Fundamentals

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

"I should limit my sodium intake to 4 grams per day." A low protein diet is recommended

A nurse is reviewing a provider's prescription for a group of clients. Which of the following client prescriptions should the LPN clarify with the provider?

Administer 1 g of vancomycin intrathecally. An intrathecal injection is not within the legal scope of practice for an LPN. This type of administration is injected directly through the intrathecal space of the spinal cord. This should only be performed by a provider.

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

Administer analgesic 30 min before Hold syringe 2.5cm/1in above upper end of wound + over area being cleaned to prevent syringe contamination + unsafe flowing pressure. Place irrigation solution in basin of hot water to warm solution to body temp. This reduces vasoconstriction. Use 35 mL syringe w/ 19-gauge needle or angiocatheter to ensure irrigation pressure w/in correct range.

A nurse is caring for a client in Buck's Traction. Which of the following nursing interventions would ensure effective therapy?

All weights must be free hanging to ensure effective traction. Avoid wrinkling and slipping of the traction bandage and to maintain countertraction.

A nurse is caring for a client who is postoperative and is experiencing nausea + vomiting. The nurse should identify which of the following findings as indications that the client has fluid volume deficit?

Cool extremities Orthostatic hypotension Flat neck veins Weak peripheral pulse Clear lungs Full bounding pulse indicates fluid volume excess Moist crackles in lungs indicates fluid volume excess.

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

Fresh vegetables During the first weeks after surgery, many providers recommend low fiber diets, particularly for clients with ileostomies, because the small bowel requires time to adapt to the diversion. Cream cheese is low in fiber and would therefore be included in the dietary recommendations for the client.

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?

Inability of the toddler to cry or speak Cyanosis: flushing of skin. Check skin, nail beds, mucous membranes. Capillary refill time/blanch testing of nail bed: < 2 sec. Indicates circulatory impairment.

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 Secure to upper thigh or lower abdomen. Decrease tension/trauma to urethra. Lateral/medial thigh: create tension/trauma to urethra Mid abdominal region: create tension on urethra. Does not allow downward flow of urine via gravity.

A nurse is preparing to help with transferring a client who can partially assist to a gurney. Which of the following actions should the nurse take?

Lower the head of the bed. It is safer for the client to move laterally if supine. Raise the bed so that it is slightly higher than the gurney. Lock the wheels on the bed and on the gurney. The gurney should be parallel to the bed. 1 caregiver on the side of the bed between the client's shoulder and hip and 2 caregivers on the gurney's side, 1 between the client's shoulder and hip and 1 between the hip and the lower legs.

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

Mild soap Isopropyl alcohol does not kill C. difficile Chlorhexidine solution effective against bacteria/viruses, but does not kill spores, Triclosan effective against some bacteria but does not kill spores

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

Pork chop and brown rice. Need low fiber + residue diet

The RN has just received a client who is schedule for a subtotal thyroidectomy. The RN has just delegated to the LPN to receive the client. Which of the following interventions would the LPN defer to the RN to perform?

Provide client education. Client education is a RN responsibility, as is the nursing process during client care and review of client systems.

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?

Remove the sleeve of the gown from the arm without the IV line. Enables gown to be moved fully off client + last stop system to remove gown off line, resulting in minimal interruption of IV flow. Slow infusion using roller clamp to prevent large volume infusion of IV solution while changing gown. Disconnect IV line from pump while removing/reapplying gown quickly. Bring IV solution/tubing through outside to end side of sleeve of gown to prevent tangling of tubing/gown.

A nurse is caring for a group of clients on a medsurg unit. Which of the following actions jeopardize client confidentiality?

Sharing a personal password with a coworker is correct. Discussing clients at the table in the cafeteria is correct. Disposing of written report sheet into the facility trash receptacle is correct.

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

"I will place a gel pad directly above your pubic area before I place the probe." Noninvasive dxstic procedure Promotes ultrasound transmission + accurate measurement. Bladder scan detects amount of urine remaining in bladder after voiding.

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

Temporal Oral not appropriate for children under 3 yrs Don't use rectal for those with diarrhea Don't use tympanic for those with ear infection

A nurse us caring for a client who has an NG tube for intermittent enteral feedings. Which of the following actions should the nurse take?

Elevate the client's head of bed 45 degrees before the feeding 30-40* Flush with 30 mL of water after feeding. Auscultate before each feeding. Formula is at room temp as cold may cause cramping.

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

Headache Offer fluids after to restore volume lost during procedure.

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

Place quad cane in left hand, extend left hand with quad cane, and right lower extremity followed by left leg. The cane should not be held on the client's weaker side.

A nurse in a provider's office is providing care for a client who has minimal exposure to sunlight. Which of the following interventions should the nurse recommend?

Take vitamin D supplements Need sunlight exposure for vitamin D. Increase calcium-rich food intake. Need vitamin D to increase calcium absorption. At least SPF 15 when exposed to direct sunlight to reduce risk of skin cancer.

Nurse is instructing a client with a right fractured tibia on the correct technique for using a 3 point gait with crutches. Which of the following should be included in teaching?

Wt is distributed on both crutches and then on the unaffected leg with the sequence being repeated. 4 point gait: wt evenly distributed, each leg being moved alternately w/ opposing crutch

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

"Do you consume pork products?" Some practicing Islam do not consume pork/alcohol. Some practicing Christianity receive Holy Communion. Some practicing Judaism require kosher food. Some practicing Jehovah's Witness faith will refuse blood transfusions.

A nurse is preparing to insert an indwelling urinary catheter for an adult male client who is uncircumcised. Which of the following actions should the nurse take? Use upward traction to hold the penis at a 45° angle from the body. Advance the catheter to the bifurcation after urine appears. Insert the catheter a maximum of 15 cm (6 in) before inflating the balloon. Leave the foreskin in place when inserting the catheter.

Advance the catheter to the bifurcation after urine appears to ensure that the balloon on the tip of the catheter is out of the urethra and in the bladder. Insert the catheter 18 to 23 cm (7 to 9 in) into the bladder or until urine flows through the catheter. Hold the penis at a 90° angle, not a 45° angle as it straightens the urethra and facilitates insertion of the catheter.

A nurse is caring 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 plan to take when obtaining the specimen?

Collect specimen upon arising in the morning Able to more easily cough up secretions that accumulated during night. Obtain before breakfast. Collect 4-10 mL.

A nurse is verifying that a client is giving informed consent to undergo electroconvulsive therapy. Which of the following actions should the nurse take?

Confirm the client's signature is authentic. Nurse's responsibilities include identifying if the client's signature is authentic, that the client gave consent voluntarily, and that the client appears to be competent to give consent. Informing the client of the adverse effects, benefits, purpose of therapy is the provider's responsibility.

A nurse is providing postmortem care for a client. Which of the following actions should the nurse take first? Elevate the client's head Remove indwelling equipment lines Wash the client's body Give the client's personal items to the family

Elevate the client's head to prevent discoloration of the face.

A nurse is contributing to the plan of 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?

Renew the prescription for the use of restraints within 24 hr Within 24 hr + only after provider has evaluated client. Secure restraint w/ softer side next to skin. Buckle/velcro closure on outside. 2 fingers inserted under restraints. Remove restraint every 2 hr.

A nurse in a provider's office is reinforcing teaching about health promotion with a client. Which of the following is an example of 2ndary prevention? The client attends a support group for depression. The client applies sunscreen twice a day when working as a lifeguard. The client attends a health seminar and has a cholesterol test. The client has had an influenza immunization this year.

The client attends a health seminar and has a cholesterol test. Primary: protect from disease 2ndary: screening techs + treating early manifestations Tertiary: long term/maintanence

A nurse is reinforcing teaching with an older adult client about home safety. Which of the following instructions should the nurse include? "Keep your hot water heater set to less than 150 degrees Fahrenheit." "Keep the thermostat on your furnace set to at least 56 degrees Fahrenheit." "Defrost foods in the refrigerator." "Consume your refrigerated leftovers within 6 days."

"Defrost foods in the refrigerator." Water heaters set < 48.9° C (120° F) to reduce the risk for burns. Older adult clients have an increased risk for burns from hot water because of a decrease in sensory skin receptors that can occur with aging. Keep the thermostat set to at least 18.3° C (65° F) to reduce the risk for injury from hypothermia. Older adult clients have a reduced ability to tolerate cold temperatures. Discard leftovers after 2 to 5 days in the refrigerator

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

"Have you had small liquid stools?" Collect data to determine if the client has any findings consistent w/ fecal impaction. Small liquid stools indicate there is seepage of liquid feces around impacted mass. Nurse should also know: What types of food they've been eating. What treatments are being used at home. Flatus can be present.

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

"I should expect my heart rate to take longer to return to normal after exercise as I get older." Decreased cardiac output which causes increased pulse rate during exercise. Bladder capacity decreases, but urinary incontinence is not a normal finding. Report. Increase buildup of cerumen. Decrease gastric emptying.

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

"I should remove constrictive clothing prior to measuring my blood pressure." Wait 20-30 min after caffeine/nicotine to measure bp. Measure bp with forearm at level of heart. Measure bp between meals.

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

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

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

"This can help prevent pneumonia." Purpose of turning, coughing, breathing deeply is to reduce risk of respiratory complications (atelectasis leads to pneumonia). This maxes lung expansion + assist w/ removal of pulmonary secretions. Do every 1-2 hr Reduce pulmonary embolus, thrombus formation

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

"We will keep her room cool to help her breathe better." Clients dying have decreased appetite. Do not force them to eat. Require oral care at least every 2-4 hr to keep oral mucosa moisturized and prevent lesions.

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

"You should cleanse your eye from the inner to the outer edge prior to putting in the drops." Prevent contamination of lacrimal duct. Look up during instillation to protect cornea + reduce blinking. Place drops on lower conjunctival sac to protect cornea. Press on nasolacrimal duct for 30 sec after instillation to prevent systemic absorption.

A nurse is reinforcing dietary teaching with a client who has chronic kidney disease and requires low-potassium diet. Which of the following food choices by the client demonstrates an understanding?

1 cup of applesauce (184mg K) 1 cup cantaloupe (473mg K) 1 large baked potato (1630mg K) 4 oz banana chips (608mg K)

A nurse is caring for 4 clients who are required to provide informed consent for treatment. The nurse should identify that which of the following clients is able to provide informed consent? A client who is receiving opioid medications via a PCA pump A client who has moderate Alzheimer's disease A 16-year-old client who has a fractured tibia An 18-year-old client who has acute appendicitis

18 year old w/ acute appendicitis Opioid medications have sedative effects, impairing understanding. Alzheimer clients have impaired judgement.

A nurse is evaluation the crutch-walking technique of a client who is required to keep weight off their right leg. Which of the following is the proper crutch gait for this client?

3 point 4 point: provides 3 points of support at all times while bearing weight on both legs. 3 point: provides at least 2 points of support at all time while bearing weight on unaffected leg. 2 point: provides 2 points of support at all times while bearing partial weight on each leg. Swing through: requires strength, skill, coordination + does not provide enough support for client who is required to keep weight off affected leg.

A nurse is preparing to document info about a client's lower legs which are swollen with 6 mm edema. Which of the following information should the nurse document?

3+ pitting edema. 1+: slight indentation about 2 mm. 2+: slight indentation about 4 mm. 3+: deep indentation about 6 mm. 4+: deep indentation about 8 mm.

A nurse is reinforcing teaching with a 45 yr old about colorectal cancer screening options. Which of the following should the nurse recommend? Computerized tomography colonography every 10 years A colonoscopy every 10 years A stool DNA test every 5 years A fecal occult blood test every 5 years

A colonoscopy every 10 years CTC every 5 yr Stool DNA test every 3 r Fecal occult blood test every year

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

A purple colored stoma. Stoma should be reddish-pink + moist. Purple stoma indicates poor circulation. Protrusion + small amount of bleeding from stoma are expected. Intestinal gas in pouch is expected.

A nurse is caring for a client who is postoperative and has paralytic ileum. Which of the following abdominal assessments should the nurse expect? Frequent bowel sounds with flatus Hyperactive bowel sounds with diarrhea Absent bowel sounds with distention Normal bowel sounds with increased peristalsis

Absent bowel sounds with distention Paralytic ileus: immobile bowel No flatus or stool

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

Amyl nitrate

A nurse is caring for a client who has urinary incontinence. Which of the following actions should the nurse take to prevent the development of skin breakdown?

Apply a moisture barrier ointment to the skin. Examine the skin at least every 2 hr and providing hygiene are two initial defenses against skin breakdown.

A client with an ileostomy reports stomal swelling along with decreased drainage of ileostomy contents. The nurse evaluates the stoma and surrounding areas by completing the following? Select all that apply.

Applying moist towels to the abdomen. Abdominal massage. Asking the client to drink hot tea. Moist towels should be applied to the abdomen to facilitate drainage. Abdominal massage should be initiated to promote drainage. Hot tea may facilitate drainage and should therefore be encouraged. The client should be instructed to lie down and assume a knee-chest position to facilitate drainage. If stomal swelling or abdominal cramping occurs, or if ileostomy contents stop draining, the client should be instructed to remove the pouch with faceplate.

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

Ask the client close-ended questions Clients w/ aphasia can have difficulty forming words. Asking "yes/no" questions allow the client to respond by shaking/nodding their head. Normal voice when speaking with the client. Speaking loudly can cause the client distress. Use facial gestures when communicating with the client to assist the client in understanding the context of the conversation. Artificial voice box for a client who had a laryngectomy.

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

Attach a humidifier to the base of the flow meter Moisten air for client to prevent drying mucous membranes when client receiving oxygen at rate > 4 L/min Apply water-based lubricant to nostril to relieve dryness, not petroleum. Simple face mask does not have reservoir bag. Simple face mask has side holes to allow CO2 to escape.

A nurse is documenting client care in a client's electronic health record. Which of the following entries should the nurse include in the documentation? "Complained about having incisional pain." "Voided adequate amounts through the shift." "Became short of breath when ambulating." "Appeared to be sleeping while in bed."

Became short of breath when ambulating Documentation should be objective + significant info. Avoid using words that reflect personal judgement about client's behavior ("complained") Avoid subjective info. Avoid nonessential info or vague terminology.

A nurse is caring for a client who has a prescription for a potassium supplement. The client tells the nurse that the pill is too large to swallow and refuses to take it. The nurse offers to break the pill into 2 smaller pieces. The nurse is demonstrating which ethical principle?

Beneficence Acting in client's best interest. Autonomy: accepting what the client wants. Justice: fairness. Nonmaleficence: avoid harm/injury.

A nurse is collecting data from a client for a comprehensive physical exam. The nurse should use the bell of the stethoscope to auscultate for which of the following? Bruits Borborygmi Crackles Rhonchi

Bruits

A nurse is preparing to administer an enteral feeding to a client who has an NG tube in place. Which of the following methods should the nurse use to verify correct placement of the NG tube?

Check the pH of the gastric aspirate. pH>6 = aspirated respirator contents or tube in the intestine. Withhold feeding.

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

Cheddar cheese Need to restrict protein and phosphorus which is present in cheese and many milk products.

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

Compare the pedal pulses bilaterally every 4 hr to check for adequate circulation. Check capillary refill distally every 4 hr. Elevate client's legs for at least 20 mins before bandaging. Remove elastic bandages daily.

A nurse is checking a client for a pulse deficit after detecting an irregular heart rate. Which of the following actions should the nurse take?

Count the radial + apical pulses simultaneously with another nurse Count pulse for 60 sec. Client in supine/sitting position. Auscultate area of chest over apex of heart. Erb's point is at 3rd intercostal angle.

A nurse is assisting with the plan of care for a client who has hypothermia. Which of the following interventions should the nurse include? Apply a cooling blanket. Cover the client's head with a cap. Provide a tepid sponge bath. Position the client with arms extended.

Cover the client's head with a cap.

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

Decrease rate of feeding. Expect to hear bowel sounds every 5-35 seconds. >40 bowel sounds/min = hypermotility, leads to diarrhea + intolerance to enteral feeding. Position of head of bed should be 30-45° to prevent aspiration Replace NG tube if coughing/vomiting (displacement).

An older adult client with a history of heart failure is admitted to the hospital with a diagnosis of digoxin toxicity. Which of the following clinical findings should the nurse expect? Select all at apply.

Digoxin level 1.5 ng/ml Yellow vision 52 HR An older adult client may experience the toxic effects of digoxin even though the drug level is within normal limits (0.5 - 1.5 ng/ml). Bradycardia is a sign of digoxin toxicity and is the reason an apical pulse is taken prior to administration of this drug. Clients with digoxin toxicity often have disturbed color vision or see halos.

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 begins to measure the blood pressure at varied intervals and the readings are inconsistent. Which of the following actions should the nurse take? Turn on the machine every 15 min to measure the client's blood pressure. Record only blood pressure readings needed for the 15-min intervals. Obtain manual and automatic readings and compare them. Disconnect the machine and measure the blood pressure manually every 15 min.

Discontinue the machine, and measure the blood pressure manually every 15 min Malfunctioning equipment can pose safety risk. Tag and remove it.

A nurse is caring for a client who is refusing medical treatment. Which of the following actions should the nurse take?

Document the client's refusal of treatment The provider is responsible for explaining the negative consequences of the client's refusal.

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

Ensure client wears surgical mask during transportation throughout facility. Streptococcal pharyngitis requires droplet precautions. Nurse should only place the client in a room with another client who has a positive throat culture for streptococci to prevent bacterial transmission.

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?

Exert pressure on the pony prominences when holding the eyelids open Hold upper lid against eyebrow + lower lid against cheekbone. Hold irrigator 2.5cm/1in above eye to prevent irrigator from touching eye and to prevent solution from damaging eye tissue. Direct irrigation solution onto lower conjunctiva sac to prevent cornea injury + having contaminated fluid flow down nasolacrimal duct. Inner to outer canthus.

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

False imprisonment Malpractice: unintentional

Nurse is caring for a client when IV infusion pump malfx and delivers 1L IV fluid over 2 hr. Which intervention is priority?

Fill out an incident report

A nurse is contributing to the plan of care for a client who has a gastrostomy tube through which he is receiving continuous enteral feedings. Which of the following interventions should the nurse include in the plan?

Flush the tube w/ 30 mL of water every 4 hr. Provide free water to the client and prevent dehydration. Elevate the head of the bed to 45 degrees (semi-Fowler's position) to limit the risk of aspiration of the formula.

A nurse is assisting to teach a group of unit nurses about a client who has surgical wound that is healing by secondary intention. Which of the following information should the nurse include in the teaching?

Granulation tissue fills the wound during healing Primary intention: provider closes wound using sutures/staples at time incision is made, suture lines are well approx. Tertiary intention: use sutures to close wound at later date after wound drains + starts to heal. Can include skin graft (deeper wounds).

A nurse is reinforcing teaching with a client who is recovering from gallbladder surgery about how to use an incentive spirometer. Which of the following information should the nurse include in the teaching?

Hold breath for 5 seconds after goal volume is reached Decreases collapse of alveoli which helps to prevent risk of atelectasis/pneumonia. Inhale slowly to reach goal volume. Breathe normally for short periods btwn cycles to reduce hyperventilation/fatigue. Repeat patterns for 10-20 breaths every hour while awake.

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

Hourly rounding by nurse

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?

I am going to listen to your abdomen Common reason nausea/vomiting after surgery is delayed gastric emptying time or decreased peristalsis. Auscultate the abdomen to determine presence of bowel sounds before clear liquids administer. When read to resume postsurgical diet, preferable to offer choice of clear liquids rather than water. Water does not provide nutrients.

A nurse is delegating client care. Which of the following leadership functions are associated with delegation? Select all that apply.

Identify situations appropriate for delegation. Use delegation as a time management strategy. Function as a resource person in delegating tasks to subordinates.

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

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

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

Insert a new IV in the other extremity. This will allow the affected extremity to heal. Discontinue the IV infusion when the IV is infiltrated to prevent further damage to the tissue. Obtain a culture specimen if suspecting an infection at the IV insertion site. Elevate the affected arm and apply moist warm compresses to decrease the edema from the IV infiltration.

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?

Insert the tip of the tubing 8 cm/3.1 in Insert tubing 7-10cm/3-4in to prevent dislodging of tube during procedure + injury to rectal mucosa. Lubricate 5-8cm/2-3in of tip. Left side Sims' position to allow solution to flow downward into sigmoid colon + rectum. Hold enema container MAX of 45cm/18in above rectum to prevent painful distention of colon.

Data collection of abdomen sequence

Inspect Auscultate Percuss Palpate Any other: Inspect Palpate Percuss Auscultate

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

Inspect the posterior pharynx for coiling of the tube. Do not clamp off the air vent of the NG tube because the vent needs to be open to air at all time to promote gastric patency. Do not instill any solution through the NG tube until placement and patency is confirmed. Do not connect the NG tube to wall suction until placement and patency is confirmed.

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

Instruct the client to tilt their head forward while eating. Prevents aspiration. Do not drink with a straw. Do not place food at back of mouth. Sit upright for at least 1 hr after meals.

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

Internally rotate the client's hips by using a trochanter roll. Place trochanter rolls at the proximal end of each leg to maintain neutral/internal rotation of client's hips + to prevent external rotation of hips. Elbows in flexed position on pillows when supine. Support shoulder w/ pillow to prevent internal rotation. Place head on pillow to not cause cervical flexion when supine.

A nurse is assisting with the care of a client who has a prescription for IV therapy. The client tells the nurse that they have numerous allergies. Which of the following allergies should the nurse bring to the attention of the charge nurse prior to the initiation of the therapy?

Latex Nurses use products containing latex (gloves, tourniquets, IV tubing) to deliver IV therapy. Foods with cross-sensitivity to latex: wheat, tomatoes, strawberries, kiwi, nectarines, avocados, potatoes, bananas.

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 stretcher to the bed? Lock the wheels on the bed and stretcher. Instruct the client to raise his arms above his head. Elevate the stretcher 2.5 cm (1 in) above the height of the bed. Log roll the client.

Lock the wheels on the bed and stretcher Client crosses arms across chest to prevent injuring arms. Stretcher should be no more than 1.3cm/0.5in above height of bed. Logrolling is a technique used to prevent injury when moving a client who requires immobilization of the neck, back, or spine.

A nurse is contributing to the plan of care for 4 clients. Which of the following clients should the nurse initiate airborne precautions? A client who has pneumonia A client who has measles A client who has pertussis A client who has methicillin-resistant Staphylococcus aureus (MRSA)

Measles Droplet: pneumonia, pertussis Contact: MRSA

A nurse is caring for a client who is receiving intermittent enteral feedings. Which of the following is the first action the nurse should take?

Measure the gastric residual before each feeding. Nursing process: assess. Change bag + tube feeding every 24 hr. Document intake + output. Flush tube w/ 30 mL of water after each feeding to maintain patency of tube.

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?

Montgomery straps Least restrictive. Adhesive strips applied to skin on either side of surgical wound. Have holes for using gauze to tie dressing securely. When dressing is changed, ties are released, dressing replaced, ties are secured again w/o having to remove strips. Abdominal binder: tends to slide out during ambulation. Securing dressing first before applying binder.

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

Nonrebreather mask Nonrebreather: highest % of O2 concentration w/o intubation + mechanical ventilation Nasal cannula: low O2 concentration Simple face mask: short term delivery of low-med O2 concentration Venturi mask: consistent lower O2 concentration

A client who is scheduled to undergo surgery tells the nurse that they do not understand the procedure and are reconsidering their decision to have it. Which of the following actions should the nurse take?

Notify the charge nurse of the client's concerns. Charge nurse then inform provider that client requires further explanation. Do not explain benefits of therapy or offer therapy alternatives. This is out of nurse's scope of practice.

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

Obtain the spill kit specifically designated for this type of spill and use it. Make sure client is safe then deal with spill

A nurse is participating in an interdisciplinary treatment meeting for a client who is to go home w/in a week. Which of the following health care providers should the nurse identify will assist the client with ADL?

Occupational therapist

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?

Offer tart/sour food first. Stimulate saliva production. Risk for choking when liquids (esp thin liquids) offered while eating solid foods. Suggest dry swallows between bites of food. Tilt head forward. Minimize distractions to concentrate chewing/swallowing.

A nurse is caring for a client who has dyspnea caused by a respiratory infection. The nurse should assist the client into which of the following positions?

Orthopneic Sit upright + lean forward. This allows max chest expansion. Dorsal recumbent: client is supine/back-lying. Breathing is difficult in this position. Sims': side-lying + partially on abdomen w/ flxion of upper hip/knee/elbow/shoulder. Useful for unconscious patients as secretions can drain from mouth. Prone: lying on abdomen. Useful for unconscious patients as secretions can drain from mouth. Prevents flexion contractures of knees/hips.

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

Output was 60 mL past 3 hours. This represents oliguria and indicates decrease in kidney perfusion or function. Report all these to provider, but the answer is highest priority: Voiding 3 times a night: nocturia Burning + discomfort w/ urination: dysuria Increased WBC: infection

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

Perform a bladder scan Collect data first

A nurse is caring for a toddler who has food lodged in the airway and cannot make any sounds. Which of the following actions is the nurse's priority? Perform abdominal thrusts on the toddler. Place the toddler in a side-lying position. Monitor the toddler's respiratory rate. Look in the toddler's mouth for a foreign object.

Perform abdominal thrusts on the toddler.

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

Perform muscle relaxation before bedtime Reduces anxiety + induce sleep. Vigorous exercise, caffeine, nicotine are stimulants. Maintaining consistent bedtime can help to induce sleep

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?

Pinch the NG tube while removing the tube. Decrease risk of aspiration of gastric contents. Disconnect NG tube from suction to decrease injury to GI mucosa. Instill 50 mL air into tube to clear contents of gastric drainage + decrease risk of aspiration. Take deep breath + hold it during removal to close off glottis + decrease risk of aspiration of gastric contents.

A nurse is collecting data from a client who has venous insufficiency. Which of the following findings should the nurse expect?

Pitting edema The venous system is unable to efficiently return blood to the heart resulting in increased venous pressure and an accumulation of fluid in the interstitial tissues. Shiny, thin skin on the lower extremities is an expected finding of a client who has arterial insufficiency. This is due to chronic undernourishment of the cells because of a decreased blood supply to the area. The client who has arterial insufficiency will develop dependent rubor, or a dusky red color of the feet, when they are dangled due to decreased blood flow. Thickened toenails are an expected finding for a client who has arterial insufficiency. This manifestation is due to chronic undernourishment of the cells because of decreased blood supply to the area.

A nurse is preparing to perform a sterile dressing change for a client. Which of the following actions should the nurse take when setting up the sterile field? Open the top flap of the sterile tray toward the body. Place sterile objects at least 2.5 cm (1 in) inside the sterile field. Prepare the sterile field 15 min before the procedure. When adding a sterile item to the field, hold the package 30.5 cm (12 in) above the field.

Place sterile objects at least 2.5 cm (1 in) inside the sterile field. Open top flap away from body. Hold package 15 cm (6 in) above field to prevent outside of item's outer packaging from contaminating field.

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

Place the bladder of the cuff over the posterior aspect of the thigh Position cuff 2.5cm/1in above popliteal artery. Auscultate for bp at popliteal artery. Prone position if possible. Otherwise, supine w/ knee flexed.

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

Pocketing food Incomplete oral clearance, or retaining food in the cheeks, under the tongue, or on the hard palate, is a common manifestation of dysphagia. Speak slowly, weakly, and imprecisely. Their vocal tone often changes after they swallow, and they commonly experience hoarseness. Drooling and copious oral secretions, rather than dry mouth, are possible indications of dysphagia due to an impaired ability of fluids to pass through the pharynx to the esophagus. More likely to have heartburn, vomiting, choking, belching, and coughing due to an impaired ability for the food to move from the esophagus into the stomach.

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

Position the affected limb in a dependent position. The affected limb should not be elevated on a pillow for the first 24 hour post-operative. Positioning the extremity in a dependent position will promote blood flow and oxygenation which will decrease the risk of infection.

A nurse is collecting data from a client who has an NG tube set to low intermittent suction. Which of the following findings indicates hypmagnesemia?

Positive Chvostek's sign To elicit Chvostek's sign, tap facial nerve near ear. If facial muscles contract, it is positive indicating low serum magnesium/calcium Hypokalemia: decreased bowel motility Hypermagnesemia: drowsiness Hypercalcemia: Bone pain

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

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

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

Provide mouth care to them at least every 2 hours Reduce discomfort from dehydration, nausea, dry mucous membranes. Decreased appetite, do not encourage feeding if they don't want it. Keep room cool for easier breathing. Turn to right side if experiencing nausea.

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

Reinforce dressing w/ additional gauze

A nurse in an acute care setting is documenting postmortem care in a client's medical record. Which of the following info should the nurse include in the documentation?

Release of personal belongings form Document name of provider who certified client's death. Document ID of client using 2 identifiers at time of death + compare these w/ ID in medical record.

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

Remove staple from skin after both sides are visible Indicates proper dislodgement of staple + prevents pulling on skin around incision. Avoid lifting staple remover when squeezing handle to prevent pulling. Completely close handle of staple remover to properly dislodge staple to prevent pulling. Staples bend at center, not the sides.

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? Tie the restraints to the side rails. Perform range-of-motion exercises to the wrists every 3 hr. Remove the restraints one at a time. Obtain a PRN prescription for the restraints.

Remove the restraints one at a time. Remove every 2 hr Do not tie to side rails. Restraint prescriptions can only be written for a 24-hr period and cannot be a PRN prescription.

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

Report a blue color as positive result. Use a wooden applicator to spread the stool thinly over the guaiac paper within the confines of the boxes on the slide. Wait 3 to 5 min after the stool is on the paper to apply the developing solution. Apply two drops of developing solution to each box on the reverse side of the slide.

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

Scheduling the case late in the day Covering IV tubing ports w/ tape (IV tubing w/o latex ports should be used. If not, cover ports w/ tape)

A nurse at a screening clinic is assessing a client who reports a history of a heart murmur related to aortic valve stenosis. At which of the following anatomical areas should the nurse place the stethoscope to auscultate the aortic valve? Fifth intercostal space just medial to the midclavicular line Second intercostal space to the left of the sternum Fifth intercostal space to the left of the sternum Second intercostal space to the right of the sternum

Second intercostal space to the right of the sternum Aortic stenosis produces mid systolic ejection murmur that can be heard with client leaning forward. Mitral valve: 5th intercostal space medial to midclavicular line. Pulmonic valve: 2nd intercostal space left to sternum. Tricuspid valve: 5th intercostal space to left of sternum.

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? "Drink a minimum of 1,000 milliliters of fluid daily." "Increase your intake of refined-fiber foods." "Sit on the toilet 30 minutes after eating a meal." "Take a laxative every day to maintain regularity."

Sit on the toilet 30 minutes after eating a meal. Increased peristalsis occurs after food enters stomach. Consume 1.5k mL of fluid. Increase intake of coarse-fiber + whole grains. Refined = very little fiber Do not recommend daily intake of laxatives and consistent use hinders natural defecation habits.

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

Stage 3 pressure injury on the coccyx. Secondary intention: pressure injury + wounds with edges not approximated. Tertiary intention: contaminated wound left open for monitoring + closed after several days. Primary intention: Sutured/surgical wound.

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

Support feet with foot boots Feet in dorsiflexion. Alternate wearing ankle-foot orthotic devices every other 2 hr. Place a hand roll in the palm of the client's immobile hand to maintain a functional position and prevent contractures.

A nurse on an inpatient mental health unit is caring for a group of clients. Which of the following actions by the nurse demonstrates the ethical concept of autonomy?

Supporting a client's wishes to refuse prescribed treatments. Veracity: Describing the adverse effects of a client's medications Beneficence: Spending extra time to calm an agitated client Fidelity: Ensuring that a client understands expectations for group participation

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

The baby is crying inconsolably for more than three hours A localized or generalized rash is associated with the MMR (measles, mumps, and rubella) or Varicella vaccines.

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

The client reports severe pain Not able to concentrate + not ready to learn a new activity.

A nurse caring for an older adult client who has sustained multiple infections the past 2 years. The nurse should identify that which of the following physiological changes increase the client's risk of infection? Core body temperature elevation Thinning of the skin Increased number of lymphocytes Increased serum albumin levels

Thinning of the skin Risk for skin abrasions, and therefore increases the client's risk and susceptibility for microorganisms to enter the damaged skin resulting in infection. With age, the body tends to maintain a lower core temperature, which reduces the body's ability to raise core body temperature and help fight infection. Older adults produce fewer lymphocytes in response to pathogen invasion. With age, the body is less able to produce lymphocytes, which weakens the body's response to pathogen invasion. With age, adults tend to have lower serum albumin levels. Lower serum albumin levels decrease the body's ability to repair and restore tissue, which can increase the risk for infection of wounds and lesions.

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

Thready pulse BUN > 20 mg/dL indicates extracellular fluid volume deficit. Expected hemoglobin range: 14-18 g/dL (M) and 12-16 g/dL (F). Increased hemoglobin indicates dehydration, COPD. Decreased hemoglobin indicates anemia, cirrhosis, hemorrhage. Client's neck veins are flat with fluid volume deficit. With excess, they are full + visible in sitting position.

A nurse is caring for a client who is unconscious. With the help of an AP, the nurse has repositioned the client from a left lateral to a right lateral position. The client's daughter asks why the nurse keeps her father lying on his side. Which of the following rationales should the nurse give the family member?

To prevent aspiration problems Secretions and emesis he might otherwise aspirate will drain from his mouth. This is especially important during oral hygiene care. Prone position is the only one that allows full extension of the hip and knee joints. Orthopneic position (sitting up and leaning on pillows on the overbed table) promotes maximal lung expansion.NG tube set to low suction prevents abdominal distention in clients who are unconscious.

A nurse has accepted a position on a pediatric unit and is learning more about psychosocial development. Identify the order of Erikson's stages of psychosocial development from birth-18yrs.

Trust vs. mistrust Autonomy vs. shame and doubt Initiative vs. guilt stage Industry vs. inferiority Identity vs. role confusion

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

Unresolved + resolved health conditions Report current meds prescribed. Report ongoing interventions.

A nurse is planning to administer pain medication to a client who has postoperative pain following abdominal surgery. Which of the following actions should the nurse take first?

Use the pain scale to determine the client's pain level

A nurse is contributing to the plan of care for a client who has a wound infection following abdominal surgery. To promote healing and fight infection, which of the following vitamins and mineral should the nurse plan to increase in the client's diet?

Vitamin C + zinc Vitamin E: skin/wound healing. Vitamin D: use with calcium to prevent osteoporosis. Maintains normal calcium + phosphorus levels in blood. Vitamin K + iron: treat normal clotting of blood + impaired intestinal synthesis by antibiotics. Iron needed to rebuild RBC.

A nurse is caring for a group of clients in a longer-term care facility. Which of the following actions should the nurse take to prevent health care-associated infections for these clients?

Wash hands after removing gloves. Perform hand hygiene after touching client's supplies. Clean stethoscope w/ antimicrobial wipe after obtaining vital signs.

A nurse is reinforcing teaching to a group of older adults about sources of complete + incomplete protein. Which of the following foods should the nurse include as complete protein?

Yogurt All nine essential amino acids in the quantities needed by the body are found in a complete protein for protein synthesis. An incomplete protein does not have sufficient quantities of the nine essential amino acids needed by the body to support protein synthesis.

A nurse is reinforcing teaching w/ a client who has pneumonia and productive cough. Which of the following instructions should the nurse include in the teaching?

You should cover your mouth with a tissue when you cough. Pneumonia spread by droplets. Client should stand 3 feet away from others when coughing. Client should receive pneumonia vaccine at 65 + every 10 years after.

A nurse is caring for a client who presents to an urgent care with a laceration on his forearm. Which of the following activities is an example of primary prevention?

immunization Primary prevention is true prevention of the manifestations of illness through health promotion and disease prevention. This level of prevention includes immunizations because they provide protection against specific infections and diseases. Secondary prevention focuses on prompt intervention for health problems or issues. Suturing the client's wound, applying a sterile dressing to the client's wound. If the client's laceration has caused nerve damage and functional disability, follow-up care would include tertiary prevention activities, such as rehabilitation.

A nurse is assisting in preparing a presentation at a senior center about age-related MS changes. Which of the following alterations is appropriate for the nurse to include?

​Decreased muscle mass With aging, muscles decrease in mass and strength. Vertebral disks thin with age.​Chest and pelvic width increase with age. The force of isometric contractions decreases with age.

A nurse observes an assistive personnel (AP) preparing to obtain blood pressure with a regular size cuff for a client who is obese. Which of the following explanations should the nurse give the AP "The reading will be inaudible if the cuff is too small for the client." "The width of the cuff bladder should be 75 percent of the circumference of the client's arm ." "As long as the cuff will circle the arm the reading will be accurate." "Using a cuff that is too small will result in an inaccurately high reading."

"Using a cuff that is too small will result in an inaccurately high reading." Width of cuff bladder should be 40% of the circumference of arm

A nurse is preparing to perform a wound irrigation for a client who has a stage 3 pressure injury. Which of the following supplies should the nurse plan to use? A piston syringe Barrier ointment Chilled irrigation solution Sterile cotton balls

A piston syringe as it provides a gentle flow to flush exudate/debris. Barrier ointment is for protecting skin of clients w/ urinary incontinence. Using this on an exudative wound will block the effects of irrigating solution. Use irrigation solution warmed to body temp. Do not use sterile cotton balls as fibers can shed onto the wound's surface + adhere to tissue. Use gauze to dry the edges of wound after procedure.

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

BUN 8 mg/dL Expected range: 10-20 mg/dL. Fluid volume excess, BUN is lower than normal due to hemodilution. Urine specific gravity expected range: 1.005-1.030. Fluid volume excess, urine specific gravity is lower than normal due to dilution. Hematocrit expected range: 37%-47% (F), 42%-52% (M). Fluid excess volume, hematocrit is lower than normal due to hemodilution. pH expected range: 4.6-8. Hydration status does not affect pH levels.

A nurse is measuring vital signs for a client and notices an irregularity in the pulse. Which of the following actions should the nurse take? Measure the pulse using a Doppler ultrasound stethoscope. Check the client's pedal pulses. Count the apical pulse rate for 1 full minute, and describe the rhythm in the chart. Take the pulse at each peripheral site and count the rate for 30 seconds.

Count apical pulse for 1 full minute + describe rhythm in chart Use a Doppler ultrasound stethoscope for a pulse that is nonpalpable. Pedal pulses to determine the client's circulation in the lower extremities. Palpate all peripheral pulses to determine the equality of blood perfusion to the extremities.

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

Determine the client's ability to assist with the bath. The first action the nurse should take using the nursing process is to collect data from the client. Instead of performing every step of hygiene for the client, the nurse should encourage the client's independence by first determining what actions the client is able to perform.

A nurse on a rehabilitation unit is preparing to transfer a client who is unable to walk from bed to a wheelchair. Which of the following techniques should the nurse use? Stand toward the client's stronger side. Instruct the client to lean backward from the hips. Place the wheelchair at a 45° angle to the bed. Assume a narrow stance with feet 15 cm (6 in) apart.

Place the wheelchair at a 45 degree angle to the bed Lean forward from the hips.

A nurse is contributing to the plan of care for a client who has a pressure ulcer on his heel. Which of the following information should the nurse include in the plan?

Provide the client a diet high in vitamin C. Vitamin C is essential for wound healing to promote formation of new capillaries, synthesis of new tissue and development of collagen. Turn the client at least every 2 hr to limit direct pressure on the ulcer. Clean the wound bed with normal saline or with a non-toxic solution. Keep the ulcer bed moist to aid in healing.

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

Administer analgesics to the child on a routine schedule throughout the day and night. Milk products are avoided because they coat mouth/throat, causing throat clearing. Clearing throat leads to bleeding. Give ice chips + ice pops. Offer ice collar

A nurse is planning care for a client who is disoriented and at risk for falls. Which of the following interventions should the nurse include?

Ensure client is wearing nonskid slippers. Bedside table should be w/in reach. Place client in room near nurses' station. Keep half side rails up only when necessary (client may climb over full side rails). Reinforce teaching about how to use call bell.

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?

Turn the stocking inside out up to the heel before applying Application of stocking easier + less constrictive wrinkles. Rolling stocking partially down decrease venous return + cause skin irritation. Also wrong size. Remove stocking once every shift to inspect skin/circulation. Slide top of stocking up over calf all at once to lessen constrictive wrinkles that can decrease venous return.

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?

Collapse the device of air after emptying Do so periodically to create enough suction to pull fluid exudate into collection area. Keep diaphragm of device compressed to maintain suction + prevent clotting of sanguineous drainage. Cleanse drain opening w/ alcohol wipe Maintain drainage tubing below level of incision to enhance drainage.

A nurse is planning care for a group of clients. The nurse should expect to witness an informed consent for a client who will undergo which procedure? Administration of an enema Performance of a paracentesis Insertion of an indwelling urinary catheter Placement of an NG tube

Performance of paracentesis. Expect to witness informed consent prior to invasive diagnostic procedure. General consent form upon admission covers procedures that are noninvasive routine treatments (enema, various meds, insertion of indwelling urinary catheter/NG tube, suctioning client's airway, irrigation of wound).

A nurse is preparing to transfer a client who has hemiparesis from a bed to a chair. Which of the following actions should the nurse take? Pivot foot closest to the bed. Keep feet close together. Position knees above the client's knees. Place the client's weaker leg in front.

Pivot foot closest to the bed to allow space and free movement of the client into the chair. Spread feet shoulder width. Align knees w/ client's knees to stabilize client. Place stronger leg forward to enhance stability.

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

Removing client's dentures Dentures remain in place to give face natural appearance. Nurse determines what items need to remain w/ body. All other belongings given to family. Absorbent pads placed under buttocks to absorb feces + urine released because of relaxation of sphincter muscles. Eyes should be closed by holding them gently shut for a few seconds.

A nurse is checking the IV insertion site for infiltration for a client who is receiving fluid replacement. Which of the following findings should the nurse identify is infiltration of the IV infusion site?

Taut skin around the IV catheter site that is cool to the touch Stop IV infusion, elevate extremity, apply warm/cold moist compress. Redness at site: local infection. Remove IV, clean with alcohol, start new IV line at another location. Palpable cord felt along vein: phlebitis. Stop IV + start new IV line at another location. Bleeding at site: IV system not intact. Check if catheter is w/in vein. May need to start new IV line in another location if bleeding does not stop after interventions.

A nurse is assisting with a presentation about caring for clients who are receiving diuretic therapy. The nurse should explain that which of the following medications can put clients at risk for hyperkalemia?

​Spironolactone Spironolactone is a potassium-sparing diuretic that blocks the effects of aldosterone in the renal tubules, causing a loss of sodium and water and retention of potassium. The nurse should instruct that spironolactone therapy can increase the risk of hyperkalemia and hyponatremia. Hydrochlorothiazide is a thiazide diuretic that increases the risk of hypokalemia, not hyperkalemia. Mannitol is an osmotic diuretic that can cause hyponatremia, not hyperkalemia. Furosemide is a high-ceiling (loop) diuretic that increases the risk of hyponatremia and hypokalemia, not hyperkalemia.

A nurse is reinforcing home safety info with an older adult client. Which of the following statements should the nurse identify as an indication that the client needs further instruction?

"I should use my walker carefully when going upstairs." The client should not use his walker on the stairs at all. If he has no one to assist him with moving the walker up or down the stairs, he should have a second walker to use on another floor of his house.

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

"I will be sure to keep the crutch tips dry." Hold both crutches in one hand, use other hand for balance when sitting down. Place weight on handgrips as weight on axillae can damage brachial plexus nerve bundle. Use unaffected leg when going upstairs.

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

"Perform three separate tests using three separate stool specimens." Avoid eating red meat for 3 days before collecting a stool specimen. Red meat can cause a false-positive reading. Do not consume vitamin C or citrus products for 3 days before collecting a stool specimen. Vitamin C supplements or citrus products can cause a false-negative result. Can take acetaminophen, but should avoid taking any type of NSAIDs such as aspirin, ibuprofen, and naproxen for 7 days before collecting a stool specimen. NSAIDs can cause a false-positive result.

A nurse is providing oral hygiene for a client who is unconscious. Identify the sequence of steps the nurse should take.

Assess gag reflex (determine risk for aspiration). Position client on their side w/ head turned to side (allow secretions to drain from mouth). Place a towel under head / emesis basin under their chin (protect bed linens). Separate upper + lower teeth w/ oral airway device (allows safe access to mouth). Cleanse mouth using toothbrush.

A nurse is caring for a client who is one month post bariatric surgery and has been diagnosed with dumping syndrome. Which of the following recommendations is appropriate points of reinforcement in teaching? Select all that apply.

Avoid consuming milk, sweets, and sugars. Eat small, frequent meals during the day. Eliminate liquids with meals, and for one hour before and after meals. Reduction in the amount of fluid ingested at one time, eating a high-protein, high-fat, and low-to- moderate carbohydrate diet. Lying down after meals to slow transit time of food in the intestines. Dumping syndrome frequently occurs after bariatric surgery and symptoms can include vertigo, syncope, pallor, diaphoresis, tachycardia, and palpitations

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

Client reports urinary incontinence. Older males can experience hypertrophy of prostate gland, older females can experience stress incontinence. Smooth, brown, irregular lesions on backs of hands are expected age-related change. Glossy, white circles around periphery of corneas (arcus senilis) are expected of age-related change. Decreased sense of taste is expected age-related change.

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

Discard the needle and syringe in a sharps disposal container. Without recapping the needle, the nurse should immediately deploy the needle safety device and drop the needle and syringe in a designated puncture-proof and leakproof sharps disposal container. Do not break, bend, recap, or manipulate used needles. A small deviation of the center of the cap from the needle could result in a needlestick injury.

A nurse working in a community clinic is talking with an older adult client who states that their life has no purpose. The nurse should identify that the client is in which of the following stages of Erikson's Theory of Psychosocial Development?

Ego integrity vs despair Supporting ego integrity will help client cope w/ challenges of aging. Generativity vs self absorption: middle adults. Client works to contribute to welfare of future generations. Identity vs role confusion: adolescents. Client works to establish sense of identity. Intimacy vs isolation: young adults. Client works to establish/maintain meaningful relationships.

A nurse is caring for a client who is receiving enteral feedings via a gastrostomy tube. The client reports nausea and a feeling of fullness. Which of the following actions should the nurse take? Administer an antacid. Measure the client's gastric residual. Dilute the formula's strength for the next 24 hr. Place the client in supine position.

Measure the client's gastric residual because this can indicate delayed gastric emptying. If the gastric residual is more than a predetermined amount, according to facility protocol, the nurse should withhold the enteral feeding and notify the provider. Elevate head of the bed 45° to 90° during enteral feedings and for at least 30 min after enteral feedings. If the client is unable to have the head of the bed elevated, the nurse can place the client in right lateral position with the head of the bed slightly elevated.

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

Pallor with scaly skin Skin should be smooth + have same same hue as other well nourished clients. BMI < 18.5 = malnutrition Red, swollen, inflamed gums are indications of malnutrition. Pink is normal.

A nurse is assisting with the admission of a client who has varicella. Which of the following isolation precautions should the nurse implement? Place the client in a room that has positive airflow. Wear a sterile gown when entering the client's room to take vital signs. Place a surgical mask on the client during transport. Discard gloves after leaving the client's room.

Place a surgical mask on the client during transport. Airborne precautions, private room, negative airflow wear respiratory mask before entering room.

A nurse is collecting data from a client who is 4 hr postop following abdominal surgery. The nurse notes the wound is eviscerating. Which of the following actions should the nurse take?

Place the client in a supine position with the knees bent to decrease strain on the abdominal muscles. This position also decreases tension on the surgical site. Wound evisceration is a medical emergency that requires immediate surgical repair. Cover the protruding bowel with a sterile towel or gauze saturated in 0.9% sodium chloride solution and prepare the client for surgery.

A nurse is planning to collect a stool specimen for ova and parasites from a client who has diarrhea. Which of the following actions should the nurse take when collecting the specimen?

Place the stool specimen collection container in a biohazard bag Place stool specimen in clean container using tongue depressor. Send collected specimen immediately to lab, prevent cold/hot.

A nurse is performing suctioning for a client who has a tracheostomy. Which of the following actions should the nurse take ?

Pull suction catheter back 1 cm (0.5 in) if the client starts coughing or if resistance is met. Removes catheter from mucosal wall of trachea Allow at least 1 min btwn suctioning passes to prevent hypoxia + hyperventilate client. Hyperventilate client w/ 100% oxygen for at least 2 min before suctioning to decrease hypoxia. Max of 3 passes because suctioning can cause hypoxia + dysrhythmia.

A nurse is discussing indications for urinary catheterization with a newly licensed nurse. Which of the following indications should the nurse include?

Relief of urinary retention Measurement of residual urine after urination Presence of an open perineal wound is correct. Valid indications for urinary catheterization include preventing irritation of wounds and rashes from urine, urinary retention, bladder distention, management of urinary elimination for clients who have spinal cord injuries, and prevention of urethral obstruction from blood clots following genitourinary surgery.

A nurse is reinforcing teaching w/ an AP about how to apply antiembolitic stockings. Which of the following instructions should the nurse include? Have the client flex their ankle when applying the stockings. Remove the stockings for 30 min every 8 hr Roll the stockings down 5 cm (2 in) to ensure the proper fit Use the client's shoe size to determine the proper fit.

Remove the stockings for 30 min every 8 hr to check for skin breakdown and to relieve pressure on the skin and bony prominences. Point their toes when applying the stockings. The stockings come in different sizes and should fit without rolling them down. Rolling down the stockings can impede circulation. Measure the circumference of the client's calves and thighs as well as the length of their legs to determine the proper size of stockings.

A nurse is caring for a female client who has pneumonia and reports incontinence when they cough. The nurse should identify this type of incontinence as which of the following? Stress incontinence Overflow incontinence Function incontinence Reflex incontinence

Stress incontinence (loss of small amounts of urine when the client is laughing, sneezing, coughing, or lifting due to weak pelvic muscles, urethra, or surrounding tissues.) Overflow: urinary retention from distension of the bladder and frequent loss of small amounts of urine due to obstruction of the urinary outlet or an impaired detrusor muscle. Function: inability to get to the bathroom due to physical or cognitive impairment. Reflex: involuntary loss of a moderate amount of urine, usually without warning due to hyperreflexia of the detrusor muscle, which can be caused by altered spinal cord movement.

A nurse is planning to perform passive ROM for a client who is immobilized. Which of the following actions should the nurse plan to take?

Support extremities above + below joints. ​Supporting extremities above and below joints will prevent muscle strain or injury. The nurse can also use the palm of the hand to support joints, or hold extremities in forearms. The nurse should not move or force any body part beyond the existing range of motion because this can result in muscle strain, discomfort, and injury. The nurse should stop moving the body part through range of motion if muscle spasticity occurs and apply gently pressure until muscle relaxation occurs. Then the nurse should continue with moving the body part. The nurse should move the body parts smoothly and slowly, avoiding jerky movements, which can cause pain and possibly injury.

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

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

A nurse is reinforcing teaching about foot care with a client. Which of the following instructions should the nurse include in the teaching? Use lukewarm water to wash the feet. Trim the nails + curve the edges with a nail file Apply clean nylon socks daily Apply lotion between the toes

Use lukewarm water to wash the feet as it softens the nails and skin of the feet. It also reduces inflammation and promotes blood circulation. Hot water can increase the risk of burning the client's feet. File their toenails straight across using a nail file to reduce the risk for injury. Curving or rounding the edges with a nail file can cause tissue damage around the toenail. Apply cotton socks daily. The client should apply clean socks daily to prevent infection from dirty or soiled socks. Cotton is a breathable material that reduces moisture around the client's feet. Apply lotion to the feet to treat dryness of the skin; however, lotion should be avoided between the toes to prevent moisture, which can increase the risk of skin breakdown or pressure injury.

A nurse is assisting with the preparation of a presentation at a community center about complementary and alternative therapies. Which of the following therapies should the nurse describe as the use of an electronic monitoring device to help clients learn to control physical responses?

Biofeedback Reiki: places her hands on or above the client's body to transfer universal energy, or ki, to restore balance and help the client heal. Acupuncture: uses needles to stimulate specific points on the body to relieve discomfort, promote health, and cure disease. Yoga: mind-body therapy that helps clients focus on creating an inner balance to promote healing. Clients can practice yoga with different body poses and meditations. Practicing yoga can loosen stiff joints, stimulate circulation, manage stress, and enhance overall wellbeing.

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

Circulation becomes less efficient with age. Increase sensitivity to temp extremes due to decrease cardiac output. Poor cardiac output leads to less efficient circulation of blood to tissues. Decrease ability to regulate body temp due to poor control of vasoconstriction/dilation. Also have reduced ability to shiver to increase body temp. Decrease body temp due to decrease in metabolic rate. Decrease in sweat gland activity which affect body temp regulation.

A nurse is preparing a client for a Romberg test. Which of the following statements should the nurse make?

Stand with your feet together and your arms at your sides. Romberg test measures stability w/ + w/o eyes closed. Rinne test: indicate when sound of tuning fork can not be heard. Babinski reflex: stroke lateral side of bottom of the foot. Fine motor skills: touch thumb to each fingertip as quickly as possible.

A nurse is assigned care of a client who has HIV. Which of the following infection control precautions should the nurse plan to use while caring for this client?

Standard precautions HIV is transmitted by direct or indirect contact with infected blood or body fluids.

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

Clean soiled areas of the body + comb hair. Dentures are in place to maintain facial shape to promote a sense of normalcy for the family. Elevate head on pillow to prevent facial discoloration. After body has been viewed, wrap body in shroud + place ID tags on body.

A nurse is caring for a client who has a stage-3 pressure ulcer that now has some granulating tissue. Which of the following interventions should the nurse recommend for inclusion in the plan of care?

Cleanse with 0.9% sodium chloride irrigation. Isotonic saline solution, a nonionic agent, prevents disruption of tissue healing. Povidone-iodine solution is a drying agent that does not promote healing of fragile skin. A healing wound with granulating tissue is a contraindication for this solution, as well as for hydrogen peroxide.

Fire in 1st floor operating room is forcing evacuation of clients from 2nd floor to another building. Which of the following clients have highest priority for the charge nurse to evacuate? Client receiving IV antibiotics every 6 hr for leg ulcer Client post left hip replacement 2 days ago whose daughter is visiting Client admitted with pancreatitis w/ nasogastric tube + PCA pump Client semi-comatose after CBV accident w/ indwelling urinary catheter

Client receiving IV antibiotics every 6 hr for leg ulcer

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

Clubbing Clubbing is an abnormal nail shape, where the angle the nail forms beyond the expected angle of 160°. Early clubbing occurs at an angle of 180°; late clubbing exceeds an angle of 180°. It is an indication of long-term inadequate oxygenation. The nurse should report this finding to the provider because it is an indication of pulmonary or cardiovascular disease. Macules are small, flat skin lesions that do not change color with palpation. Freckles are an example of dark tinted macules. Bronchovesicular lung sounds are normal breath sounds created by air moving through the large airways. Red tinted angiomas are small, red, raised skin growths, or papules that appear most often on the trunk of the body. They are especially common in older adults.

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

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

A nurse is collecting data from an older adult client. Which of the following should the nurse identify as an expected finding? Increased hearing of high-frequency tones Increased core temperature Decreased chest wall rigidity Decreased muscle mass

Decreased muscle mass Decreased hearing of high-freq tones Decreased core temp Increased chest wall rigidity

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

Decreased urine output, listlessness, sunken eyes, decreased tears, and dry mucous membranes indicates dehydration and should be reported immediately to the provider.

A nurse is monitoring a client's response to the application of a cold compress to the client's ankle after a sprain. Which of the following findings should the nurse expect in response to the therapy? Increased blood flow Decreased blood clotting Pallor Diminished pain

Diminished pain (reduces inflammation and edema) Reduces blood flow. Increases blood coagulation. Pallor indicates decreased perfusion and should not be an expected finding.

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

Place an SCD sleeve under each leg with the opening at the knee. Place an SCD sleeve under each leg, with the opening at the level of the knee, and then wrap the sleeve around the leg so that it is secure. Supine or semi-Fowler's position 2 fingers fit ankle pressure on the device is between 35 and 55 mg Hg to prevent circulatory impairment and damage to the client's skin. The average ankle pressure is 40 mm Hg.

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

Prepare a container of sterile solution before putting on sterile gloves. A bottle of sterile solution is sterile inside and contaminated on the outside. Handling the bottle with sterile gloves contaminates the gloves. The nurse should pour the sterile solution into a sterile receptacle on the field before donning sterile gloves. Although the inside surface of the bottle cap is sterile, the outer edge of the cap is not. The nurse should place the bottle cap, inner surface up, on a clean surface.

A nurse is caring for a client who is Hindu and adheres strictly to the traditional dietary laws of this religion. The client has no other dietary restrictions. Which of the following foods should the nurse select as a component of the client's meals?

Steamed vegetables Hindus avoid dairy + meat

A nurse is collecting data from a client who is receiving a continuous IV infusions of lactated Ringer's to treat dehydration. Which of the following findings should the nurse identify as a manifestation of infiltration? The vein feels hard upon palpation. Purulent drainage is noted at the IV site. Seepage of fresh blood is noted at the IV insertion location. The area around the infusion site is cool to the touch.

The area around the infusion site is cool to the touch. Infiltration: swelling, coolness, paleness, discomfort at site Phlebitis: redness, tenderness, pain, warmth along the course of the vein starting at the access site, and a red streak or palpable cord along the vein. Apply warm, moist compress to area. Choose location proximal, NOT DISTAL. Infection: redness, heat, swelling at the site of entry of the catheter, and purulent drainage Bleeding: fresh blood

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

The client advances the unaffected leg first while climbing stairs. Do not lean on crutches to support body weight. Stand with the back of legs placed against the chair for support before sitting. Axilla should not bear any weight while in tripod position due to pressure injury formation. Bear weight with arms + hands.

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

Use warm water when bathing client Hot water dries/damages skin. Use gel, foam, air cushion to redistribute weight away from ischial areas. Rigid/donut shaped cushions are contraindicated because they reduce blood supply. Do not massage bony prominences because it can lead to tissue trauma. Keep head of bed at 30° or less to prevent pressure injuries

A client with pneumonia is experiencing respiratory distress. The order states, "if respiratory distress occurs, apply a face mask with precise concentration of oxygen". Which of the following masks delivers precise oxygen concentration?

Venturi mask Partial rebreather mask: This mask has a reservoir bag attached with no valve, which allows the client to rebreathe up to 1/3 of exhaled air together with room air. Non-rebreather mask: This mask delivers the highest O2 concentration possible, not at a precise amount. Aerosol mask: This mask is a face tent. This provides high humidification with oxygen delivery.

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

Attend an exercise program Priority activity is to fulfill the client's physiological needs for activity

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

"This dressing allows the wound bed to breathe." Allows oxygen to pass. Promotes moist environment that should increase epithelial growth Does not need secondary dressing as all secretions are contained Self-adhesive.

A nurse is caring for a client who is postoperative following a mastectomy. The client states, "I can barely look at myself in the mirror." The nurse should identify that the client is experiencing? Complicated grief Maturational loss Disenfranchised grief Actual loss

Actual loss. When person can no longer feel, see, hear, or know an object/person/themselves (loss of a body part). Complicated grief: usual stages of grieving don't take place. Maturational loss: developmental process (child to adult) Disenfranchised grief: have a loss they are unable to share publicly + that society may view as controversial.

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

Place feet apart with the foot nearest the head of the client's bed in front of the other foot Placing feet apart provides wide base of support, which improves balance. Forward-backward stance enables nurse to shift their weight Face the head of the bed. Facing the direction of movement prevents twisting of the nurse's body while moving the client. Flex knees and hips, bring forearms close to the level of the bed. This position brings the nurse's center of gravity closer to the client and enables the nurse to use their thigh muscles instead of their back muscles to move the client. Encourage the client to flex their knees with their feet flat on the bed, which assists with moving up in bed and reduces the workload for the nurse.

A nurse is providing preoperative teaching to a client who is scheduled for arthroplasty in the next month that might require a blood transfusion. The client expresses concern about the risk of acquiring an infection from the blood transfusion. Which of the following statements should the nurse make to the client? "Ask your provider to prescribe epoetin before the surgery." "You should take iron supplements prior to the surgery." "Request a family member donate blood for you." "Donate autologous blood before the surgery."

"Donate autologous blood before the surgery." Autologous blood transfusions is collection + reinfusion of client's own blood. Blood is drawn from client 3-5 weeks before surgical procedure + stored for transfusion at time of surgery. Safest form of blood transfusion + eliminates exposure to transfusion-transmitted infection. Epoetin is hematopoietic growth factor used to treat anemia. Taking iron supplement may boost hemoglobin levels, but is inappropriate if there is adequate hemoglobin levels

A nurse is caring for a client who has recently undergone a total bilateral mastectomy. Which of the following statements by the client requires immediate action by the nurse?

"When I look at myself in the mirror, I don't know if i can go on." This statement shows sadness and a decreased initiative. The greatest risk to this client is injury for suicidal ideation. Therefore, the priority action is for the nurse to immediately contact the client's provider regarding this statement.

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 halo of erythema on the surrounding skin May indicate infection: purulent drainage, swelling, warmth, strong odor, severe pain. Serosanguineous drainage: made of RBCs/plasma is expected. Granulation tissue: proliferative stage of healing. Pink, shiny tissue w/ grainy appearance. Tenderness is expected.

A nurse is reinforcing teaching with a client who has a new colostomy about proper care. Which of the following information should the nurse include in the teaching?

Cleanse the skin around the stoma with warm water Do not use soap as it can leave residue + cause poor adherence of pouch adhesive. Change colostomy bag before meal because drainage from ostomy least likely. Change pouch every 3-7 days to avoid skin breakdown. Do not put aspirin as it can cause bleeding.

A nurse is caring for a client who is postoperative and who has an indwelling urinary catheter to gravity drainage. The nurse notes no urine output in the past 2 hr. Which of the following actions should the nurse take first?

Check to determine if the catheter tubing is kinked Common reason tube is not draining is that there is a kink or client is lying on it. Palpate bladder to check if bladder contains urine. Obtain prescription to irrigate catheter to determine if absent urine output is due to obstruction from blood clots/sloughing of bladder. Encourage fluid intake if fluid overload is not a problem to help increase kidney profusion + urine filtration.

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

Clean perineal at least once a day Reduce risk of infection. Empty drainage bag when 1/2 full. Avoid flushing catheter routinely as it increases risk of infection. Do not disconnect drainage bag when emptying/measuring urine as it increases risk of infection.

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

Client has tenderness + warmth in calf ABC approach (airway, breathing, circulation). Indicates thrombus.

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

Client's face should be turned toward Mecca Hindu: place body on floor Chinese: oldest child bathe body under older relative/priest Hispanic/Latino: adorn with amulets/rosary beads

A nurse is collecting data for a client who has had diarrhea and decreased urination for several days. Which of the following actions should the nurse take to determine if the client is dehydrated? Push on a fingernail bed until it blanches, release it, and observe how long it takes the skin to become pink. Grasp a skin fold on the chest under the clavicle, release it, and note whether it springs back. Press the skin in above the ankle for 5 seconds, release it, and note the depth of the impression. Measure the skin fold thickness at the upper arm using a pair of calibrated skinfold calipers.

Grasp a skin fold on the chest under clavicle or on back of forearm, release it, and note whether it springs back Skin turgor collecting. Good turgor/properly hydrated = skin immediately return to normal. Capillary refill: push on fingernail bed until blanching, release it, and observe how long it takes skin to become pink. Pitting edema: press skin above ankle for 5 sec, note depth of impression. Body fat percentage: measure skin fold thickness at upper arm w/ calibrated skinfold calpiers.

A nurse is assessing the heart sounds of a client who has developed chest pain that becomes worse wth inspiration. the nurse auscultates a high-pitched scratching sound during both systole and diastole with diaphragm of the stethoscope positioned at the left sternal border. Which of the following heart sounds should the nurse document? Audible click Murmur Third heart sound Pericardial friction rub

Pericardial friction rub Scratching/grating/squeaking leathery sound. Heard at 3rd intercostal space of left sternal border. Manifestation of pericardial inflammation and can be heard with infective pericarditis, myocardial infarction, following cardiac surgery or trauma, and with some autoimmune problems, such as rheumatic fever. The client who develops pericarditis typically has chest pain which becomes worse with inspiration or coughing and which may be relieved by sitting up and leaning forward. Audible clicking: prosthetic valve replacement surgery Murmur: swishing/whistling sound. Caused by turbulent blood flow through valves/ventricular outflow tracts. Low/med freq sounds more easily heard w/ bell. High freq sounds more easily heard w/ diaphragm 3rd heart sound: low-pitched sound. S3 caused by rapid ventricular filling during diastole. Best heard at mitral area lying on left side. Commonly heard in children/young adults. Older adults or those w/ heart disease, S3 indicates heart failure.

A nurse is planning to administer medication to a client who has C. difficile infection. Which of the following actions should the nurse plan to take to prevent the transmission of this infection to others?

Remove the cover gown in the client's room after providing care. Contact precautions for those w. C. difficile (remove gloves + gown in room prior). Wear mask for droplet precautions.

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?

The side hip between the iliac crest and anterior iliac spine Ventrogluteal injection. Preferred site for adult clients. Place hand on greater trochanter w/ 2 fingers touching iliac crest + anterior superior iliac spine, forming V shape Dorsogluteal site: upper, lateral quadrant of butt. However, increase risk of injury as med likely to be injected into subcutaneous tissue + piercing of sciatic nerve. Vastus lateralis site: middle portion of muscle from midline of thigh to midline of outer side of thigh. Place one hand below greater trochanter + other hand above knee to locate middle portion of muscle Outer, posterior tissue of upper arm: subcutaneous injection. IM injections < 1 mL, use deltoid by placing 4 fingers on deltoid muscle w/ top finger on acromion process. Injection site is 3 fingers below acromion process (5cm/2in).

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

Young adults should receive dental assessment every 6 months Young adult males should have testicular exam annually. Young adult females should have routine physical exam every 1-3 years. Young adults who have an increased risk of exposure should have TB skin test every 2 years.

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

"I will remove all stuffed animals from my baby's crib." Place infant in supine position. Use pacifier during sleep until 1 yr. Remove blankets/soft bedding when sleeping.

A nurse is reinforcing teaching with a client about the use of TENS to manage chronic pain. Which of the following statements by the client indicates the need for further teaching?

"It's unfortunate that I have to be in the hospital for this treatment." TENS units are portable.

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

"You should alternate pointing your toes upward and downward." Perform antiembolic exercises, including ankle pumps, foot circles, and knee flexion. For ankle pumps, the nurse should instruct the client to alternate plantar flexion and dorsiflexion.

A nurse is caring for a group of clients who are receiving oxygen therapy. Which of the following clients should the nurse plan to see first?

A client who has heart failure and is receiving 100% oxygen via a partial rebreather mask Higher oxygen concentration increases risk of injury. 3 L/min oxygen = 32% oxygen delivery. 6 L/min oxygen = 40% oxygen delivery. COPD clients depend on low oxygen level. 2 L/min = 28% oxygen delivery.

A nurse is caring for an older adult client who has constipation. Which of the following actions should the nurse take?

Add fluid and fiber to the diet. Gas-producing foods such as beans, broccoli, corn, and cabbage can help promote defecation.

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

Administer acetaminophen Reduce fever. Acetaminophen inhibits synthesis of prostaglandins, resulting in reduced fever. Do not apply ice packs to axillae/groin which can lead to shivering, increasing the body temp. Room temp should be 70-80°F. Limit physical activity to decrease body heat.

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

Clamp the infusion tubing. Stops the flow of IV + prevents it from leaking out during removal.

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

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

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

Dorsalis pedis Posterior tibial pulse: inner side of ankle below medial malleolus. Popliteal pulse: behind knees Brachial pulse: inner aspect of biceps.

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

Drain urine from tubing before ambulation. Prevent backflow of urine into bladder. Empty drainage bag whenever it is half full. Use sterile technique to collect specimens. Hang drainage bag below level of bladder to prevent backflow of urine.

A nurse is caring for a client who has a gastrostomy tube and is receiving intermittent formula feedings. Which of the following actions should the nurse take? Check for gastric residual volume after feeding. Flush gastrostomy tube with 10 mL of sterile water. Keep the formula refrigerated until ready to use. Elevate the head of the client's bed to a 45° angle.

Elevate the head of the client's bed to a 45° angle to prevent aspiration.

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

Empty the ostomy pouch when one-third full to prevent the pouch from becoming too heavy and pulling away from the skin. Change the ostomy pouch every 3 to 7 days to decrease odor and maintain cleanliness. Cut the wafer opening for the pouch according to the diameter of the stoma with no peristomal skin visible. The peristomal skin can blister and ulcerate if stool meets the skin. Peristomal skin is dry prior to applying the wafer for the pouch. This allows for better adhesion.

A nurse is caring for a client hospitalized with Guillain-Barré Syndrome. Which of the following data collected can help the nurse evaluate for complications of immobility? Select all that apply

Observe skin color over sacral, heels, and scapulae areas. Performing range of motion on the client's ankles, knees, and hips. Reviewing the character of bowel sounds and frequency of stools. Guillain-Barré is an ascending, usually temporary, neurologic condition that most often begins with loss of sensation and ability to move lower extremities and ends with the regaining of sensation and ability to move lower extremities.

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

Pad bony prominences on the wrist. Prevent skin breakdown. Remove restraint every 2 hr. Use quick-release knot or buckle to secure restraint. Tie restraint to part of bedframe that moves when raising/lowering head of bed. Do not tie to siderails or immovable part of bedframe.

A nurse working on a medsurg unit suspects that several clients have C. difficile when they all develop watery diarrhea. Which of the following actions should the nurse plan to take while waiting for the client's lab results?

Place all clients who have manifestations on contact precautions. Toxins produced by C. difficile bacteria will be detected in a stool culture. Mild, moderate, or severe symptoms of watery diarrhea and abdominal cramping develop during or shortly after antibiotic therapy. Stool cultures should also be obtained from those clients who are symptomatic. Alcohol-based solutions are not effective against C. difficile, which is a spore-forming organism. Soap and water is the best defense against transmission of bacterial agents. May be treated with vancomycin or metronidazole.

A nurse is reinforcing teaching with a client about smoking cessation. Which of the following should the nurse identify as the first stage of health behavior change?

Precontemplation Precontemplation Contemplation Preparation Action Maintenance

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

Return to the nurse's station and check all medications against provider orders (prime source for med verification)

A nurse is collecting data from a client who has hypokalemia as a result of nausea, vomiting, and diarrhea. Which of the following findings should the nurse expect?

Weak, irregular pulse, muscle weakness, fatigue, and ventricular dysrhythmias.

A nurse is reinforcing teaching w/ a client about the prevention of stress injuries. Which of the following instructions should the nurse include?

When lifting a heavy object, keep it close to your body Increase stability + decrease back strain when lifting. Avoid standing for long periods of time. If not possible, place one foot on a stool to minimize stress on back. Keep back straight + bend at knees. Maintain wide base of support by keeping feet apart.