FUNDAMENTALS - ADAPTIVE QUIZ

1) A nurse is assessing the heart sounds of a client who has developed chest pain that becomes worst with inspiration. The nurse asucultates a high-pitched scratching sound during both sytstole and diastole with the diaphragm of the stethoscope positioned at the left sternal border. Which of the following heart sounds should the nurse document? 2) What is the sound that occurs in clients who have prosthetic valve replacement surgery? 3) What has a swishing or a whistling sound? 4) What has a low-pitched sound after the second heart sound and best heard at the mitral area?

1) *PERICARDIAL FRICTION RUB* = *Scratching, grating, or squeaking leathery sound( heard best with the diaphragm of the stethoscope at *LEFT STERNAL BORDER.* 2) Audible click 3) Murmur 4) Third heart sound

What are the 4 parts of auscultation for heart?

1) Aortic -- second intercostal space to the right of the sternum 2) Pulmonic -- Second intercostal space to the left of the sternum 3) Tricuspid -- Fifth intercostal space to the left of the sternum 4) Mitral -- Fifth intercostal space, just medial to the midclavicular line

WOUND HEALING / INTENTIONS: Match each 1) The wound is closed at a later date: 2) The wound edges are well-approximated: 3) A skin graft is placed over the wound bed: 4) Granulation tissue fills the wound during healing:

1) Tertiary intention 2) Primary intention 3) Tertiary intention 4) Secondary intention

If a client is experiencing stress and anxiety, what happens to each: - bp - blood sugar - oxygen - GI motility

> BP goes up > Blood sugar goes up -- release of glucocorticoids and gluconeogenesis > Oxygen - goes up -- oxygen demands of the body go up > Decrease GI motility -- can result in constipation and flatus

A nurse is teaching a group of older adults about expected changes of aging. Which of the following statements by a group member indicates the teaching has been effective? A) "I should expect my heart rate to take longer to return to normal after exercise as I get older." B) "Urinary incontinence is something I will have to live with as I grow older." C) "I can expect to have less ear wax as I get older." D) "My stomach will empty more quickly after meals as I grow older."

A) "I should expect my heart rate to take longer to return to normal after exercise as I get older." ^^ *EVERYTHING DECREASES AS YOU GET OLDER* -- Older adults experience decreased cardiac output, which causes increased pulse rate during exercise. It takes *LONGER TO RETURN TO NORMAL*." Rationales: B) Not true! But bladder capacity decreases in older adults C) INCREASED CERUMEN BUILD UP in OLDER ADULTS D) Decreased gastric emptying is an expected finding in older adults

Interventions if client can't sleep at night: A) Avoid beverages with caffeine B) Take a sleep medication regularly at bedtime C) Watch television for 30min in bed to relax prior to falling asleep D) Advise the client to take several naps during the day

A) Avoid beverages with caffeine Rationale: B) LAST RESORT. Remember, least to most invasive C) Clients should associate going to bed with sleep. Therefore, the client should not get into bed until she is sleepy.

A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following actions should the nurse take first after discovering that the client's wound has eviscerated? A) Cover the incision with a moist sterile dressing B) Have the client lie on his back with his knees flexed C) Call the client's surgeon D) Reassure the client

A) Cover the incision with a moist sterile dressing ^^ Open wound places the client at risk for peritonitis, and any exposed organ tissue could dry out. *Protect it from drying BY COVERING IT W/ MOIST STERILE DRESSING* Rationale: Everything else is correct, but not priority B) This reduce pressure on the incision. C) Notify surgeon or ask a colleague to notify surgeon, but not first priority D) Not first priority

A nurse is caring for a client who has bilateral casts on her hands. Which of the following actions should the nurse take when assisting the client with feeding? A) Sit at the bedside while feeding the client B) Order pureed foods C) Make sure feedings are at room temperature D) Offer the client a drink of fluid after every bite

A) Sit at the bedside while feeding the client ^^ The nurse *SHOULD AVOID APPEARING TO BE IN A HURRY*. Sitting at the bedside provides the client with the nurse's full attention during the feeding. Rationale: B) Pureed foods are for clients who CAN'T CHEW, DYSPHAGIA, or DON'T HAVE TEETH. Our client is okay! C) Food temp should depend on the client's preference D) The client can communicate!!! so not necessary

A nurse is preparing to assist with ambulation of an older adult client who was on bed rest for 3 days. Which of the following actions should the. nurse take to decrease the risk of a fall? A) Use a gait belt during ambulation B) Ensure the client is earring socks before ambulating C) Instruct the client to sit on the edge of the bed for 15 encodes before ambulating. D) walk 2 feet behind the clients doing adulation

A) Use a gait belt during ambulation ^^ To keep client's center of gravity midline and decrease the risk of a fall Rationales: B) Should be *NONSKID SHOES or SLIPPERS* to decrease risk of fall C) Should be 60 seconds!!! D) Walk BESIDE CLIENT

Administration of eye drops following a surgery: A. Drop the eye medication into the lower conjunctival sac B. Apply gentle pressure in the outer opening of the eye for 2 min. C. Hold the eye dropper 0.5 cm (0.2 in) from the cornea. D. Instruct the client to close eyes tightly after administration

A. Drop the eye medication into the lower conjunctival sac ^^ At lower conjunctival sac to avoid cornea and cause damage. Rationales: B) Gentle pressure *AT NASOLACRIMAL DUCT for 30-60secs* to keep medication from running down the duct or out of the eye C) Hold eye dropper 1-2cm (0.4-0.8 in) to prevent tip touching the ey D) Close eyes GENTLY -- to distribute the med and avoid expelling the med or injuring the eye

What's the order for an abdominal assessment? (4)

AB ASSESSMENT: Inspection Auscultation Percussion Palpation

"A bird in the hand is worth two in the bush." This is an evaluation of what intellectual function? How do you test judgement? What about attention span?

ABSTRACT REASONING -- higher-level thinking and the ability to understand and interpret abstract thoughts. Judgement: Response to a specific real-life challenge Attention span: Counting backward from 100 in intervals of 7.

Assisting pt with dysphagia. Which action should nurse take? A) Assist the client into semi-sitting position B) Have the client lean slightly backward C) Advise the client to tuck his chin downward D) Instruct the client to tilt his head slightly backward

Advice the client to tuck his chin downward RATIONALE: A) Assist client to sit in an upright position when eating B) Have client lean slightly forward when eating D) Instruct client to til his head slightly forward when eating

A nurse is responding to a parent's question about his infant's expected physical development during the first year of life. Which of the following information should the nurse include? A) A 2-month-old infant can turn from his abdomen to his back B) A 10-month-old infant can pull up to a standing position C) A 4-month-old infant can sit up without support D) A 6-month-old infant can crawl on his hands and knees

B) A 10-month-old infant can pull up to a standing position ^^ 8-10mo, they can pull themselves to a standing position Rationale: A) This until 5 months! C) This is until 6-8mos D) This is until 8-10mo

A nurse is planning care for a client who has a single-lumen nasogastric (NG) tube for gastric decompression. Which of the following actions should the nurse include in the plan of care? (Select all that apply.) A) Set the suction machine at 120mm HG B) Provide oral hygiene frequently. C) Measure the amount of drainage from the NG tube every shift. D) Secure the NG tube to the client's gown. E) Apply petroleum jelly to the client's nares

B, C, D Rationales: A) 80-100 mm HG E) Should be water-soluble not oil

A nurse is caring for a toddler at a well-child visit when the mother calls to the nurse, "Help! My baby is choking on his food!" Which of the following findings indicates the toddler has an airway obstruction? A. Flushing of the skin B. Inability of the toddler to cry or speak C. Presence of nausea and mild emesis D. Capillary refil time 1.5 seconds

B. Inability of the toddler to cry or speak ^^ No passing sound through vocal cords mean airway obstruction Rationales: A) Should be CYANOSIS -- skin, nail beds, and mucous membranes C) Not indications of airway obstruction D) If it's delayed ( > 2secs), then indication of circulatory impairment

A nurse is taking a client's vital signs. Which of the following -- out of range? A) Pulse rate 90/min B) Rectal Temp 38* (100.4*F) C) Pulse ox 95% D) BP 145/90 mmHg

BP 145/90 mmHg is out of range!

A nurse in a provider's office is teaching a client about foods that are high in fiber. Which of the following food choices made by the client indicate an understanding of the teaching? A) Canned peaches B) White rice C) Black beans D) Whole-grain bread E) Tomato juice

C and D: Black beans and whole grains ^^ Dried peas and beans and grains are HIGH in FIBER. Rationale: A) Canned fruits are for low-fiber diets. Fresh fruits contain more fiber. B) White rice are lower in fiber. Brown rice are higher in fiber. E) Canned juices (expect prune juice) are recommended for clients on a low-fiber diet.

A nurse is caring for an older adult client who is violent and attempting to disconnect her IV lines. The provider prescribes soft wrist restraints. Which of the following actions should the nurse take while the client is in restraints? A) Tie the restraints to the side rails B) Perform ROM exercises to the wrists every 3 hr. C) Remove the restraints one at a time. D) Obtain a PRN prescription for the restraints.

C) Remove the restraints one at a time. Rationale: B) ROM should be every 2 hr D) Restraint prescriptions can only be written for a 24-hour period and cannot be a PRN prescription.

A nurse is planning care for a young adult client who has a terminal illness. How do YAs view death? A) Death is unacceptable under any circumstances B) Magical thinking helps avoid thoughts of death C) Death is viewed as an interruption of what might have been D) Death is a natural consequence of a deteriorating body

C. Death is viewed as an interruption of what might have been RATIONALE: YAs tend to see a whole life ahead of them, so death is often seen as interrupting that life. YAs typically dont' welcome death at this time. *Adolescents* tend to reject the end of life, especially their own. *Preschoolers* tend to avoid thoughts of death by employing magical thinking Accepting the deterioration of the body is more *likely among older adults,* some of whom might be consider death a relief from chronic or temrinal disease.

A nurse is collecting data from a newborn. Which of the following findings should the nurse report to the provider? A) Pink-tinged urine B) Scant amount of nipple discharge C) Grunting with expiration D) Bluish discoloration of feet and hands

C. Grunting with expiration Rationale: A) Pink-tinged urine is as expected *caused by uric acid crystals* B) Nipple discharge is expected due to the *effects of maternal estrogen during pregnancy.* D) Also known as acrocyanosis. Expected finding.

A nurse is inserting an IV catheter for a client that results in a blood spill on her gloved hand. The client has no documented bloodstream infection. Which of the following actions should the nurse take?

Carefully remove the gloves and follow with hand hygiene. ^^ Standard precautions require the use of gloves and hand hygiene in the care of all clients. *Unless there is a break in the nurse's skin, there is no need for further investigation.*

What is the most important factor in the client's ability to learn new habits?

Client's *INVOLVEMENT*

A nurse is performing assessment of a client. Which of the following questions should the nurse ask? A) "When did you start to believe in your faith?" B) "How often do you perform religious rituals?" C) "Which church do you regularly attend?" D) What is your source of strength and hope?"

D) "What is your source of strength and hope?" ^^ Broad and open-ended question that encourages the client to express feelings without any assumptions on the nurse's part. It focuses on a GLOBAL VIEW of SPIRITUALITY and COMPLEX CONCEPT Rationales: A) Non-therapeutic -- assumes client has a religion-based belief B) Non-therapeutic -- assumption C) Non-therapeutic -- assumption

Acetaminophen's adverse effect is? A) Constipation B) Gastric ulcers C) Respiratory depression D) Liver damage

D) Liver damage Rationale: Adverse effects *CONSTIPATION*, respiratory depression, and decreased bp -- opioid analgesic *Gastric Ulcer* -- aspirin or nonselective NSAIDs *Respiratory depression* - opioid analgesics

A client is being discharged home with oxygen therapy via a nasal cannula. Which of the following instructions should the nurse provide to the client and family? A) Use battery-operated equipment for personal care B) Apply mineral oil to protect the facial skin from irritation C) Remove the TV set from the client's bedroom D) Wear cotton clothing to avoid static electricity

D) Wear cotton clothing to avoid static electricity ^^ Oxygen is highly combustible. Cotton clothing will limit the buildup of static electricity. Rationale: A) Electrical equipment in good condition with no frayed wires is accetable for personal care when oxygen is administered. B) NOOO OIL / PETROLEUM -- must be water soluble C) As long as the television is in proper working order, there is no oxygen-related need to remove it from the client's bedroom.

A nurse is applying antiembolitic stockings for a client who has a history of deep-vein thrombosis. Which of the following actions should the nurse take when applying the stockings? A. Roll the stocking partially down if too long B. Remove the stocking once per day C. Bunch and pull the stocking half way up the calf D. Turn the stocking inside out up to the heel before applying

D. Turn the stocking inside out up to the heel before applying ^^ so it's easier and cause less constrictive wrinkles. Rationales: A) If it's too long, nurse should apply ANOTHER STOCKING!!! B) *REMOVE ONCE EVERY SHIFT* to check circulation and inspect skin C) Nurse shouild slide the top of the stocking up over the client's calf ALL AT ONCE to lessen constrictive wrinkles that can decrease venous return.

A nurse has given a client a nursing diagnosis of self-care deficit related to a musculoskeletal disorder. Which intervention regarding activities of daily living would be most appropriate?

Encourage the client to be independent, but help when necessary. Rationale: Encourage independence and provide intervention when necessary to avoid frustrating the client.

BLOOD TRANSFUSION 101: Epoetin is a hematopoietic growth factor used for the treatment of what? T/F Taking iron before blood transfusion can help prevent infection. T/F Asking a family member to donate blood for a client will reduce risk of infections. T/F Donating autologous blood before the surgery will help reduce risk of infections.

Epoetin = for anemia; not necessary before blood transfusion bc it might increase the already adequate hematocrit! FALSE: Iron increases hemoglobin, and if client already has adequate hgb, it is inappropriate. FALSE!!!! TRUE!!! It is the client's own blood is the *"SAFEST FORM OF BLOOD TRANSFUSION" (ATI)*; this is done 3-5 weeks before surgery

URINARY CATHETER 101: T/F Applies sterile gloves to open catheter package T/F Wipes the labia minor in an anteroposterior direction. T/F Spreads the labia with the dominant hand. T/F Uses one cotton ball to wipe the right and left major.

False TRUE - anteroposterior means front and back FALSE: NON-DOMINANT HAND FALSE: Separate cotton balls

Define each: Fidelity Autonomychovost Nonmalficence Justice

Fidelity: Keeping a promise that was made Autonomy: Ensuring the client has the right to make personal decisions Nonmaleficence: Doing no harm Justice: Treating everyone fairly

MATH EACH FOOD: Cream of rice Cottage cheese Gelatin Ice cream

Full liquid Soft diet Clear liquid Full liquid

INCENTIVE SPIROMETER 101: What does incentive spirometer do secretions? T/F Inhale deeply to elevate the balls in the device. T/F Cough deeply after each use. T/F Clean the mouth piece with an alcohol swab after each use.

It loosens it. TRUE TRUE -- Coughing facilitate removal of secretions from lungs FALSE -- must clean with water and dry after each use

A nurse is preparing to anchor with tape the catheter tube for a male client who has a newly inserted indwelling urinary catheter. At which of the following locations should the nurse tape the catheter?

LOWER ABDOMEN ^^ or the upper aspect of the thigh to eliminate the penoscrotal angle and prevent tissue injury.

What is the lithothomy position for? What about the lateral? Sims?

Lithotomy: Vaginal Lateral: Auscultation of the heart Sims': Rectal and vaginal

Which part of the body do we use percussion to evaluate?

Lungs

When should middle-age people do each: 1) Eye exams ? 2) Papanicolaou Testing? 3) Mammogram? 4) Colonoscopy?

MIDDLE-AGE 1) Eye exam: EVERY 2 years 2) Pap test: EVERY 3 years 3) Mammogram: YEARLY 4) Colonoscopy: every 10 years

Right way to demonstrate proper SURGICAL handwashing technique?

Nurse holds her hands HIGHER than her elbows while washing. ^^ So water and soapsuds can drain away from the clean area toward the dirty area. - 15 Strokes nails - 10 strokes each other part of the hand --> from *HANDS TO ELBOWS!!!* not the other way around

Tap water enema to a client. Which action should nurse take? A) Raise the enema bag if the client experiences cramping B) Lubcricate 2.54 (1 in) of the tip of the rectal tube prior to insertion C) Place the client in a left Sims' position D) Don sterile gloves prior to the procedure

PLACE LEFT SIMS POSITION Rationale: Adminster fluid *SLOWLY* and should *LOWER* it during pain or fullness *Lubricate 2 in* prior Clean gloves is needed. Not sterile

Client is postoperative and has paralytic ileus. What would you expect to find in the abdominal assessment?

Paralytic ileus = *IMMOBILE BOWEL* = so *absent bowel sounds with distention*.. no flatus or stool or any activity

What do you call the test to check a client's balance? What test for the higher CNS by striking the sole of the foot? What does it mean if all of the toes bend? What do you call the test where the client has to determine the difference between two points?

ROMBERG'S TEST BABINSKI TEST - Test for adequacy of higher CNS: if it bends downward, negative! if it's outward, positive! Two-point discrimination test: by touching the skin with two sharp, pointed objects.

MATCH EACH TYPE OF DRAINAGE: Accumulation of RBCs from the plasma that appears bright red on the dressings? Drainage on the client's dressings indicates plasma from the blood and appears clear to light yellow, and is watery? Drainage on the client's dressings indicates plasma mixed with light bloody drainage, which is typically pale yellow to blood-tinged and watery drainage? Drainage on the client's dressings is thick yellow, green and brown drainage and usually indicates wound sloughing or infection?

Sanguineous exudate Serous exudate Serosanguineous exudate Purulent exudate

T/F It's appropriate to use assistive devices for weight more than 15.8kg (35 lbs)

TRUE

HAND HYGIENE 101: T/F Warm water preserves the protective oil of the skin better than hot water. T/F Friction should be applied for 10 seconds. T/F "After washing my hand, I will dry them from the elbows down."

TRUE FALSE: Friction should be 15-20secs. FALSE: From hands down to elbows! Cleanest to dirtiest

T/F Blood pressure readings can be falsely high if the cuff is too small for the client. T/F The width of the cuff bladder should be 48% of the circumference of the client's arm.

TRUE FALSE: should be 40% of the circ of the client's arm

A nurse is planning care for a client who has a wound infection following abdominal surgery. To promote healing and fight infection, which of the following vitamins and minerals should the nurse plan to increase in the client's diet? A) Vitamin C and zinc B) Vitamin D C) Vitamin K and iron D) Calcium

Vitamin C and Zinc Rationale: *Vitamin D* with *calcium* prevent osteoporosis. Vitamin D maintains normal Ca+ and Phosphorus, and may *PROTECT AGAINST CANCER* *Vitamin K* is important for normal blood clotting and for impaired synthesis caused by antibiotics. *Iron* is for rebuilding RBCs*

A nurse is planning care for a group of clients who are receiving oxygen therapy. Which of the following clients should the nurse plan to see first? A) A client who has heart failure and is receiving 100% oxygen via a partial rebreather mask B) A client who has emphysema and is receiving oxygen at 3L/min via a transtracheal oxygen cannula C) A client who has an old tracheostomy and is receiving 40% humidified oxygen via tracheostomy collar D) A client who has COPD and is receiving oxygen at 2 L/ min via nasal cannula

A) A client who has heart failure and is receiving 100% oxygen via a partial rebreather mask ^^ Nurse should make sure REBREATHER MASK BAG is INFLATED PROPERLY. Higher concentrations of oxygen increase risk of client injury. Rationales: Everything else not the priority B) Client will learn to use this device on his own, and the system can provide adequate oxygenation with a low flow rate of oxygen. C) The nurse should use humidification to promote loosening of respiratory secretions and prevent cannula obstruction. D) Client with COPD depend on LOW OXYGEN LEVEL to drive their respiratory rate.

A newly licensed nurse is preparing to administer medications to a client. The nurse notes that the provider has prescribed a medication that is unfamiliar to her. Which of the following actions should the nurse take? A) Consult the medication reference book available on the unit B) Ask a more experienced nurse for information about the medication C) Call the client's provider and verify the prescription D) Ask the client if she takes this medication at home

A) Consult the medication reference book available on the unit ^^ A nurse must have knowledge about medications to administer them safely. The nurse should become familiar with the medication by looking it up it in the medication reference on the unit. Rationale: C) It's not a med prescription error, so it's unnecessary for the nurse to confirm it with the provider.

A nurse is preparing to provide chest physiotherapy for a client who has left lower lobe atelectasis. Which of the following actions should the nurse plan to take? A) Place the client in Trendelenburg's position B) Perform percussions directly over the client's bare skin C) Use a flattened hand to perform percussions D) Remind the client that chest percussions can cause mild pain

A) Place the client in Trendelenburg's position ^^ Nurse should place the client in right side lying position in Trendelenburg's position to *PROMOTE DRAINAGE* from the client's lower lobe. *GOOD LUNG DOWN* Rationale: B) Percussions should be *OVER A SINGLE LAYER OF CLOTHING* C) Hands hould be CUPPED when providing percussions D) It SHOULD NOT CAUSE PAIN

A nurse is providing education about cultural and religious traditions and rituals related to death for the assistive personnel on the unit. Which of the following information should the nurse include? A) Place the client in a lateral position with the head turned to the side before beginning the procedure B) Use the thumb and index finger to keep the client's mouth open C) Rinse the client's mouth with an alcohol-based mouth was following the procedure D) Cleanse the client's mucous membranes with lemon-glycerin sponges

A) Place the client in a lateral position with the head turned to the side before beginning the procedure ^^ Reduce risk of aspiration Rationales: B) Should use PADDED TONGUE BLADE -- prevent risk of injury (self and client) C) either with WATER or *ALCOHOL-FREE* D) FOAM SWAB and not lemon-glycerin swabs -- bc they dry and irritate mouth and can cause damage to teeth

A nurse is performing suctioning for a client who has a tracheostomy. Which of the following actions should the nurse take? A) Pull suction catheter back 1 cm (0.5 in) if the client starts coughing. B) Allow 30 seconds between suctioning passes C) Hyperventilate the client with 50% oxygen for 30 seconds D) Perform a maximum of 4 passes with the suction catheter

A) Pull suction catheter back 1 cm (0.5 in) if the client starts coughing. ^^ Pull 1 cm or 0.5in when resistance is met. This will remove the catheter from the mucosal wall of the trachea prior to suctioning Rationale: B) Must be *1 MINUTE BETWEEN SUCTIONING PASSES* to prevent hypoxia and to hyperventilate the pt C) Should be 100% for at least 2 min before suctioning to decrease hypoxia D) Max of 3 passes with suction catheter

A nurse is planning to perform passive range-of-motion exercises for a client. Which of the following actions should the nurse take? A) Repeat each joint motion five times during each session B) Move the joint to the point of considerable resistance C) Sit approximately 2 feet from the side of the bed closest tot eh joint being exercised D) Exercise the smaller joint first

A) Repeat each joint motion five times during each session ^^ *Maintain client's joint mobility -- 3-5x* Rationale: B) ... to a *SLIGHT* RESISTANCE. not considerable C) Stand *CLOSEST* to the joint. D) Start with BIGGER JOINTS at FIRST

REPLACING SURGICAL DRESSING 101: A) Don clean gloves to remove the old dressing B) Loosen the dressing by pulling the tape away from the wound C Remove the entire old dressing at once D) Open sterile supplies after applying sterile gloves

A) TRUE -- clean technique B) FALSE -- Remove by loosening and pulling toward the wound or dressing to decrease tension or stress on the healing wound edges C) FALSE: Remove each layer at a time!! This will allow nurse to assess the drainage D) FALSE: The nurse should open the sterile supplies after the removal of the old dressings, after washing her hands, and before applying sterile gloves to apply the sterile dressing to prevent microorganisms from contaminating the sterile field.

A nurse is caring for a client who has Clostridium difficile and is in contact isolation. Which of the following actions should the nurse take? A) Wear gloves when changing the client's gown B) Use alcohol-based sanitizer to cleanse the hands C) Wear a mask when assisting the client with his meal tray D) Place the client on complete bed rest

A) Wear gloves when changing the client's gown ^^ Nurse should *wear gloves when handling articles that have the potential to contaminate the hands* when caring for a client who is in contact isolation.. Rationale: B) WASH HANDS WITH WATER AND SOAP C) Mask is for droplet D) Client should KEEP MOVING to prevent immobility -- impaired skin integ and retained respiratory secretions.

A nurse is providing teaching to a client who has a new colostomy about proper care. Which of the following information should the nurse include in the teaching? A) Change the colostomy bag following breakfast B) Cleanse the skin around the stoma with warm water C) Change the pouch everyday D) Place an aspirin in the ostomy pouch to decrease the odor

B) Cleanse the skin around the stoma with warm water ^^ Soap and water can leave residue on the skin and cause poor adherence of the pouch adhesive Rationales: A) *CHANGE BEFORE MEALS.* C) *Change pouch 3-7 days to avoid skin breakdown* D) Placing an aspirin may cause stoma bleeding, so issa no

A nurse is caring for a client who is receiving IV therapy via a peripheral catheter. The nurse should identify that which of the following findings is an indication of infiltration? A) Redness at the infusion site B) Edema at the infusion site C) Warmth at the infusion site D) Oozing of blood at the infusion site

B) Edema at the infusion site ^^ Edema due to fluid entering subcutaneous tissue is an indication of infiltration. Rationales: A and C) Can be phlebitis or infection D) IV system may is not intact

A nurse is teaching a client who is recovering from gallbladder surgery how to use an incentive spirometer. Which of the following information should the nurse include in the teaching? A) Exhale slowly to reach goal volume B) Hold breath for 5 seconds after goal volume is reached C) Continue to deep breathe between each cycle. D) Limit repeat pattern of breathing to 5 breaths

B) Hold breath for 5 seconds after goal volume is reached ^ for 3-5 secs. This decreases the collapse of alveoli, which helps to prevent the risk of atelactasis and pneumonia. Rationale: A) INHALE slowly, not exhale C) Normal breathing between cycles *to avoid hyperventilation and fatigue* D) This should be done 10-20 breaths every hour while awake -- prevention of atelactasis and pneumonia

Neuro exam: Nurse instructs a client to keep his eyes closed, places an object in his hand, and asks him to identify the object. Which of the following abilities is the nurse evaluating with this technique? A) Gustation B) Stereognosis C) Proprioception D) Kinesthesia

B) Stereognosis Rationale: Stereognosis is the ability to identify an object's size, shape, and texture via tactile sensation Gustation is the ability to taste Proprioception is the awareness of the position of the body Kinesthesia is the ABILITY TO SENSE the position and movement of body parts without visualizing them.

A nurse is teaching a client who has lower extremity weakness how to use a four-point crutch gait. Which of the following instructions should the nurse include in the teaching? A) "Support the majority of your weight on the axillae." B) "Keep your elbows extended." C) "Bear weight on both of your legs." D) "Move both crutches forward at he same time."

C) "Bear weight on both of your legs." ^^ The client has three points on the ground at all times. Therefore, he must be able to bear weight on both legs. Rationale: A) This increases risk to underlying nerves and could result in partial paralysis of the arms B) Elbows should be flexed about 30deg D) Move each leg alternately with each opposite crutch so that three points of support are on the floor at all times.

A nurse is providing education about cultural and religious traditions and rituals related to death for the assisstive personnel on the unit. Which of the following information should the nurse include? A) "People who practice the islamic faith pray over the deceased for a period of 5 days before burial." B) "People who practice the Hindu faith bury the deceased with their head facing north" C) "People who practice Judaism stay with the body of the deceased until burial." D) "People who are practicing the Buddhist faith have the female family members prepare the body following death."

C) "People who practice Judaism stay with the body of the deceased until burial." ^^ In the Jewish faith, a family member often *STAYS WITH THE BODY UNTIL BURIAL OCCURS.* Rationale: A) Body is *WASHED, WRAPPED UP, and IMMEDIATELY BURIED.* B) Body facing north, but *CREMATED*. they don't bury. D) *MALES* not females *PREPARE THE BODY* following death.

A nurse is teaching a client how to self-administer insulin. Which of the following actions should the nurse take to evaluate the client's understanding of the process within the pyschomotor domain of learning? A) Ask the client if he wants to self-administer his insulin B) Have the client list the steps of the procedure C) Have the client demonstrates the procedure D) Ask the client if he understands the purpose of insulin

C) Have the client demonstrates the procedure ^^ Psychomotor: relating to the origination of movement in conscious mental activity. Rationale: A) Affective domain of learning B) Cognitive domain of learning D) Cognitive domain of learning

A nurse is planning care for an adult client who has fluid volume excess. Which of the following interventions should the nurse plan to include to monitor the client's weight? A) Calibrate the scales weekly B) Use a different scale each time C) Weigh the client on arising D) Weigh the client without clothing

C) Weigh the client on arising ^^ Each day, after voiding, before breakfast Rationales: A) Should calibrate the scales to 0 each day or before each use to provide accurate information B) Use SAME SCALE EACH TIME D) Should weigh using the same type of clothing each day to provide accurate reading and avoid embarrassment

A nurse is caring for a client who has an NG tube for intermittent enteral feedings. Which of the following actions should the nurse take? A. Auscultate for bowel sounds after each feeding B. Ensure the formula is cold before administering C. Elevate the client's head of bed 45 degrees before the feeding D. Flush the tubing with 15 mL of water after the enteral feeding

C. Elevate the client's head of bed 45 degrees before the feeding ^^ elevate 30-45 deg to prevent aspiration Rationales: A) Auscultate *BEFORE each feeding to ensure the client has peristalsis bowel activity* B) should not be cold but ROOM TEMP. Cold may cause cramping and discomfort. D) Should *flush 30 mL of water* after the enteral feeding to maintain patency of the feeding tube.

A nurse is collecting a urine specimen for culture and sensitivity for a client who has a urinary tract infection. The client has an indwelling urinary catheter in place. Which of the following actions should the nurse take? A) Withdraw the specimen from the drainage bag. B) Cleanse the collection port with soap and water C) Place the specimen in a clean specimen cup D) Clamp the tubing below the collection port

D) Clamp the tubing below the collection port ^^ To *ALLOW FRESH UNCONTAMINATED URINE TO COLLECT* before withdrawing the specimen through the port Rationales: A) Should be *FRESH URINE SPECIMEN* to prevent contamination B) Use *ANTIMICROBIAL SWAB* C) Use *STERILE CUP*

A nurse is caring for a client who is 48 hr postoperative following a small bowel resection. The client reports gas pains in the periumbilical area. The nurse should plan care based on which of the following factors contributing to this postoperative complication? A) Blood loss B) NPO status after surgery C) Nasogastric tube suctioning D) Impaired peristalsis of the intestines

D) Impaired peristalsis of the intestines ^^ Normal bowel function is delayed for up to several days following a bowel resection. *When PERISTALSIS is absent or sluggish, INTESTINAL GAS BUILDS UP*, producing pain and abdominal distention. Intervention? *AMBULATE TO PROMOTE PERISTALSIS* Rationale: A) It can cause shock but does not contribute to the findings demonstrated by this client B) Can cause dehydration but does not contribute to the findings demonstrated by this client C) NG tube suctioning keeps the stomch and intestines decompressed and can help prevent the findings demonstrated by this client

A nurse is preparing to provide tracheostomy care for a client. Which of the following actions should the nurse perform first. A) Open all sterile supplies and solutions B) Stabilize the tracehostomy tube C) Put on sterile gloves D) Perform hand hygiene

D) Perform hand hygiene ^^ FIRST THINGS FIRST!! This is vital because contamination of the nurse's hands is a primary source of infection. Rationale:

A nurse is planning to collect a stool specimens for ova and parasites from a client who has diarrhea. Which of the following actions should the nurse take when collecting the specimen? A) Instruct the client to defecate into the toilet bowl. B) Transfer the specimen to a sterile container. C) Refrigerate the collected specimen D) Place the stool specimen collection container in a biohazard bag

D) Place the stool specimen collection container in a biohazard bag ^^ with *CLIENT LABEL* place on the container and the bag for *easy identification*, and to prevent contamination with microorganisms. Rationales: A) Must be on *BEDPAN* or *CONTAINER FOR STOOL COLLECTION*. Since toilet water can dilute and contaminate the liquid specimen B) Not sterile but *CLEAN CONTAINER* with a tongue depressor C) Must send to lab immediately!! Must prevent from getting cold

A nurse is preparing to administer an intramuscular injection to a young adult client. Which of the following injection sites is the safest for this client? A) Vastus lateralis B) Dorsogluteal C) Deltoid D) Ventrogluteal

D) Ventrogluteal ^^ Muscles be thick and no major vessels Rationale: A) Thick muscles and away from major blood vessels and nerves, but not # 1 evidenced based B) Close to sciatic nerve C) Easy access, but muscle is small and sometimes poorly developed

OLDER ADULTS MYTHS AND FACTS T/F Clients who are age 65 or older are reluctant to report pain. T/F Clients who are age 65 or older experience decreased ability to perceive pain compared to young adult clients. T/F Older adult clients should receive opioid narcotics when needed. Do older adult clients' medication have shorter or longer duration of action?

TRUE: they may not want to bother nurse/caregivers FALSE!!! TRUE Renal and liver function declines with age. So, LONGER duration.

A nurse is preparing a sterile field for a procedure the provider will perform at the client's bedside. Which of the following actions should the nurse take? A) Hold the sterile drape above the waist and away from the body B) Drop the sterile objects toward the edges of the sterile field C) Hold packaged supplies 7.6 cm (3 in) above the sterile field D) Hold sterile objects over the field before setting them down on the field.

A) Hold the sterile drape above the waist and away from the body ^^ Contamination occurs when the nurse holds any object that will be part of the sterile field BELOW THE WAIST Rationales: B) Must drop *TOWARDS CENTER OF THE STERILE FIELD* C) Nurse should hold packaged supplies 15 cm (6in) above the sterile field before opening them and dropping them onto the field. D) Must add sterile objects to the SIDE, not above. Avoid reaching over.

A nurse is teaching a group of young adults. Which of the following should the nurse identify as an expected developmental task for this age group? A) Independent moral development B) Acceptance of body changes C) Strengthening ties with the family of origin D) Development of concrete reasoning

A) Independent moral development ^^ According to *KOHLBERG'S THEORY* -- young adults who have reached this level separate themselves from the rules and tenets of others and make their own decisions according to personal beliefs and principles. Rationale: B) Acceptance of body changes: this is during *ADOLESCENCE* C) Strengthening ties with the family of origin: Young adults need to develop intimacy outside of the family D) Development of concrete reasoning: this is during *MIDDLE CHILDHOOD*; abstract reasoning develops during adolescence.

A nurse is explaining the use of written consent forms to a newly licensed nurse. The nurse should ensure that a written consent form has been signed by which of the following clients? A) A client who has a prescription for a transfusion of packed RBC. B) A client who is being transported for a radiograph of the kidney, ureters, and bladder C) A client who has a prescription for a tuberculin skin test D) A client who has a distended bladder and needs a urinary catherization

A) A client who has a prescription for a transfusion of packed RBC. ^^Administration of blood is a procedure that carries RISK. so needs written consent Rationales: B) Clients sign a general consent form when admitted. This *GIVES CONSENT* to *DIAGNOSTIC EXAMS* C) Implied consent -- like client holding out an arm for the procedure D) Implied consent

A nurse is admitting a client who has decreased circulation in his left leg. Which of the following actions should the nurse take first? A) Evaluate pedal pulses B) Obtain a medical history C) Measure vital signs D) Assess for leg pain

A) Evaluate pedal pulses IMPORTANT to determine adequate blood supply to the foot. Rationale: Every other answer is correct, but what's the priority!?

A nurse is removing PPE after procedure with client who requires isolation precautions. Which PPE should be removed first? A) Gloves B) Gown C) Eyewear D) Mask

A) Gloves ^^ MOST CONTAMINATED. Next is goggles/face shield, then gown. From most contaminated to least.

A nurse is receiving a client from the PACU who is postoperative following abdominal surgery. Which of the following actions should the nurse take to transfer the client from the stretcher to the bed? A) Lock the wheels on the bed and stretcher B) Instruct the client to raise his arms above his head C) Elevate the stretcher 2.5cm (1 in) above the height of the bed. D) Log roll the client.

A) Lock the wheels on the bed and stretcher ^^ Locking the wheels prevents the client from falling to the floor by not allowing the cart or bed to move apart or away from the client. Rationales: B) Client should cross his arms across his chest to prevent injury C) Stretcher should be *NO MORE THAN HEIGHT* of the bed D) Logrolling technique is used to prevent injury when moving a client who requires *immobilization of the neck, back, or spine.* NOT FOR CLIENT FOLLOWING ABDOMINAL SURGERY.

A charge nurse is observing a newly licensed nurse perform tracheostomy care for a client. Which of the following actions by the newly licensed nurse requires intervention? A) Obtaining hydrogen peroxide for tracheostomy care B) Obtaining cotton balls for trach care C) Obtaining sterile gloves for trach care D) Obtaining sterile brush for trach care

B) Obtaining cotton balls for trach care ^ Cotton balls partciles can be aspirated into the trach opening causing tracheal abscess. A) Half-strength peroxide solution is used to CLEAN INNER CANNULA C) Trach care is a sterile procedure!!!!!!! D) Pipe cleaners or a small sterile brush can be used to remove thick or crusty secretions from the inner cannula

During the insertion of a urinary catheter for a client, the tip of the catheter brushes against the nurse's arm. Which of the following actions should the nurse take? A) Wipe the catheter with povidone-iodine and continue the catheter insertion. B) Soak the catheter in chlorhexidine for 15mins and then reattempt insertion. C) Continue with the catheter insertion D) Obtain a new catheter and reattempt insertion.

D) Obtain a new catheter and reattempt insertion. ^^ Sterile procedure. Must start-over if contaminated. Rationales: Other choices do not guarantee sterility.

A nurse is helping a client change his hospital gown. The client has an IV infusion on an infusion pump. Which of the following actions should the nurse take first? A) Remove the sleeve of the gown from the arm without the IV line B) Slow the infusion using the roller clamp C) Disconnect the IV line from the pump D) Bring the IV-solution and tubing from the outside to the end side of the sleeve of the gown

This question is asking what action to do *FIRST.* A) Remove the sleeve of the gown from the arm without the IV line ^^ This'll result in minimal interruption of the IV flow. Rationale: Everything else is correct, but they're not the FIRST thing to do.

A nurse is planning care for a client who is confused and requires a prescription for wrist restraints. Which of the following interventions should the nurse include in the plan of care? A) Renew the prescription for the use of restraints within 24 hours B) Secure the restraints with the buckle side next the client's skin C) Ensure 4 fingers can be inserted under the secured restraint D) Remove the restraint every 3 hr.

A) Renew the prescription for the use of restraints within 24 hours ^^ The nurse should plan to renew the prescription for the restraints within 24 hr, and only after the provider has evaluated the client. Rationale: B) Should secure on the softer side next to the client's skin -- with the BUCKLE or velco closure on the OUTSIDE C) Should *be 2 FINGERS*, not 4 D) Should be removed every 2 hours, to check skin to prevent skin breakdown

Which breath sounds should the nurse expect to hear over the periphery of the major lung fields? A) Vesicular B) Bronchial C) Rhonchi D) Bronchovesicular

A) Vesicular Rationales: B) Will be heard over trachea -- high-pitched, hollow, and loud C) Over trachea and bronchi due to secretions and swelling D) Will be heard either side of the sternal border anteriorly and between the scapulae posteriorly -- moderately loud with a medium pitch

A nurse is caring for a client who has a history of dysrhythmias. Upon entering the room, the nurse discovers the client is unresponsive to verbal or painful stimuli, has no respirations, and is pulseless. which of the following actions should the nurse take first? A) start chest compressions B) Provide breaths with a manual resuscitation bag. C) Administer oxygen D) Establish an airway

A) start chest compressions ^^ starts with chest compression, then opening the airway, and breathing for adults and pediatric clients *Evidence indicates there is a great survival rate when chest compressions are started before a breath is initiated.*

A nurse is planning care for a client who has a prescription for collection of a sputum specimen for culture and sensitivity. Which of the following actions should the nurse take when obtaining the specimen? A. Collect the specimen upon arising in the morning B. Force fluids during the day and collect the specimen in the evening C. Collect the specimen after antibiotics have been started D. Collect 2 mL of sputum before sending the specimen to the lab

A. Collect the specimen upon arising in the morning ^^ to more easily cough up the secretions that have accumulated during the night. *Generally, the deepest specimens are obtained in the early morning, and it is preferable to collect the specimen before breakfast* Rationales: B) *FORCING FLUIDS is ENCOURAGED*; however, evening hours are not preferred for collection of DEEP sputum specimen! C) Should be *PRIOR to ANTIBIOTICS* to prevent interference with the lab results D) Should be 4-10mL of sputum for adequate amount to test for C/S

A nurse is planning an in-service training session about various dietary practices. Which of the following pieces of info should the nurse include in the teaching? A) Ovo-vegetarian diets exclude eggs. B) Kosher diets have restrictions regarding how the food must be prepared. C) Macrobiotic diets are plant-based and exclude all animals and seafood. D) Flexitarian diets exclude the consumption of dairy products.

B) Kosher diets have restrictions regarding how the food must be prepared. ^^ Kosher diets are guided by a set of laws regarding the processing, preparation, and eating of food. Rationales: A) Ovo-vegetarian diets are primarily vegetable-based diets that exclude meat and dairy *except for eggs.* C) Macrobiotic diets are primarily plant-based -- do not include *FISH* and *SEAFOOD* D) Flexitarian -- primary plant-based with *occasional consumption of meat, fish, and dairy products.*

A community health nurse is preparing a campaign about seasonal influenza. Which of the following plans should the nurse include as a form of secondary prevention? A) Holding a community clinic to administer influenza immunizations B) Screening groups of older adults in nursing care facilities for early influenza manifestations C) Educating parents of young children about the dangers of influenza D) Finding rehabilitation programs for older adults who have complications related to influenza.

B) Screening groups of older adults in nursing care facilities for early influenza manifestations Secondary is preventing complications of an illness or providing care to prevent an illness from becoming severe. Rationales: A) Holding a community clinic to administer influenza immunizations: Immunization is *Primary prevention* -- healthy clients in danger of becoming ill C) Educating parents of young children about the dangers of influenza: Education is *PRIMARY PREVENTION* D) Finding rehabilitation programs for older adults who have complications related to influenza: *TERTIARY PREVENTION* -- prevent complications and help people recover form an existing illness

A nurse is caring for an adult client who communicates an unmet spiritual need. Which of the following client statements should indicate to the nurse that the client is experiencing spiritual distress? A) "Life has its ups and downs." B) "I believe that I control my own destiny." C) "God is punishing me for something." D) "I like to keep my rosary beads in bed with me."

C) "God is punishing me for something." ^^ Manifestations of spiritual distress can include a feeling that a higher power is punishing the individual for some behavior. Rationales: All the other choices are *incorporating a sense of spiritual wellbeing* by *insert each answer*.

A nurse is providing teaching to an older adult client who has constipation. Which of the following statements should the nurse include in the teaching? A) "Drink a minimum of 1,000 millimeters of fluid daily." B) Increase your intake of refined-fiber foods C) Sit on the toiler 30 mins after eating a meal D) Take a laxative every day to maintain regularity.

C) Sit on the toiler 30 mins after eating a meal ^^ Increased peristalsis occurs after food enter the stomach. Regardless of feeling the urge to defecate, it is recommended method to sit on the toilet 30mins after eating a meal to bowel retrain and treat constipation Rationales: A) *Should drink 1500mL of fluids* to prevent constipation!! B) *Increase COARSE-FIBER* and not refined fiber for constipation D) not recommended bc it may *hinder defecation habits* and can cause more constipation

A nurse is leading an education session about disposing of biohazardous materials. Which of the following instructions should the nurse include in the teaching? A) Use isopropyl alcohol to clean blood spills B) Discard empty blood bags in a bedside trash can. C) Break used needles before discarding. D) Place soiled linen in a single linen bag.

D) Place soiled linen in a single linen bag. ^^ Should be put there and is tightly secured to reduce risk of transmission of microorg Rationale: A) Use isopropyl alcohol to clean blood spills: *SHOULD USE* --> *CHLORINE BLEACH!!!* B) Discard empty blood bags in a bedside trash can. -- *SHOULD BE RETURNED to BLOOD BANK* in case there's a transfusion reaction and reduce risk of transfer... C) Break used needles before discarding: NO!! Reduce risk of injury -- don't break or bend

A nurse is obtaining the blood pressure in a client's lower extremity. Which of the following actions should the nurse take? A) Auscultate for the blood pressure at the dorsalis pedis artery B) Measure the blood pressure with the client sitting on the side of the bed C) Place the cuff 7.6 cm (3in) above the popliteal artery. D) Place the bladder of the cuff over the posterior aspect of thigh.

D) Place the bladder of the cuff over the posterior aspect of thigh. ^^ Correct way when doing lower extremity bp Rationales: Nurse should position the cuff *2.5 (1 in) ABOVE POPLITEAL ARTERY*

A nurse is planning to obtain the vital signs of a 2- year old who is experiencing diarrhea and who might have a right ear infection. Which of the following routes should the nurse use to obtain a temperature? A) Rectal B) Tympanic C) Oral D) Temporal

D) Temporal ^^ While not as accurate as rectal, this is the best route since 2 year old is having diarrhea (not rectal) and ear infection (not tympanic). Rationales: C) Oral -- CAN'T USE ORAL for CHILDREN under 3

A nurse is planning weight loss strategies for a group of clients who are obese. Which of the following actions by the nurse will improve the client's commitment to a long-term goal of weight loss? A) Attempt to increase the clients' self-motivation B) Keep detailed records of each client's progress C) Test client learning after each teaching session D) Avoid discussing areas that might cause client anxiety.

A) Attempt to increase the clients' self-motivation ^^ Motivation to learn is important in improving a client's commitment to achievement of a health goal, as well as increasing the amount and speed of learning. Rationales: B) Will help individual progress but not improve client progress toward individual goals D) Anxiety should be address EARLY in the teaching process

A nurse is admitting a client who has tuberculosis. In addition to standard precautions, which of the following transmission-based precautions should the nurse add to the client's plan of care?

AIRBORNE precaution Rationale: Remember ACRONYM. AIRBORNE is for smaller droplets (eg measles and varicella -- *MTV*) *PROTECTIVE* is for immunocompromised and are at high risk for infections. *DROPLET* is larger droplets (rubella, pertussis, and meningococcal pneumonia) *CONTACT* is direct or indirect contact with blood or bodily fluids (like SHIGELLA, HERPES SIMPLEX, E.COLI)

A nurse is caring for a client who is postoperative following a vaginal hysterectomy and asks for a drink. Her postoperative diet prescription reads: clear liquids; advance diet as tolerated. Which of the following responses should the nurse make? A) "Lunch trays should be here within the hour" C) "I am going to listen to your abdomen" C) "I'll get you some water to drink." D) I would wait a bit, or you could feel sick"

C) "I am going to listen to your abdomen" ^^ A common reason clients experience nausea and vomiting after surgery is delayed gastric emptying time or decreased peristalsis. *Auscultation* determine presence of bowel sounds before clear liquids can be administered. Rationales: A) This response is the nontherapeutic because it indicates that the client's immediate needs are not important. C) When a client is ready to resume a postsurgical diet, it is preferable to offer a choice of clear liquids, rather than water. Water provides hydration, but no other nutrients. D) This response reflects the nontherapeutic communication response of offering *unsolicited advice to the client.*

A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the following actions should the nurse take? A) Encourage the child to cough frequently to clear congestion from anesthesia B) Place a heating pad at the child's neck for comfort C) Administer analgesics to the child on a routine schedule throughout the day and night D) Provide the child with ice cream when oral intake is initiated

C) Administer analgesics to the child on a routine schedule throughout the day and night ^^ Pain meds around the clock will soothe the client's throat. It can be rectally or IV to avoid oral. Rationales: A) MUST NOT COUGH bc bleeding B) Ice collar would help, and not heating pad D) NO MILK PRODUCTS after tonsillectomy procedure bc this might coat the throat and cause client to cough and it may bleed

During a physical exam of a client, the nurse suspects strabismus. Which of the following tests should the nurse use to collect additional data? A) Confrontation test B) Symmetry of palpebral fissures C) Corneal light reflex D) Accommodation test

C) Corneal light reflex ^^ Strabismus means CROSS-EYED. Corneal light will visualize whether the light shines on the same spot BILATERALLY. This test will indicate the alignment of the client's eyes as well as any deviation inward or outward. With strabismus, eyes won't align when the client focuses. Rationale: A) Confrontation test: Compares visual fields of the client with that of the examiner. B) Symmetry of palpebral fissures: Palpebral fissure is the space between the eyelids -- clients with *PTOSIS* will have it unequal. D) Accommodation test: Determines whether the client's pupils constrict as they focus on an object the examiner brings closer to the eyes.

A nurse is caring for a client who is unstable and has vital signs measured every 15 minutes by an electronic blood pressure machine. The nurse notices the machine beings to measure the blood pressure at varied intervals and the readings are inconsistent. Which of the following actions should the nurse take? A) Turn on the machine every 15 min to measure the client's blood pressure. B) Record only blood pressure readings needed for the 15-min intervals. C) Obtain manual and automatic readings and compare them. D) Disconnect the machine, and measure the blood pressure manually.

D) Disconnect the machine, and measure the blood pressure manually. ^^ If the nurse questions the reliability of the monitoring equipment, *a manual process should be used*. Also, malfunctioning equipment can pose a safety risk for the client, so *IT MUST BE TAGGED and REMOVED.* Rationales: Th fact that IT IS NOT OPERATING CORRECTLY. Must TAG and REMOVE from use.

While admitting a client to the medical unit, the nurse asks him if he has advanced directives. The client states, "I have a document with me that names someone who can make health care decisions for me if i am not able." The nurse should identify that the client is referring to which of the following documents? A) Informed consent form B) Living will document C) DNR directive D) Durable power of attorney document

D) Durable power of attorney document ^^ When *ALIVE* It names a surrogate who can make health care decisions for the client if he is unable to do so. Rationales: A) Informed consent form: it's *PRIOR* to specific procedures explaining risks and benefits and pertinent information about the procedure B) Living will document: Advance directives that inform a medical personnel about the care to provide in case the individual is unable to make decisions C) DNR directive: provider writes on the client's request to instruct the staff to forego resuscitation efforts for the client.

A nurse is preparing a client who is scheduled for a hysterectomy for transport to the operating room. The client states she no longer wants to have the surgery. Which of the following actions should the nurse take? A) Tell the client it is too late for her to change her mind because the surgery is already scheduled. B) Telephone the operating room and cancel the surgery. C) Inform the client's family about the situation. D) Notify the provider of the client's decision.

D) Notify the provider of the client's decision. ^^ While acting as the *CLIENT'S ADVOCATE*, nurse should support decison and notify provider. Rationales: A) The client has the *RIGHT TO REFUSE* even after *CONSENT* is given. B) THIS IS NOT a nursing responsibility but the surgeon and the client must make. C) RESPECT CLIENT'S CONFIDENTIALITY, the family can be notified only after the client requests that the nurse do so.

A nurse is preparing to remove an NG tube for a client who had a partial colectomy. Which of the following actions should the nurse take? A) Maintain sunctioning while removing the NG tube B) Instill 100 mL of air into the NG tube before removal C) Instruct the client to breath in and out during the removal of the NG tube D) Pinch the NG tube while removing the tube

D) Pinch the NG tube while removing the tube ^^ This'll *DECREASE RISK OF ASPIRATION* of any gastric contents Rationales: A) *MUST DISCONNECT SUCTION* before removal to decrease injury to GI mucosa B) Should be 50mLs of air (not 100mls) -- to clear the contents of gastric drainage and decrease the risk of aspiration on removal of the tube C) Must TAKE DEEP BREATH and HOLD BREATH o glottis is closed and decrease aspiration

Dextran belongs in which of the following functional classifications? A) Skeletal muscle relaxant B) Beta-adrenergic blockers C) Broad-spectrum anti-infective agents D) Plasma volume expanders

D) Plasma volume expanders Dextran and albumin are plasma volume expanders that help correct hypovolemia in emergency situations, such as after hemorrhage or burns. Rationale: A) Skeletal muscle relaxant examples: cyclobenzaprine and metaxalone B) Beta-adrenergic blockers examples: propanolol and carvedilol C) Broad-spectrum anti-infective agents examples: ampicillin and cefixime

A nurse is witnessing a client sign an informed consent form for surgery. Which of the following describes what the nurse is affirming by this action? A) The client fully understands the provider's explanation of the procedure B) The client has been informed about the risks and benefits of the procedure C) The nurse witnessed the provider's explanation of the procedure D) The signature on the preoperative form is the client's

D) The signature on the preoperative form is the client's ^^ Nurse acts as a witness to attest that it is the client's signature on the preoperative consent form! Provider's responsibilities: -- *obtaining consent* -- *explain procedure* -- *risk and benefits of procedure* -- It is not necessary for the nurse to witness the explanation of provider

A middle-aged adult client is discussing the future plans with the nurse. Which of the following statements should the nurse identify as an indication that the client is having difficulty achieving Erikson's developmental task for this age group? A) "We miss our daughter so much that we are going to move closer to her." B) "I think this year i can plan on managing the funding at church." C) "I really wish I could lose some of this weight." D) "I find I am spending more time at work now that my son is at college."

A) "We miss our daughter so much that we are going to move closer to her." ^^ Middle-aged adult in Erikson is *Generativity vs. Stagnation*. *Accepting the independence of adult children* is part of the developmental task of middle age. Rationales: B) They should focus to community and volunteer activities C) Metabolism slows during middle age, and clients tend to gain unnecessary weight. Concern about this weight gain is an expected finding. D) Middle-aged adults often focus more on work as they try to achieve the dev. task of generativity vs. stagnation.

A nurse is applying an ice bag to the ankle of a client following a sports injury. Which of the following actions should the nurse take? A) Leave the bag in place for 45min B) Fill the bag 2/3 full with ice C) Place the ice bag uncovered on the client's ankle D) Tell the client that numbness is expected when the ice bag is in place

B) Fill the bag 2/3 full with ice ^^ this allows bag to be molded around the clients ankle Rationales: A) Should be 30mins C) Must have cover and not direct D) At risk for being too cold and injury!! numbness is not an expected result

A nurse is caring for a client who is immobile. The nurse should recognize that immobility places the client at risk of which of the following health alterations? A) Increased intestinal motility B) Respiratory Alkalosis C) Decreased cardiac output D) Hyocalcemia

C) Decreased cardiac output ^^ immobility decreased bp and cardiac output Rationales: B) This will lead to HYPOVENTILATION --> Respiratory acidosis D) This will lead to HYPERCALCEMIA -- immobility, bones will demineralize from lack of weight-bearing. The excess calcium can deposit in joints, causing stiffness and pain.

A nurse is administering a cleansing enema to a client who is scheduled for a diagnostic procedure. WHich of the following actions should the nurse take? A. Lubricate up to 3.2 cm of the tip of the rectal tube B. Position the client on his right side C. Insert the tip of the tubing 8 cm (3.1 in) D. Hold the enema container 61 cm above the rectum --------------------------------- A nurse is preparing to administer a cleansing enema to a client. Which of the following actions should the nurse plan to take? A) Insert the rectal tube 15.2 cm (6 in) B) Wear sterile gloves to insert the tubing C) Position on his left side D) Hold the solution bag 91 cm (36 in) above the client's rectum

C. Insert the tip of the tubing 8 cm ^^ Must be 7-10cm or 3-4in to prevent dislodging of the tube Rationales: A) Must ubricate 5-8cm (2-3in) to decrease irritation B) Should be SIMS' POSITION D) Should hold 45cm or 18in above the rectum to prevent painful distention of the colon ------------------ C) Position on his left side LEFT SIDE; this'll facilitate the flow of the enema solution into the sigmoid and descending colon Rationales: A) Should insert 7-10cm (3 to 4 in) B) Wear clean (nonsterile) gloves to prevent contamination D) Hold solution bag 30 cm (12 in) above the client's rectum for a low enema, and 45 cm (18 in) for a high enema. Holding solution bag too high may cause it to run too fast, causing discomfort and spasms.

A nurse is reviewing the laboratory values for a client who has a positive Chvostek's sign. Which of the following laboratory findings should the nurse expect? A) Decreased calcium B) Decreased potassium C) Increased potassium D) Increased calcium

A) Decreased calcium ^^ Calcium is for nerve conduction and muscle contractions. Below 8.4, it's hypocalcemia - tetany and muscle spasms may occur RATIONALES: D) Hypercalcemia: lethargy and weakness and others

AP is obtaining capillary finger stick blood sample. When will nurse intervene? A) Elevate the finger above heart level B) Rubbing the fingertip with an alcohol pad C) Puncturing the side of the fingertip D) Wrapping the finger in a warm cloth

A) Elevate the finger above heart level Rationale: --> should be *BELOW HEART LEVEL* Alcohol is correct bc we need to clean and dry completely. Should be the side of the finger -- avoiding sites beside bone Wrapping in warm cloth may increase blood flow to the area

A nurse is caring for a client who has acute renal failure. Which of the following assessments provides the most accurate measure of the client's fluid status? A) Daily weight B) Blood pressure C) Specific Gravity D) Intake and output

A) Daily weight ^^ MOST IMPORTANT FOR FLUID STATUS. Rationales: B) It is not the most accurate way C) Specific gravity is the kidney's ability to CONCENTRATE URINE, but not the most accurate D) Not the most accurate

A nurse is caring for a client who is receiving a blood transfusion. The client reports flank pain and the nurse notes reddish-brown urine in the client's urinary catheter bag. The nurse recognizes these manifestations as which of the following types of transfusion reactions? A) Hemolytic B) Febrile C) Circulatory overload D) Sepsis

A) Hemolytic ^^ Incompatible blood. *Chills, low back pain, hypotension, and tachycardia* are indications of hemolytic transfusion reaction. Rationales: B) Sensitive to the WBCs and platelets in the dono'rs blood: *Fever, chills, headache, and flushing* are indications of a febrile reaction C) When blood is administered too quickly for the client's circulatory system to handle. *Dyspnea, cough, headache, and hypertension* are circulatory overload D) When blood s contaminated with bacteria. *HIGH FEVER, vomiting, and diarrhea* are indications of sepsis.

A nurse is caring for a client who has a terminal illness. Which of the following findings indicates that the client's death is imminent? A) Urinary retention B) Cold extremities C) Hypertension D) Tachycardia

B) Cold extremities ^^ First in the feet, then hands. RATIONALE: Everything else should be OPPOSITE to become a physical change that indicates death is imminent

A nurse is reviewing the correct use of a fire extinguisher with a client. Which of the following actions should the nurse direct the client to take first? A) Aim the hose at the base of the fire B) Squeeze the handle of the extinguisher C) Remove the safety pin from the extinguisher D) Sweep the hose from side to side to dispense material

C) Remove the safety pin from the extinguisher Rationale: RACE: Rescue, Alarm, Confine, Extinguish PASS: Pull safety pin, Aim at the base, Squeeze the handle, Sweep side to side

A nurse is caring for a client who has a terminal illness. The client asks several questions about the nurse's religious beliefs related to death and dying. Which of the following actions should the nurse take? A) Contact the family and ask them to stay with the client B) Offer to call the client's minister C) Sit and hold the client's hand D) Leave the room and allow the client to cry privately

C) Sit and hold the client's hand ^^ Therapeutic communication techniques of *silence, touch, and offering of self to the client* Rationales: A) Not an immediate action and shifts responsibility B) Nontherapeutic -- communication block of putting the client's needs on hold and shifts responsibility D) Fails to acknowledge the client's distress

A nurse is examining a client for signs of costovertebral angle tenderness. The nurse should place the client in which of the following positions for evaluation? A) Sims' B) Supine C) Sitting D) Standing

C) Sitting ^^ Costovertebral is located in the central back. RATIONALES: A) Sims': For rectal exams/procedures B) Supine: Assessment like thoracic and abdominal exams D) Standing: observation of client's posture

A nurse is caring for a client who is receiving an IV fluid replacement. Which of the following findings should the nurse identify as infiltration of the IV infusion site? A) Redness at the IV catheter entry site B) A palpable cord is felt along the vein used for the infusion C) Taut skin around the IV catheter site that is cool to the touch D) Bleeding at the IV insertion site

C) Taut skin around the IV catheter site that is cool to the touch ^^ True statement. The nurse should STOP THE IV INFUSION, ELEVATE the EXTREMITY, and APPLY a WARM MOIST COMPRESS, or a COLD COMPRESS according to the type of infiltration. Rationales: A) Redness can be asign of infection. So nurse should remove the IV, clean the site with alcohol, and start a new IV line in another location B) This may be PHLEBITIS -- inflammation of the inner layer of a vein D) May mean that IV system is not intact.

A nurse is caring for an adult client who is grieving following the death of a loved one. Which of the following factors increases the client's risk of developing complicated grief? A) The deceased was a close friend. B) The client lived far from the deceased C) The death was sudden. D) The client has not visited the deceased in a long time

C) The death was sudden ^^ Complicated grief can occur when the death of a loved one is sudden and unexpected. Rationales: All the other ones are just risk factors for complicated grief.

A nurse is providing discharge teaching to a client who is recovering from lung cancer. The provider instructed the client that he could resume lower-intensity activities of daily living. Which of the following activities should the nurse recommend to the client? A) Sweeping the floor B) Shoveling snow C) Cleaning windows D) Washing dishes

D) Washing dishes ^^ Low intensity Rationales: A and C) Moderate intensity B) High intensity

A nurse is caring for a client who had a mastectomy and has a self-suction drainage evacuator in place. Which of the following actions should the nurse take to ensure proper operation of the device? A. Irrigate the tubing with sterile normal water once each shift B. Cleanse the opening with soap and water after emptying C. Maintain the tubing above the level of the surgical incision D. Collapse the device of air after emptying

D. Collapse the device of air after emptying ^^ to create enough suction to pull fluid exudate into the collection area of the device Rationale: A) Drainage system is not made for irrigating. Keep diaphragm of the device compressed to maintain suction and *prevent clotting of sanguineous drainage* B) Use *ALCOHOL WIPE* after opening it to decrease entry of microorganism. C) Drainage tubing *BELOW THE LEVEL OF INCISION* to enhance drainage.

Biceps reflex as 2+. Documentation would mean what? A) Diminished B) Average C) Brisk D) Hyperactive

B) Average ^^ Reflexes range on a scale of 0 to 4+. Active or expected reflexes are 2+. Rationales: A) Diminished is 1+ or less C) Brisk reflexes are 3+ or more D) Hyperactive reflexes are 4+

A nurse is changing the bed linens for a client who is on bed rest. Which of the following actions should the nurse plan to take? A) Place the soiled linens on the chair while making the bed B) Hold the linens away from the body and clothing C) Place the linens on the floor until able to place it in a linen bag D) Shake the clean linens to unfold

B) Hold the linens away from the body and clothing ^^ *to prevent soiling or the transfer of microorganisms.* The microorganisms present on the nurse's clothing can expose other clients to microorganisms.

A nurse is changing the dressings for a client who has two Penrose drains near an abdominal incision. Which of the following adhering devices is the best choice for the nurse to use to decrease skin irritation? A. Abdominal Binder B. Montgomery straps C. Hypoallergenic tape D. Plastic tape

B. Montgomery straps ^^ Least restrictive. It minimizes irritation to the skin near the incisional area. Rationales: A) It decreases skin irritation while the client rests in bed. However, it SLIPS OUT when STANDING. C) It's good for when client is sensitive to adhesive material, but it can cause skin sensitivity when frequently removed and reapplied. D) It adheres well to skin but not restrictive intervention priority.

A nurse is changing the dressings for a client recovering from an appendectomy following a ruptured appendix. The client's surgical wound is healing by secondary intention. Which of the following observations should the nurse report to the provider? A. Tenderness when touched B. Pink, shiny tissue with a granular appearance C. Serosanguineous drainage D. A halo of erythema on the surrounding skin

D. A halo of erythema on the surrounding skin ^^ underlying infection. Other manifestation of infection, such as purulent drainage, swelling, warmth, or a strong odor, should be reported to the provider. ^^ Rationales: A) Expected finding postoperative B) Expected finding -- preoperative stage of wound healing by secondary intention C) Expected finding postoperative by secondary intention

A nurse is performing eye irrigation for a client who was exposed to smoke and ash. Which of the following actions should the nurse take? A) Direct the irrigation solution upward toward the upper eyelid B) Exert pressure on the bony prominences when holding the eyelids open C) Hold the irrigator 1.25 (0.5 in) above the eyed. D) Direct the irrigation from the outer canthus to the inner canthus of the eye

B) Exert pressure on the bony prominences when holding the eyelids open ^^ *Should hold* the *UPPER LID against the eyebrow* and the *LOWER LID against the cheekbone* when irrigating the eye. Rationales: A) Should *DIRECT TO LOWER CONJUNCTIVA* C) Should be 2.5cm (1 in) D) Should be INNER CANTHUS to OUTER CANTHUS

A nurse is employing thorough, systematic method while obtaining objective data about a client. Through which of the following methods should the nurse collect this information? A) Health history B) Physical Examination C) Review of systems D) Interview

B) Physical Examination ^^ Physical findings are objective, and the nurse should collect this info in a systematic way. A) Health history --> *SUBJECTIVE DATA* which come verbally from the client or the client's representative C) Review of systems --> *SUBJECTIVE DATA* that nurse collects during the interview about the client's body system and mental status. This is from client and client's representative D) Interview: SUBJECTIVE DATA

A nurse is demonstrating postoperative deep breathing and coughing exercises to a client who is scheduled for emergency surgery for appendicitis. Which of the following statements indicates a lack of readiness to learn by the client? A) The client asks the nurse to repeat the instructions before attempting the exercises. B) The client reports severe pain C) The client asks the nurse how often deep breathing should be done after the surgery. D) The client tells the nurse that this exercise will probably be painful after surgery.

B) The client reports severe pain ^^ Client won't be able to concentrate bc of pain Rationales: A) This is a sign of readiness to learn even though he might no understand the mechanics of performing the exercises C) Readiness to learn --> Eager to know how often to do them D) Readiness to learn: client is able to think about the possible effects of the exercise following surgery

A nurse is preparing to administer an intramuscular injection to a client who is overweight. Which of the following sites should the nurse select for the injection? A) The lower, medial quadrant of the buttock near the coccyx B) The side hip between the iliac crest and anterior iliac spine C) The tissue of the posterior upper arm D) The lower, inner thigh 4 finger widths above the patella

B) The side hip between the iliac crest and anterior iliac spine ^^ This makes VENTROGLUTEAL. Rationales: C) Nurse should select the OUTER, POSTERIOR ISSUE of the upper arm when preparing to administer a *subcutaneous injection*. For IM, should be deltoid muscle.. 3 finger widths belowe the acromion process or about 5 cm or 2 in. A) For *dorsogluteal, it's LOWER, LATERAL*. This might increase risk of injury tho bc it may be injected to subcutaneous tissue and there is increased risk of piercing the sciatic nerve. D) Vastus laterlis should be middle portion of the muscle from the midline of the thigh to the midline of the outer side of the thigh.

Prescription for a vest restraint. Which of the following actions should the nurse take? A) Fasten the ties on the restraint to the side rails of the bed B) Tie the restraint with a quick-release knot C) Allow fingerbreadth between the restraint and the client's chest D) Place the restraint under the client's clothing

B) Tie the restraint with a quick-release knot ^^ Should be UNTIED EASILY in case the client's well-being requires quickly removing the restraints. Rationales: A) Fasten the ties on the restraint to the side rails of the bed -- *NO!!!!!!!!!!* Don't fasten on side of bed. if it's lowered, client could be injured. C) Allow fingerbreadth between the restraint and the client's chest -- Should be *TWO FINGERBREADTHS* between restraint and chest!!! D) Place the restraint under the client's clothing -- should be *OVER client's clothing*

A nurse is caring for a client who has a fecal impaction. Before digital removal of the mass, which of the following types of enemas should the nurse plan to administer to soften the feces? A) Carminative B) Hypertonic C) Oil retention D) Sodium polystyrene sulfate

C) Oil retention ^^ Less painful for the client Rationales: A) This is for expelling flatus B) This is for cleansing client's bowels. One type of us is for preparation for surgery D) This is for clients who has a very high levels potassium

A nurse is caring for an older adult client who has dysphagia following a cerebrovascular accident. Which of the following actions should the nurse take when assisting the client at mealtime? A. Encourage the client to drink fluids before swallowing food. B. Offer the client tart or sour foods first C. Tilt the clients head backward when swallowing D. Turn on the television

B. Offer the client tart or sour foods first ^^ *Tart or sour food* help with *chewing and swallowing* Rationale: A) DON'T!!! Will put at risk for choking C) Should be head forward to promote swallowing D) MUST MINIMIZE DISTRACTIONS

A nurse is supervising a newly licensed nurse who is caring for a client with streptococcal pharyngitis and is on transmission-based precautions. Which of the following actions by the newly licensed nurse indicates an understanding of droplet precautions? A) Shaking soiled linen before putting it in a hamper B) Removing a face mask when standing 0.5m (1.6ft) from the client C) Assigning another client with the same infection to share the room with the client. D) Allowing the client to visit a family member in the lobby of the facility.

C) Assigning another client with the same infection to share the room with the client If a private room is not available, the nurse *CAN* place clients who are infected with the same pathogen in the same room. Rationale: A) Shaking soiled linen before putting it in a hamper: *SHOULDN'T* bc this action can transfer microogranisms B) Removing a face mask when standing 0.5m (1.6ft) from the client: *SHOULD* wear mask within *1 m or 3.3 ft) of a client -- reduce risk of transferring the particle droplets D) Allowing the client to visit a family member in the lobby of the facility: *Nurse should STRICTLY LIMIT* client's activity outside the room to reduce transfer of microorg. *If client leaves room*, should out *MASK ON PT*

A nurse is planning to document care provided for a client. Which of the following abbreviations should the nurse use? A) BT for bedtime B) SC for subcutaneously C) PC for after meals D) HS for half-strength

C) PC for after meals ^^ Rationale: A) Don't bc we might B) Subcutaneously: Subcut or subcutaneously D) NO, just use "half-strength"

Rehab client transferring from wheelchair to bed -- what technique? A) Stand toward the stronger side B) Instruct the client to lean backward from the hips C) Place the wheelchair at a 45* angle to the bed D) Assume a narrow stance with feet 15cm (6 in) apart.

C) Place the wheelchair at a 45* angle to the bed ^^ Positioning the wheelchair at a 45deg *allows the client to pivot*, *lessening the amount of rotation required* Rationales: A) Stand on weaker side!!! B) LEAN FORWARD from the hips!!! This technique positions the client in the proper direction of the movement D) WIDE STANCE!!!!!

A nurse is preparing to perform mouth care for an unresponsive client. Which of the following actions should the nurse plan to take? A) Place the client supine B) Keep both side rails up C) Raise the level of the bed D) Inspect the client's mouth using a finger sweep

C) Raise the level of the bed ^^ Use of proper body mechanics and reduce risk of self-injury Rationales: A) Prevent risk of aspiration, so raise HOB 30 deg B) Prevent straining by lowering down the near side rail before mouth care D) Reduce risk of caregiver injury, nurse should NEVER insert fingers into the mouth of an unresponsive client

A nurse is planning care for a client who is postoperative and has a history of poor nutritional intake. Which of the following actions should the nurse include in the plan of care to promote wound healing? A) Limit total caloric intake to 25 kcal/kg of body weight B) Provide an intake of 500 mg/day of vitamin E C) Limit fluid intake to 20 mL/kg of body weight per day D) Provide a protein intake of 1.5g/kg of body weight per day

D) Provide a protein intake of 1.5g/kg of body weight per day ^^ *1-1.5 g/kg protein* is necessary to maintain positive *NITROGEN BALANCE* -- promotes wound healing Rationales: A) Should be 35-40 kcal/kg to promote wound healing B) Vitamin E is not essential for wound healing C) Should be 30-35 mL/kg -- water is essential to wound healing