this is an age-appropriate recommendation for this developmental group.

A nurse is collecting data from an older adult client as part of a neurosensory examination. Which of the following findings should the nurse expect as changes associated with aging? (Select all that apply) A) Slower light touch sensation B) Some vision and hearing decline C) Slower fine finger movement D) Some short-term memory decline E) Slower superficial pain sensation

B, C, D Rationale: With aging, losses in vision, hearing, taste and smell decline. With aging, fine finger movement slows, along with some reflex and motor responses. With aging, some decline in short-term memory is an expected finding. Major cognitive decline is an expected finding.

A nurse is performing a comprehensive physical examination for an older adult. Which of the following interventions should the nurse use in consideration of the client's age? (Select all that apply) A) Perform the assessments in one continuous session. B) Plan to allow plenty of time for position changes. C) Make sure the client has any essential sensory aids in place. D) Tell the client to take her time answering questions. E) Invite the client to use the bathroom before beginning the examination.

B, C, D, E Rationale: Because many older adults have mobility challenges, the nurse should plan the session to allow extra time for position changes. The nurse should make sure older adults who use sensory aids have them available for use. The client has to be able to hear the nurse and see well enough to avoid injury. Some older clients need more time to collect their thoughts and answer questions, but most are reliable historians. Feeling rushed can hinder communication. Inviting the client to use the bathroom before examination is a courtesy for all clients, to avoid discomfort during palpation of the lower abdomen for example, but this is especially important for older clients who might have a diminished bladder capacity.

A nurse is planning a presentation to a group of older adults at a senior community center about the essential screening tests and preventive procedures during this stage of life. Which of the following should the nurse include? (Select all that apply) A) HPV immunization B) Pneumococcal immunization C) Eye examination D) Mental health screening E) Dual-energy x-ray absorptiometry (DEXA) scanning

B, C, D, E Rationale: Older adults are especially susceptible to pneumococcal infections, so this is an essential preventive measure for this stage of life. Screening for glaucoma via regular eye examinations, depression via mental health assessments, and osteoporosis via DEXA scanning is essential for older adults.

A nurse is contributing to the plan of care for a client who is being admitted to the facility with a suspected diagnosis of pertussis. Which of the following should the nurse include in the plan of care? (Select all that apply) A) Place the client in a room that has negative air pressure of at least six exchanges per hour. B) Wear a mask when providing care within 3 ft of the client. C) Place a surgical mask on the client if transportation to another department is unavoidable. D) Use sterile gloves when handling soiled linens. E) Wear a gown when performing care that may result in contamination from secretions.

B, C, E

A nurse is explaining the differences among the various agencies that address health care. The nurse should note that which of the following are health care regulatory agencies? (Select all that apply) A) American Nurses Association (ANA) B) The Joint Commission C) State boards of nursing D) National League for Nursing (NLN) E) Food and Drug Administration (FDA)

B, C, E

A nurse is preparing an in-service program about delegation. Which of the following elements should she identify when presenting the five rights of delegation? (Select all that apply) A) Right client B) Right supervision/evaluation C) Right direction/communication D) Right time E) Right circumstances

B, C, E Rationale: All of the above in addition to the right task and the right person.

A nurse is caring for a client who has a new diagnosis of type 2 diabetes mellitus. Which of the following nursing interventions for stress, coping, and adherence to the treatment plan would be appropriate at this time? (Select all that apply) A) Suggest coping skills for the client to utilize in this situation. B) Allow the client to provide input in the treatment plan. C) Assist the client with time management, and address the client's priorities. D) Provide extensive instructions on the client's treatment regimen. E) Encourage the client in the expression of feelings and concerns.

B, C, E Rationale: Allowing the client to contribute to the treatment plan allows for greater adherence to the plan. Helping the client to prioritize is an intervention that ca reduce levels of stress for the client because many times time management is extremely difficult in times of stress. By using effective communication techniques, encouraging the client to verbalize feelings is an intervention for stress, coping, and adherence that allows the client reduce stress, validate emotions, and start planning for valid concerns.

A nurse is caring for a client who is postoperative following knee surgery. Which of the following should the nurse examine to assess the client's peripheral vascular system? (Select all that apply) A) Range of motion B) Skin color C) Edema D) Skin lesions E) Skin temperature

B, C, E Rationale: Assessing the peripheral vascular system to verify adequate circulation to the client's legs includes skin color. Pallor and cyanosis reflect inadequate circulation. Assessing the peripheral vascular system to verify adequate circulation to the client's legs includes edema. Edema reflects inadequate venous circulation. Assessing the peripheral vascular system to verify adequate circulation to the client's legs includes skin temperature. Coolness of the extremity compared with the nonoperative extremity indicates inadequate circulation.

A nurse is caring for a group of clients on a medical-surgical unit. Which of the following clients are at high risk for body image distribution? (Select all that apply) A) 30-year-old male following laproscopic appendectomy B) 45-year-old female following mastectomy C) 20-year-old female following left above-the-knee amputation D) 65-year-old male following cardiac catheterization E) 55-year-old male following stroke with right-sided hemiplegia

B, C, E Rationale: Having a mastectomy involves a change in the physical appearance of a woman and can lead to body image disturbances related to femininity and sexuality. Having an above-the-knee amputation involves a change in physical appearance and can lead to body image disturbances related to function. health, and strength. Having right-sided hemiplegia involves a change in physical appearance and can lead to body image disturbances related to function, health, and strength.

A nurse is preparing the discharge summary for a client who has had knee arthroplasty and is going home. Which of the following information about the client should the nurse include in the discharge summary? (Select all that apply) A) Advance directives status B) Where to go for follow-up care C) Instructions for diet and medications D) Most recent vital sign data E) Contact information for the home health care agency

B, C, E Rationale: It is essential to include the names and contact information of health care providers and community resources the client will need after he returns home. For example, a client who has had knee arthroplasty might require physical therapy at home until he can travel to a physical therapy department or facility. The client will need written information detailing his medication and dietary therapy at home. A client who has had knee arthroplasty typically requires analgesics, possibly anticoagulants, and dietary instructions for avoiding postoperative complications such as constipation.

A nurse is providing discharge instructions to a client who has a prescription for the use of oxygen in his home. Which of the following should the nurse teach the client about using oxygen safely in his home? (Select all that apply) A) Family members who smoke must be at least 10 ft from the client when oxygen is in use. B) Nail polish should not be used near a client who is receiving oxygen. C) A "No Smoking" sign should be placed on the front door. D) Cotton bedding and clothing should be replaced with items made from wool. E) A fire extinguisher should be readily available in the home.

B, C, E Rationale: Nail polish and other flammable materials may cause a fire and should not be used. A "No Smoking" sign should be placed near the front door. A sign also may be placed on the client's bedroom door. A readily available fire extinguisher should be placed in all homes, including the home of a client who is receiving oxygen.

A nurse is introducing herself to a client as the first step of a comprehensive physical examination. Which of the following strategies should the nurse use with this client? (Select all that apply) A) Address the client with the appropriate title and her last name. B) Use a mix of open- and closed-ended questions. C) Reduce environmental noise. D) Have the client complete a printed history form. E) Perform the general survey before the examination.

B, C, E Rationale: Open-ended questions help the client tell her story in her own way. Closed-ended questions are useful for clarifying and verifying information the nurse gathers from the client's story. A quiet, comfortable environment eliminates distractions and helps the client focus on the important aspects of the interview. The general survey is noninvasive and, along with the health history and vital sign measurement, can help put the client at ease before the more sensitive parts of the assessment, such as the examination.

A nurse is caring for a client who is 24 hr postoperative following abdominal surgery. The nurse suspects the client's pain management is inadequate. Which of the following data reinforce this suspicion? (Select all that apply) A) The client seems easily agitated. B) The client is non adherent with coughing, deep breathing, and dangling. C) The client may have pain medication ever 4 to 6 hr but accepts it every 6 to 7 hr. D) The client reports tenderness in his right lower leg. E) The client's vital signs are heart rate 110/min, respiratory rate 20/min, temperature 37 degrees celsius (98.6 degrees fahrenheit), and blood pressure 136/80 mm Hg.

B, C, E Rationale: Refusal to perform interventions that could increase his pain level (coughing, deep breathing) supports that the client has unrelieved pain. Acceptance of pain medication only at or beyond the maximum interval suggests that the client has pain between the time the effects of the previous dose subside and the new dose takes effect. Elevated blood pressure and pulse rate without elevated temperature or other signs of distress support that the client has unrelieved pain.

A nurse is reviewing the Centers for Disease Control and Prevention's (CDC's) immunization recommendations with the parents of two preschoolers. Which of the following recommendations should the nurse include in this discussion? (Select all that apply) A) Haemophilus influenzae type b B) Varicella C) Polio D) Hepatitis A E) Seasonal influenza

B, C, E Rationale: The CDC recommends a varicella (chickenpox) immunization, a polio immunization, and a seasonal influenza immunization during the preschool years.

A nurse is reviewing the Centers for Disease Control and Prevention's (CDC's) immunization recommendations with a middle adult client. Which of the following recommendations should the nurse include in this discussion? (Select all that apply) A) Haemophilus influenzae type b B) Varicella C) Herpes zoster D) Human papilloma virus E) Seasonal influenza

B, C, E Rationale: The CDC recommends varicella (chickenpox) immunizations, herpes zoster (shingles) immunizations, and seasonal influenza immunizations during middle adulthood.

A home health nurse is discussing the dangers of food poisoning with a client. Which of the following information should the nurse include in her counseling? (Select all that apply) A) Most food poisoning is caused by a virus. B) Immunocompromised individuals are at risk for complications from food poisoning. C) Clients who are especially at risk are instructed to eat or drink only pasteurized milk, yogurt, cheese, or other dairy products. D) Healthy individuals usually recover from the illness in a few weeks. E) Handling raw and fresh food separately to avoid cross contamination may prevent food poisoning.

B, C, E Rationale: Very young, very old, and immunocompromised individuals, as well as pregnant women, are at risk for complications from food poisoning. Clients who are especially at risk are instructed to follow a low-microbial diet, which includes eating or drinking only pasteurized milk, yogurt, cheese, or other dairy products. Performing proper hand hygiene, ensuring that meat and fish are cooked to the correct temperature, handling raw and fresh foods separately to avoid cross contamination, and refrigerating perishable items may prevent food poisoning.

A nurse is reviewing hand hygiene techniques with a group of assistive personnel (AP). Which of the following instructions should the nurse include when discussing handwashing? (Select all that apply) A) Apply 3 to 5 mL of liquid soap to dry hands. B) Wash the hands with soap and water for at least 15 seconds. C) Rinse the hands with hot water. D) Use a clean paper towel to turn off hand faucets. E) Allow the hands to air dry after washing.

B, D Rationale: This is the amount of time it takes to remove transient flora from the hands. For soiled hands, the recommendation is 2 min. If the sink does not have foot or knee pedals, the APs should turn off the water with a clean paper towel and not with their hands.

During a cardiovascular examination, a nurse in a provider's office places the diaphragm of the stethoscope on the left midclavicular line at the fifth intercostal space. Which of the following heart sounds is the nurse attempting to auscultate? (Select all that apply) A) Ventricular gallop B) Closure of the mitral valve C) Closure of the pulmonic valve D) Closure of the tricuspid valve E) Murmur

B, D Rationale: To auscultate the closure of the mitral valve, the nurse places the diaphragm of the stethoscope over the apex, or apical/mitral site, which is on the left midclavicular line at the fifth intercostal space. To auscultate the closure of the tricuspid valve, the nurse places the diaphragm of the stethoscope over the apex, or apical/mitral site, which is on the left midclavicular line at the fifth intercostal space.

A nurse is assessing an adult client's internal ear canals with an otoscope as part of a head and neck examination. Which of the following actions are appropriate? (Select all that apply) A) Pull the auricle down and back B) Insert the speculum slightly down and forward C) Insert the speculum 2 to 2.5 cm (0.8 to 1 in) D) Make sure the speculum does not touch the ear canal E) Use the light to visualize the tympanic membrane in a cone shape

B, D, E Rationale: Inserting the speculum slightly down and forward follows the natural shape of the ear canal. The lining of the ear canal is sensitive. Touching it with the speculum could cause pain. Due to the angle of the ear canal, the nurse can only visualize the light reflecting off of the tympanic membrane as a cone shape rather than a circle.

A nurse is reviewing the Centers for Disease Control and Prevention's (CDC's) immunization recommendations with the parents of an adolescent. Which of the following recommendations should the nurse include in this discussion? (Select all that apply) A) Rotavirus B) Varicella C) Herpes zoster D) Human papilloma virus E) Seasonal influenza

B, D, E Rationale: The CDC recommends varicella (chickenpox) immunizations, HPV (genital warts) immunizations, and seasonal influenza immunizations during adolescence.

A nurse is collecting data from an older adult client as part of a comprehensive physical examination. Which of the following findings should the nurse expect as changes associated with aging? (Select all that apply) A) Skin thickening B) Decreased height C) Increased saliva production D) Nail thickening E) Decreased bladder capacity

B, D, E Rationale: With aging, height decreases due to thinning of intervertebral disks. Aging brings thickening of the nails of the fingers and toes, and also changes their shape, color, and growth rate. While young adults have a bladder capacity of about 500 to 600 mL, older adults have a capacity of about 250 mL.

A nurse is explaining the various types of health care coverage clients might have to a group of nursing students. The nurse should mention that which of the following health care financing mechanisms are federally funded? (Select all that apply) A) Preferred provider organization (PPO) B) Medicare C) Long-term care insurance D) Exclusive provider organization (EPO) E) Medicaid

B, E

A nurse on a pediatric unit is caring for an adolescent who has multiple fractures. Which of the following interventions are appropriate for this client? (Select all that apply) A) Suggest that his parents room in with him. B) Provide a television and DVDs for him to watch. C) Limit visitors to immediate family. D) Devise a regular schedule for inpatient routines. E) Allow him to perform his own morning care.

B, E Rationale: Nonviolent DVDs are appropriate diversional activities for an adolescent. Allowing him to perform his own morning care helps promote a sense of independence.

A nurse has noticed several occasions in the past week when another nurse on the unit seemed drowsy and unable to focus on the issue at hand. Today, she found the nurse asleep in a chair in the break room when she was not on a break. Which of the following actions should the nurse take? A) Remind the nurse that safe client care is a priority on the unit. B) Ask others on the team whether they have observed the same behavior. C) Report the observations to the nurse manager on the unit. D) Conclude that her coworker's fatigue is not her problem to solve.

C Rationale: Any nurse who notices behavior that could jeopardize client care or could indicate a substance abuse disorder has a duty to report the situation immediately to the nurse manager.

A nurse is caring for a client awaiting transport to the surgical suite for a coronary artery bypass graft. Just as the transport team arrives, the nurse takes the client's vital signs and notes an elevation in blood pressure and heart rate. The nurse should recognize this response as which part of the general adaptation syndrome (GAS)? A) Exhaustion stage B) Resistance stage C) Alarm reaction D) Recovery reaction

C Rationale: As a component of GAS, body functions, such as blood pressure and heart rate, are heightened in order to respond to the stressor in the alarm stage.

A nurse is providing preoperative teaching for a client who is scheduled for a mastectomy the next day. Which of the following client statements indicates that the client is ready to learn? A) "I don't want my spouse to see my incision." B) "Will you be able to give me pain medicine after the surgery?" C) "Can you tell me about how long the surgery will take?" D) "My roommate listens to everything I say."

C Rationale: Asking a concrete question about the surgery indicates that the client if ready to discuss the surgery. The client's new diagnosis of cancer may cause anxiety, fear, or depression, all of which can interfere with the learning process.

A nursing instructor is explaining the various stages of the lifespan to a group of nursing students. The nurse should offer which of the following behaviors by a young adult as an example of appropriate psychosocial development? A) Becoming actively involved in providing guidance to the next generation B) Adjusting to major changes in roles and relationships due to losses C) Devoting a great deal of time to establishing an occupation D) Finding oneself "sandwiched" in between and being responsible for two generations

C Rationale: Exploring career options and then establishing oneself in a specific occupation is a major developmental task for a young adult.

A nurse is assessing a client who reports pain when the nurse evaluates the internal rotation of her right shoulder. Which of the following activities is this problem likely to affect? A) Mopping her floors B) Brushing the back of her hair C) Fastening her bra behind her back D) Reaching into a cabinet above her sink

C Rationale: Fastening a bra from behind requires internal rotation of the shoulder, so this activity will elicit pain.

A nurse is talking with the parents of a 10-year-old child who express concern that their son is suddenly becoming secretive, for example, closing the door when he showers, dresses, and does his homework in his room. Which of the following responses by the nurse is appropriate? A) "Perhaps you should try to find out what he is doing behind those closed doors." B) "Suggest that he leave the door ajar for his own safety." C) "At this age, children tend to become more modest and value their privacy." D) "Tell him it's okay to close the door when he is undressed, but he has to do his homework when you can see him."

C Rationale: From a developmental perspective, it is an exception that school-age children develop privacy. They have their own way of doing things and spend more time alone.

A client in a managed care organization (MCO) requires hospitalization. Which of the following parties must first approve the admission? A) Emergency department physician B) Utilization review committee C) Provider D) Managed care administrator

C Rationale: In an MCO, the provider oversees all of the client's care including hospitalizations; therefore, the provider must approve the admission.

An occupational health nurse is caring for an employee who was exposed to an unknown dry chemical, resulting in a chemical burn. Which of the following interventions should the nurse include in the plan of care? A) Irrigate the affected area with running water. B) Wash the affected area with antimicrobial soap. C) Brush the chemical off the skin and clothing. D) Apply a neutralizing agent.

C Rationale: In the event of a dry chemical exposure, the recommendation is to brush the chemical off the skin and clothing.

A nurse is instructing a group of nursing students about the responsibilities involved with organ donation and procurement. When the nurse explains that all clients waiting for a kidney transplant have to meet the same qualifications, the students should understand that this aspect of care delivery is an example of which of the following ethical principles? A) Fidelity B) Autonomy C) Justice D) Nonmaleficence

C Rationale: Justice is fairness in care delivery and in the use of resources. By applying the same qualifications to all potential kidney transplant recipients, organ procurement organizations demonstrate this ethical principle in determining the allocation of these scarce resources.

A nurse is instructing a group of nursing students about how to know and what to expect when ethical dilemmas arise. Which of the following situations should the students identify as an ethical dilemma? A) A nurse on a medical-surgical unit demonstrates signs of chemical impairment. B) A nurse overhears another nurse telling an older client that if he doesn't stay in bed, she will have to apply restraints. C) A family has conflicting feelings about the initiation of enteral tube feedings for their father, who is terminally ill. D) A client who is terminally ill hesitates to name her spouse on her durable power of attorney form.

C Rationale: Making the decision about initiating enteral tube feedings is an example of an ethical dilemma. A review of scientific data cannot resolve the issue, and it is not easy to resolve. The decision will have a profound effect on the situation and on the client.

When entering a client's room to change a surgical dressing, a nurse notes that the client is coughing and sneezing. When preparing the sterile field, it is important that the nurse A) keep the sterile field at least 6 ft away from the client's bedside. B) instruct the client to refrain from coughing and sneezing during the dressing change. C) place a mask on the client to limit the spread of micro-organisms into the surgical wound. D) keep a box of facial tissues nearby for the client to use during the dressing change.

C Rationale: Placing a mask on the client prevents contamination of the surgical wound during the dressing change.

A nurse is talking with the father of a 4-year-old child who states that his daughter goes to bed at 8:30 p.m. and wakes up about 7:30 a.m., but she often lies in bed talking to herself or gets up a few times before falling asleep 40 min later. At her preschool, the children take a 2-hr afternoon nap. Which of the following recommendations should the nurse make to help improve the child's sleep behavior? A) Offer the child a snack of her favorite treat right before bedtime. B) Allow the child to watch an extra 30 min of TV in the evening. C) Change the child's bedtime to 9 p.m. on days she napped. D) Request that the preschool staff limit her nap time to 1 hr.

C Rationale: Preschoolers start to need less sleep than they did in previous stages. Putting the child to bed 30 min later, when she might be more tired, could help her fall asleep more readily.

A nurse observes smoke coming from under the door of the staff lounge. Which of the following is the priority action by the nurse? A) Extinguish the fire. B) Pull the fire alarm. C) Evacuate the clients. D) Close all open doors on the unit.

C Rationale: Rescue is the first action in the fire response. Protecting and evacuating clients in close proximity to the fire is the priority action.

A nurse is reviewing nutritional guidelines with the parents of a 2-year-old toddler. Which of the following parents' statements should indicate to the nurse that they understand the feeding guidelines for this age group? A) "I should keep feeding my son whole milk until he is 3 years old." B) "It's okay for me to give my son a cup of apple juice with each meal." C) "I'll give my son about 2 tablespoons of each food at mealtimes." D) "My son loves popcorn, and I know it is better for him than sweets."

C Rationale: Serving sizes for toddlers should be about 1 tbsp of solid food per year of age, so 2-year-olds should have about 2 tbsp per serving.

A nurse on a medical-surgical unit has received change-of-shift report and will care for four clients. Which of the following client's needs may the nurse assign to an assistive personnel (AP)? A) Feeding a client who was admitted 24 hr ago with aspiration pneumonia B) Reinforcing a teaching with a client who is learning to walk using a quad cane C) Reapplying a condom catheter for a client who has urinary incontinence D) Applying a sterile dressing to a pressure ulcer

C Rationale: The application of a condom catheter is a noninvasive, routine procedure that the nurse may delegate to an AP.

A nurse is preparing information for change-of-shift report. Which of the following information should the nurse include in the report? A) The client's input and output for the shift B) The client's blood pressure from the previous day C) A bone scan that is scheduled for today D) The medication routine from the medication administration record

C Rationale: The bone scan is important because the nurse might have to modify the client's care to accommodate leaving the unit.

A client who will undergo neurosurgery the following week tells the nurse in the surgeon's office that he will prepare his advance directives before he goes to the hospital. Which of the following statements by the client indicates to the nurse that he understands advance directives? A) "I'd rather have my brother make decisions for me, but I know it has to be my wife." B) "I know they won't go ahead with my surgery unless I prepare these forms." C) "I plan to write that I don't want them to keep me on a breathing machine." D) "I will get my regular doctor to approve my plan before I hand it in at the hospital."

C Rationale: The client has the right to decide and specify which medical procedures he wants when a life-threatening situation arises.

A nurse is completing discharge teaching to a client who has COPD. The client verbalizes understanding of the orthopneic position when he states, "When I have difficulty breathing at night, I will A) lie on my back with my head and shoulders elevated on a pillow." B) lie flat on my stomach with my head to one side." C) sit on the side of my bed and rest my arms over pillows on top of my raised bedside table." D) lie on my side with my weight on my hips and shoulder with my arms flexed in front of me."

C Rationale: The client is describing the orthopneic position. This position allows for chest expansion and is especially beneficial to clients who have COPD.

A nurse in a family practice clinic is performing a physical examination of an adult client. Which part of her hands should she use during palpation for optimal assessment of the client's skin temperature? A) Palmar surface B) Fingertips C) Dorsal surface D) Base of the fingers

C Rationale: The dorsal surface of the hand is the most sensitive to temperature.

A nurse is caring for a 19-year-old client who is sexually active and has come to the college health clinic for the first time for a checkup. Which of the following interventions should the nurse perform first to determine the client's need for health promotion and disease prevention? A) Measure the client's vital signs. B) Encourage HIV screening. C) Determine the client's risk factors. D) Instruct the client to use condoms.

C Rationale: The first action the nurse should take using the nursing process is assessment. The nurse should talk with the client first to determine what risk factors the client might have before initiating the appropriate health promotion and disease prevention measures.

A nurse is talking with the father of a 12-year-old boy who is concerned that he hasn't observed any indications that his son is approaching puberty. The nurse should explain that the first sign of sexual maturation in boys is A) the appearance of downy hair of the upper lip. B) hair growth in the axillae. C) enlargement of the testes and the scrotum. D) deepening of the voice.

C Rationale: The first prepubescent change in boys is an increase in the size of the testicles along with a thinning and expanding of the scrotum.

A nurse is caring for multiple clients during a mass casualty event. Which of the following clients is the highest priority? A) A client who received crush injuries to the chest and abdomen and is expected to die B) A client who has a 4-inch laceration to the head C) A client who has partial-thickness and full-thickness burns to his face, neck, and chest D) A client who has a fractured fibula and tibia

C Rationale: The nurse should give first priority to the client who has the greatest chance of survival with prompt intervention. If not treated immediately, a client who has burns to his face, neck, and chest is at risk for airway obstruction, but is still expected to live. Therefore, this client is the highest priority.

A nurse is counseling a young adult who describes having difficulty dealing with several issues. Which of the following problems the client verbalized should the nurse identify as the priority for further assessment and intervention? A) "I have my own apartment now, but it's not easy living away from my parents." B) "It's been so stressful for me to even think about having my own family." C) "I don't even know who I am yet, and now I'm supposed to know what to do." D) "My girlfriend is pregnant, and I don't think I have what it takes to be a good father."

C Rationale: When using the urgent vs. nonurgent approach to client care, the nurse determines that the counseling priority is the problem that reflects a lack of completion of the previous stage and progression to the current stage of development. According to Erikson, it is a task of adolescence to develop identity vs. role confusion. This young adult is still struggling with this task and needs assistance in working through that dilemma.

A nurse is talking with an adolescent who describes having difficulty dealing with several issues. Which of the following problems the client verbalized should the nurse identify as the priority for further assessment and intervention? A) "I kind of like this girl in my class. She doesn't like me back, though, not that way." B) "I like hanging out with the guys in the science club, but the jocks pick on them." C) "I just don't seem to be good at anything. I can't play any sports at all." D) "My dad wants me to be a layer like him, but I don't want to learn all that stuff."

C Rationale: When using the urgent vs. nonurgent approach to client care, the nurse determines that the counseling priority is the problem that reflects a lack of completion of the previous stage and progression to the current stage of development. According to Erikson, it is a task of the school-age years to develop industry (such as by learning new skills and experiencing achievements in them) vs. inferiority. This adolescent is still struggling with this task and needs assistance in working through that dilemma.

During an abdominal examination, a nurse in a provider's office determines that a client has abdominal distention. The protrusion is at midline, the skin over the area is taut, and the nurse notes no involvement of the flanks. Which of the following possible causes of distention should the nurse suspect? A) Fat B) Fluid C) Flatus D) Hernias

C Rationale: With flatus, the protrusion is mainly midline, and there is no change in the flanks.

A nurse on a medical-surgical unit is informed that a mass casualty event occurred in the community and that it is necessary to discharge clients to make beds available for injury victims. Which of the following clients can be safely discharged? (Select all that apply) A) A client who is dehydrated and receiving IV fluid and electrolytes B) A client who has a nasogastric tube to treat a small bowel obstruction C) A client who is scheduled for a transurethral resection of the prostate (TURP) D) A client who is 24 hr postoperative following a mastectomy E) A client who is scheduled for an appendectomy

C, D Rationale: A client who is scheduled for a TURP could be safely discharged because TURP is not an emergent surgery. A client who 24 hr postoperative following a mastectomy is stable and could be safely discharged.

A nurse is wearing sterile gloves in preparation for performing a sterile procedure. Which of the following objects may the nurse touch without breaching sterile technique? (Select all that apply) A) A bottle containing a sterile solution B) The edge of the sterile drape at the base of the field C) The inner wrapping of an item on the sterile field D) An irrigation syringe on the sterile field E) One gloved hand with the other gloved hand

C, D, E Rationale: All of the above are sterile.

A nurse is caring for a client who was just admitted to the unit after falling at a nursing home. This client is oriented to person, place, and time and can follow directions. Which of the following actions by the nurse are appropriate to decrease the risk of a fall? (Select all that apply) A) Place a belt restraint on the client when he is sitting on the bedside commode. B) Keep the bed in low position with full side rails up. C) Ensure that the client's call light is within reach. D) Provide the client with nonskid footwear. E) Complete a fall-risk assessment.

C, D, E Rationale: Ensuring that the call light is within reach enables the client to contact the nursing staff to ask for assistance and prevents the client from falling out of bed while reaching for the call light. Nonskid footwear may keep the client from slipping. A fall-risk assessment serves as the basis for an individualized plan of care.

A nurse is talking with an older adult client about improving her nutritional status. Which of the following interventions should the nurse recommend? (Select all that apply) A) Increase iron intake to prevent anemia. B) Decrease fluid intake to prevent urinary incontinence. C) Increase calcium intake to prevent osteoporosis. D) Limit sodium intake to prevent edema. E) Increase fiber intake to prevent constipation.

C, D, E Rationale: Older adults are at risk for osteoporosis, edema, HTN, and constipation.

A nurse is caring for a client who is concerned about being discharged home with a new colostomy because he is an avid swimmer. Which of the following statements made by the nurse indicates use of an effective communication technique? (Select all that apply) A) "You will do great! You just have to get used to it." B) "Why are you worried about going home?" C) "Your daily routines will be different when you get home." D) "Tell me about your support system when you leave the hospital." E) "Let me tell you about a friend of mine with a colostomy who also enjoys swimming."

C, D, E Rationale: Presenting reality is an effective communication technique that can help the client focus on what will really happen based on the changes that have occurred. Asking open-ended questions and offering general leads and broad opening statements are effective communication techniques that encourage the client to express feelings through dialogue and offer additional information. Offering self is an effective communication technique that can convey understanding and shared experience to the client. The focus should return to the client as soon as the relevant point is communicated.

A nurse is planning diversionary activities for children on an inpatient unit. Which of the following should the nurse incorporate as appropriate play activities for a toddler? (Select all that apply) A) Building simple models B) Working with clay C) Filling and emptying containers D) Playing with blocks E) Looking at books

C, D, E Rationale: These activities are toddler-appropriate and help develop fine motor skills and coordination. Looking at books helps with preparation for learning to read.

A nurse is performing a head and neck examination for an older adult client. Which of the following age-related findings should the nurse expect? (Select all that apply) A) Reddened gums B) Lowered vocal pitch C) Tooth loss D) Glare intolerance E) Thickened eardrums

C, D, E Rationale: Tooth loss and gum disease are common in older adults. Older adults tend to become intolerant of glaring lights and also lose some ability to distinguish colors. Tympanic membranes (eardrums) thicken in older adults, and they tend to accumulate cerumen in their ear canals.

A nursing instructor is reviewing which actions nurses can initiate without a provider's prescription with a group of nursing students. The students should identify which of the following interventions as nurse-initiated? (Select all that apply) A) Give morphine sulfate 1 to 2 mg IV every 1 hr as needed for pain. B) Insert an NG tube to relieve a client's gastric distention. C) Show a client how to use progressive muscle relaxation. D) Perform a daily bath after the evening meal. E) Reposition a client every 2 hr to reduce pressure ulcer risk.

C, D, E Rationale: Unless it is a contraindication for a specific client, this is a nurse-initiated intervention.

A nurse in a provider's office is preparing to auscultate and percuss a client's thorax as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply) A) Rhonchi B) Crackles C) Resonance D) Tactile fremitus E) Bronchovesicular sounds

C, D, E Rationale: Resonance is the expected percussion sound over the thorax. It is a hollow sound that indicates air inside the lungs. Tactile fremitus is an expected vibration the nurse can expect to feel as the client vocalizes. Speech creates sound waves, the vibrations of which travel from the vocal cords through the legs and to the chest wall. Bronchovesicular sounds are expected breath sounds of medium pitch and intensity and of equal inspiration and expiration time. The nurse can expect to hear them over the larger airways.

A nurse is collecting data to evaluate a middle adult's psychosocial development. The nurse should expect middle adults to demonstrate which of the following capabilities? (Select all that apply) A) Develop an acceptance of diminished strength and increased dependence on others. B) Feel frustrated that time is too short for attempting to start another life. C) Welcome opportunities to be creative and productive. D) Commit to finding friendship and companionship. E) Become involved with community issues and activities.

C, E Rationale: Psychosocially healthy middle adult's accept life opportunities for creativity and productivity and use these opportunities for achieving Erikson's stage of generativity vs. stagnation. Psychosocially healthy middle adults achieve Erikson's stage of generativity vs. stagnation by contributing to future generations through community involvement as well as teaching and parenting.

A nurse is caring for an older adult client who lives alone and is to be discharged in 3 days. He states that it is difficult to prepare adequate nutritious meals at home for just one person. To which of the following members of the health care team should the nurse refer him? A) Registered dietician B) Occupational Therapist C) Physical Therapist D) Social Worker

D Rationale: A social worker can make arrangements for a meal delivery service to provide nutritious meals daily, or recommend a congregate meal site near the client's home.

A client who has had a cerebrovascular accident has persistent problems with dysphagia. The nurse caring for the client should initiate a referral with which of the following members of the interprofessional care team? A) Social worker B) Certified nursing assistant C) Occupational therapist D) Speech-language pathologist

D Rationale: A speech-language pathologist can initiate specific therapy for clients who have difficulty with feeding due to swallowing difficulties.

A goal for a client who has difficulty with self-feeding due to rheumatoid arthritis is to use adaptive devices. The nurse caring for the client should initiate a referral to with which of the following members of the inter professional care team? A) Social worker B) Certified nursing assistant C) Registered dietician D) Occupational therapist

D Rationale: An occupational therapist can assist clients who have physical challenges to use adaptive devices and strategies to help with self-care activities.

Which of the following approaches should the nurse use when working with a family using an open structure for coping with crisis? A) Prescribing tasks unilaterally B) Delegating care to one member C) Speaking to the primary client privately D) Convening a family meeting

D Rationale: An open structure is loose, and convening a family meeting would give all family members input and an opportunity to express their feelings.

A nurse offers pain medication to a client who is postoperative prior to ambulation. The nurse understands that this aspect of care delivery is an example of which of the following ethical principles? A) Fidelity B) Autonomy C) Justice D) Beneficence

D Rationale: Beneficence is taking positive actions to help others. By administering pain medications before the client attempts a potentially painful exercise like ambulation, the nurse is taking a specific and positive action to help the client.

A home health nurse is discussing the dangers of carbon monoxide poisoning with a client. Which of the following information should the nurse include in her counseling? A) Carbon monoxide has a distinct odor. B) Water heaters should be inspected every 5 years. C) The lungs are damaged from carbon monoxide inhalation. D) Carbon monoxide binds with hemoglobin in the body.

D Rationale: Carbon monoxide is a very dangerous gas because it binds with hemoglobin and ultimately reduces the oxygen supplied to the tissues in the body.

A nurse uses a head-to-toe approach to conduct a physical assessment of a client who will undergo surgery the following week. Which of the following critical thinking attitudes did the nurse demonstrate? A) Confidence B) Perseverance C) Integrity D) Discipline

D Rationale: Discipline is developing a systematic approach to thinking. Proceeding head to toe is a systematic approach to collecting the data a physical assessment yields.

A nurse is evaluating a client's neurosensory system. To evaluate stereognosis, she should ask the client to close his eyes and identify which of the following items? A) A word she whispers 30 cm from his ear B) A number she traces on the palm of his hand C) The vibration of a tuning fork she places on his foot D) A familiar object she places in his hand

D Rationale: Identifying a familiar object in the hand confirms the client's sense of stereognosis, which is tactile recognition.

A security officer is reviewing actions to take in the event of a bomb threat by phone to a group of nurses. Which of the following statements by a nurse indicates understanding of proper procedure? A) "I will get the caller off the phone as soon as possible so I can alert the staff." B) "I will use overhead paging to alert the entire facility." C) "I will not ask any questions and just let the caller talk." D) "I will listen for background noises."

D Rationale: In order to identify the location of the caller, the nurse should listen for background noises such as church bells, train whistles, or other distinguishing noises.

A nurse questions a medication prescription as too extreme in light of the client's advanced age and unstable status. The nurse understands that this action is an example of which of the following ethical principles? A) Fidelity B) Autonomy C) Justice D) Nonmaleficence

D Rationale: Nonmaleficence is the avoidance of harm or injury. In this situation, administering the medication could harm the client. By questioning it, the nurse is demonstrating this ethical principle.

A nurse is reviewing nutritional guidelines with the parents of an 11-year-old child. Which of the following parents' statements should indicate to the nurse that they understand the guidelines for school-age children? A) "She wants to eat as much as we do, but we're afraid she'll soon be overweight." B) "She skips lunch sometimes, but we figure it's okay as long as she has a healthy breakfast and dinner." C) "We limit fast-food restaurant meals to three times a week now." D) "We reward her school achievements with a point system instead of a pizza or ice cream."

D Rationale: Parents should avoid rewarding children with food for good behavior or achievements. Associations children form between food and feeling good can lead to weight problems.

An RN is making assignments for client care to a licensed practical nurse (LPN) at the beginning of the shift. Which of the following assignments should the LPN question? A) Assisting a client who is 24 hr postoperative to use an incentive spirometer B) Collecting a clean-catch urine specimen from a client who was admitted on the previous shift C) Providing nasopharyngeal suctioning for a client who has pneumonia D) Replacing the cartridge and tubing on a patient-controlled analgesia (PCA) pump

D Rationale: The RN is responsible for maintaining the PCA pump.

A nurse is preparing an instructional session about managing stress incontinence for an older adult. Which of the following actions should the nurse take first when meeting with the client? A) Encourage the client to participate actively in learning. B) Select instructional material appropriate for the older adult. C) Identify goals the nurse and the client agree are reasonable. D) Determine what the client knows about stress incontinence.

D Rationale: The first action the nurse should take using the nursing process is to assess or collect data from the client. The nurse should determine how much the client knows about stress incontinence, the accuracy of this knowledge, and what the client needs to learn to manage this condition before proceeding to instructing the client.

A nurse is caring for a client who is sitting in a chair and asks to return to bed. Which of the following is the priority action for the nurse to take at this time? A) Obtain a walker for the client to use to transfer back to bed. B) Call for additional personnel to assist with the transfer. C) Use a transfer belt and assist the client to bed. D) Assess the client's ability to help with the transfer.

D Rationale: The first action the nurse should take using the nursing process is to assess/collect data from the client. The nurse should assess the client's ability to help with transfers (Balance, muscle strength, endurance). Then the nurse can proceed with a safe transfer of the client.

As part of the admission process, a nurse at a long-term care facility is gathering a nutrition history for a client who has dementia. Which of the following components of the nutrition evaluation is the priority for the nurse to determine from the client's family? A) BMI B) Usual times for meals and snacks C) Favorite foods D) Any difficulty swallowing

D Rationale: The greatest risk to a client if related to a nutrition-related evaluation is from difficulty swallowing, or dysphagia. It puts to client at risk for aspiration, which can be life-threatening.

A nurse is counseling an older adult who describes having difficulty dealing with several issues. Which of the following problems verbalized by the client should the nurse identify as the priority? A) "I spent my whole life dreaming about retirement, and now I wish I had my job back." B) "It's been so stressful for me to have to depend on my son to help around the house." C) "I just heard my friend AI died. That's the third one in 3 months." D) "I keep forgetting which medications I have taken during the day."

D Rationale: The greatest risk to this client is injury from overdosing or underdosing his medications due to loss of short-term memory. The priority issue for the nurse is to assist the client to implement safe medication strategies. The nurse should assist the client to use a pill organizer to help him remember to take his medications and to keep a list of all current medications.

A nurse is caring for a client who reports a severe sore throat, pain when swallowing, and swollen lymph nodes. The client is experiencing which of the following stages of infection? A) Prodromal B) Incubation C) Convalescence D) Illness

D Rationale: The illness stage is when the client experiences signs and symptoms specific to the infection.

A nurse has removed a sterile pack from its outside cover and placed it on a clean work surface in preparation for an invasive procedure. Which of the following flaps should the nurse unfold first? A) The flap closest to the body B) The right side flap C) The left side flap D) The flap furthest from the body

D Rationale: The priority goal in setting up a sterile field is to maintain sterility and thus reduce the risk to the client's safety. Unless the nurse pulls the top flap (the one furthest from her body) away from her body first, she risks touching part of the inner surface of the wrap and thus contaminating it.

A nursing instructor is explaining the various stages of the lifespan to a group of nursing students. The nurse should offer which of the following behaviors by a young adult as an example of accomplishing Erikson's tasks for psychosocial development during middle adulthood? A) The client evaluates his behavior after a social interaction. B) The client states he is learning to trust others. C) The client wishes to find meaningful friendships. D) The client expresses concerns about the next generation.

D Rationale: The task for a middle adult is generatively vs. stagnation. Concern for the next generation is a positive sign that the middle adult is meeting the task.

A charge nurse is designating room assignments for clients who will be admitted to the unit. Based on the nurses' knowledge of fall prevention, which of the following clients should be assigned to the room closest to the nurses' station? A) A 43-year-old client who is postoperative following a laparoscopic cholecystectomy B) A 61-year-old client being admitted for telemetry to rule out a myocardial infarction C) A 50-year-old client who is postoperative following an open reduction internal fixation of the ankle D) A 79-year-old client who is postoperative following a below-the-knee amputation

D Rationale: This client should be assigned to a room near the nurses' station due to risk factors that include client's age, mobility, and balance issues related to the surgery, and potential side effects, such as drowsiness, as a result of analgesic medication.

A nurse is caring for a client who presents with linear clusters of fluid-containing vesicles with some crusting. Which of the following should the nurse suspect? A) Allergic reaction B) Ringworm C) Systematic lupus erythematosus D) Herpes zoster

D Rationale: Vesicles that follow along a unilateral dermatome can indicate herpes zoster.

A nurse is reviewing the various types of lesions nursing students might encounter when performing integumentary assessments for their clients. Which of the following lesions should the nursing students recognize as vesicles? (Select all that apply) A) Acne B) Warts C) Psoriasis D) Herpes simplex E) Varicella

D, E Rationale: Herpes simplex lesions are vesicles, which are circumscribed fluid-filled skin elevations. Varicella (chickenpox) lesions are vesicles, which are circumscribed fluid-filled skin elevations. Eczema and impetigo also cause vesicles to appear on the skin.