HESI Fundamentals V.2

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

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

To assess the quality of an adult client's pain, what approach should the nurse use? A) Observe body language and movement. B) Provide a numeric pain scale. C) Ask the client to describe the pain. D) Identify effective pain relief measures.

C) Ask the client to describe the pain.

What self-care outcome is best for the nurse to use in evaluating a client's recovery form a stroke that resulted in left-sided hemiparesis? A) Promote independence by allowing client to perform all self-care activities. B) Participates in self-care to optimal level of capacity. C) Client verbalizes importance of hygienic practices in the recovery process. D) Self-care needs to be completed by the unlicensed assistive personnel.

C) Client verbalizes importance of hygienic practices in the recovery process.

A client hospitalized with pneumonia has thick, tenacious secretions. Which intervention should the nurse include when planning this client's care? A) Turning the client every 2 hours. B) Maintaining a cool room temperature. C) Encouraging increased fluid intake. D) Elevating the head of the bed 30 degrees.

C) Encouraging increased fluid intake.

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

A) Check capillary refill of toes on lower extremity with Unna's paste boot.

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

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

A client who is in hospice care complains of increasing amounts of pain. The healthcare provider prescribes an analgesic every four hours as needed. Which action should the nurse implement? A) Give an around-the-clock schedule for administration of analgesics. B) Administer analgesic medication as needed when the pain is severe. C) Provide medication to keep the client sedated and unaware of stimuli. D) Offer a medication-free period so that the client can do daily activities.

A) Give an around-the-clock schedule for administration of analgesics. The most effective management of pain is achieved using an around-the-clock schedule that provides analgesic medications on a regular basis (A) and in a timely manner. Analgesics are less effective if pain persists until it is severe, so an analgesic medication should be administered before the client's pain peaks (B). Providing comfort is a priority for the client who is dying, but sedation that impairs the client's ability to interact and experience the time before life ends should be minimized (C). Offering a medication-free period allows the serum drug level to fall, which is not an effective method to manage chronic pain.

When assessing a client with wrist restraints, the nurse observes that the fingers on the right hand are blue. What action should the nurse implement first? A) Loosen the right wrist restraint. B) Apply a pulse oximeter to the right hand. C) Compare hand color bilaterally. D) Palpate the right radial pulse.

A) Loosen the right wrist restraint. The priority nursing action is to restore circulation by loosening the restraint (A), because blue fingers (cyanosis) indicates decreased circulation. (C and D) are also important nursing interventions, but do not have the priority of (A). Pulse oximetry (B) measures saturation of hemoglobin with oxygen and is not indicated in situations where the cyanosis is related to mechanical compression- the restraints.

A nurse is preparing to give medications through a nasogastric feeding tube. Which action should prevent complications during administration? A) Mix each medication individually. B) Use sterile gloves for the procedure. C) Monitor vital signs before giving medications. D) Mix all medications together to facilitate administration.

A) Mix each medication individually. Medications should be mixed separately (A) to prevent clumping.

The nurse assesses an older adult for signs of dehydration. Which findings would be consistent with a diagnosis of dehydration? A) Orthostatic hypotension. B) Moist crackles. C) Bounding pulse. D) Shortness of breath.

A) Orthostatic hypotension. Orthostatic hypotension or persistent hypotension is present in dehydration, as are poor skin turgor, dry oral mucous membranes, and tachycardia. If the dehydration is severe, the client may also be restless, confused, and thirsty. Most instances of crackles is indicative of excess fluid volume, not dehydration. Shortness of breath or a bounding pulse may be indicative of excess fluid, not dehydration.

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

A) Put the soiled linens in an isolation bag, then place it in the dirty linen hamper.

The nursing staff in the cardiovascular intensive care unit are creating a continuous quality improvement project on social media that addresses coronary artery disease (CAD). Which action should the nurse implement to protect client privacy? A) Remove identifying information of the clients who participated. B) Recall that authored content may be legally discoverable. C) Share material from credible, peer reviewed sources only. D) Respect all copyright laws when adding website content.

A) Remove identifying information of the clients who participated.

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

A) Sensory pattern, area, intensity, and nature of the pain.

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

A) Snack of potato chips, and diet soda. B) Lunch of tuna fish sandwich, carrot sticks, fresh fruit, and coffee. E) Bedtime snack of crackers and milk.

The home health nurse is reviewing the personal care of an elderly client who lives alone. Which client assessment findings indicate the need to assign unlicensed assistive personnel (UAP) to provide routine foot care and file the client's toenails? Select all that apply. A) Syncope when bending. B) Hand tremors. C) Diminished visual acuity. D) Urinary incontinence. E) Shuffling gait.

A) Syncope when bending. B) Hand tremors. C) Diminished visual acuity.

To avoid nerve injury, what location should the nurse select to administer a 3 mL IM injection? A) Ventrogluteal. B) Outer upper quadrant of the buttock. C) Two inches below the acromion process. D) Vastus lateralis.

A) Ventrogluteal.

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

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

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

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

A nurse is performing an admission assessment on a client newly admitted to the hospital and has documented the client as being a member of the Native American subculture. A subculture is best described as which of the following? A) A cultural group with fewer than 5 million members in the United States. B) A unique cultural group that exists within the larger culture. C) A cultural group with values that are incongruent with those of the dominant culture. D) A unique cultural group with unspecified geographic origins.

B) A unique cultural group that exists within the larger culture. Subcultures are unique cultural groups that coexist within the dominant culture of the United States. Subcultures are not defined according to the size of their membership or the lack of specific geographic origins. Subcultures may have some values that differ from those of the dominant culture, but this is not their defining characteristic.

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

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

The nurse is teaching a client how to do active range of motion (ROM) exercises. To exercise the hinge joints, which action should the nurse instruct the client to perform? A) Tilt the pelvis forwards and backwards. B) Bend the arm by flexing the ulnar to the humerus. C) Turn the head to the right and left. D) Extend the arm at the side and rotate in circles.

B) Bend the arm by flexing the ulnar to the humerus.

The nurse observes that there are reddened areas on the cheekbones of a client receiving oxygen per nasal cannula at 3L/minute, and the client's oxygen saturation level is 92%. What intervention should the nurse implement? A) Decrease the flow rate to 1 L/minute. B) Discontinue the use of the nasal cannula. C) Apply lubricant to the cannula tubing. D) Place padding around the cannula tubing.

B) Discontinue the use of the nasal cannula.

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

B) Draw up the irrigating solution into the syringe.

A client is discharged to a long-term care facility with an indwelling urinary catheter. Which nursing action should be included in the plan to reduce the client's risk for infection related to the catheter? A) Flush the catheter daily with sterile saline. B) Encourage increased intake of oral fluids. C) Administer a PRN antipyretic if a fever develops. D) Secure the drainage bag at bladder level during transport.

B) Encourage increased intake of oral fluids.

The nurse is administering medications through a nasogastric tube (NGT) which is connected to suction. After ensuring correct tube placement, what action should the nurse take next? A) Clamp the tube for 20 minutes. B) Flush the tube with water. C) Administer the medications as prescribed. D) Crush the tablets and dissolve in sterile water.

B) Flush the tube with water. The NGT should be flushed before, after, and in between each medication administered (B). Once all medications are administered, the NGT should be clamped for 20 minutes (A). (C and D) may be implemented only after the tubing has been flushed.

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

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

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

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

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

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

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

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

A client's infusion of normal saline infiltrated earlier today, and approximately 500 mL of saline infused into the subcutaneous tissue. The client is now complaining of excruciating arm pain and demanding stronger pain medications. What initial action is most important for the nurse to take? A) Ask about any past history of drug abuse or addiction. B) Measure the pulse volume and capillary refill distal to the infiltration. C) Compress the infiltrated tissue to measure the degree of edema. D) Evaluate the extent of ecchymosis over the forearm area.

B) Measure the pulse volume and capillary refill distal to the infiltration. Pain and diminished pulse volume (B) are signs of compartment syndrome, which can progress to complete loss of the peripheral pulse in the extremity. Compartment syndrome occurs when external pressure (usually from a cast) or internal pressure (usually form subcutaneous infused fluid), exceeds capillary perfusion pressure resulting in decreased blood flow to the extremity. (A) should not be pursued until physical causes of the pain are ruled out. (C) is less of a priority than determining the effects of the edema on circulation and nerve function. Further assessment of the client's ecchymosis can be delayed until the signs of edema and compression that suggest compartment syndrome have been examined (D).

When evaluating a client's plan of care, the nurse determines that a desired outcome was not achieved. Which action will the nurse implement first? A) Establish a new nursing diagnosis. B) Note which actions were not implemented. C) Add additional nursing orders to the plan. D) Collaborate with the healthcare provider to make changes.

B) Note which actions were not implemented. First, the nurse reviews which actions in the original plan were not implemented (B) in order to determine why the original plan did not produce the desired outcome. Appropriate revisions can then be made, which may include revising the expected outcome, or identifying a new nursing diagnosis (A). (C) may be needed if the nursing actions were unsuccessful, or were unable to be implemented. (D) other members of the healthcare team may be necessary to collaborate changes once the nurse determines why the original plan did not produce the desired outcome.

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

B) Position prone with a small pillow below the diaphragm.

A male client with unstable angina needs a cardiac catheterization, so the healthcare provider explains the risks and benefits of the procedure, and then leaves to set up for the procedure. When the nurse presents the consent form for signature, the client hesitates and asks how the wires will keep his heart going. Which action should the nurse take? A) Answer the client's specific questions with a short understandable explanation. B) Postpone the procedure until the client understands the risks and benefits. C) Call the client's next of kin and ask them to provide verbal consent. D) Page the healthcare provider to return and provide additional explanation.

B) Postpone the procedure until the client understands the risks and benefits.

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

B) Reposition the client's arm.

A female client's significant other has been at her bedside providing reassurances and support for the past 3 days, as desired by the client. The client's estranged husband arrives and demands that the significant other not be allowed to visit or be given condition updates. Which intervention should the nurse implement? A) Obtain a prescription from the healthcare provider regarding visitation privileges. B) Request a consultation with the ethics committee for resolution of the situation. C) Encourage the client to speak with her husband regarding his disruptive behavior. D) Communicate the client's wishes to all members of the multidisciplinary team.

B) Request a consultation with the ethics committee for resolution of the situation.

Using the Morse Fall Risk scale, the nurse should initiate highest fall risk precautions for which client? A) An 84-year-old client with diabetes admitted with new-onset confusion who reportedly fell at home last week, is currently on bed rest, and has normal saline infusing per saline lock. B) A 48-year-old alert and oriented client with quadriplegia admitted for wound care of a stage IV pressure ulcer, receiving IV antibiotics per a peripherally inserted central catheter. C) A 62-year-old client with a history of Parkinson's disease, admitted for pneumonia and receiving IV antibiotics, who has fallen at home but is able to ambulate with a cane and who during his hospitalization has gotten out of bed without calling for assistance. D) A 27-year-old client with acute pancreatitis receiving morphine sulfate IV every 2 hours as needed for pain; no significant medical history, smokes two packs of cigarettes.

C) A 62-year-old client with a history of Parkinson's disease, admitted for pneumonia and receiving IV antibiotics, who has fallen at home but is able to ambulate with a cane and who during his hospitalization has gotten out of bed without calling for assistance.

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

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

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

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

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

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

A client presents to the OB triage unit with no prenatal care and painless bright red vaginal bleeding. Which interventions are most indicated? A) Applying an external fetal monitor and completing a physical assessment. B) Obtaining a fundal height assessment on the client. C) Applying an external fetal monitor and performing a sterile vaginal examination. D) Obtaining fundal height and performing a sterile vaginal examination.

C) Applying an external fetal monitor and performing a sterile vaginal examination. Bright red vaginal bleeding without contractions could indicate a placenta previa. A sterile vaginal exam should never be done on a woman with a known or suspected placenta previa. Applying the external fetal monitor will allow the nurse to assess fetal status. A complete physical assessment of the client is indicated. A fundal height is used to monitor fetal growth during pregnancy but does not provide information related to vaginal bleeding.

A female nursing home resident and her family only speak Spanish. During a visit, the entire family begins to cry hysterically. When unable to determine why the family is upset, what intervention is most important for the nurse to implement? A) Ask a Spanish speaking staff member to talk with the family. B) Use a Spanish translation reference to interview the family. C) Close the door to client's room to provide family privacy. D) Sit quietly with the family to offer comfort and support.

C) Close the door to client's room to provide family privacy.

While suctioning a client's nasopharynx, the nurse observes that the client's oxygen saturation remains at 94%, which is the same reading obtained prior to starting the procedure. What action should the nurse take in response to this finding? A) Reposition the pulse oximeter clip to obtain a new reading. B) Stop suctioning until the pulse oximeter reading is above 95%. C) Complete the intermittent suction of the nasopharynx. D) Apply an oxygen mask over the client's nose and mouth.

C) Complete the intermittent suction of the nasopharynx.

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

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

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

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

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

C) Document that the client is being discharged against medical advice.

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

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

The nurse is completing a mental assessment for a client who is demonstrating slow thought processes, personality changes, and emotional lability. Which area of the brain controls these neuro-cognitive functions? A) Thalamus. B) Hypothalamus. C) Frontal lobe. D) Parietal lobe.

C) Frontal lobe. The frontal lobe (C) of the cerebrum controls higher mental activities, such as memory, intellect, language, emotions, and personality. (A) is an afferent relay center in the brain that directs impulses to the cerebral cortex. (B) regulates body temperature, appetite, maintains a wakeful state, and links higher centers with the autonomic nervous and endocrine systems, such as pituitary. (D) is the location of sensory and motor functions.

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

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

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

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

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

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

A client is admitted with a fever of unknown origin. To assess fever patterns, which intervention should the nurse implement? A) Document the client's circadian rhythms. B) Assess for flushed, warm skin regularly. C) Measure temperature at regular intervals. D) Vary sites for temperature measurement.

C) Measure temperature at regular intervals.

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

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

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

C) Serum albumin.

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

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

When measuring vital signs, the nurse observes that a client is using accessory neck muscles during respiration. What follow-up action should the nurses take first? A) Determine pulse pressure. B) Auscultate heart sounds. C) Measure oxygen saturation. D) Check for neck vein distention.

D) Check for neck vein distention.

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

D) Cradle the client's heel.

A client with cancer-related pain has been prescribed a narcotic analgesic to be given around the clock. The client is competent and has been actively involved in decisions regarding care. What should the nurse do if the client refuses the next dose of analgesia? A) Ask the client's spouse wife to hold the client's hands while the nurse puts the pill under the tongue. B) Emphasize the rationale for taking the medication now as ordered. C) Try to persuade the client to take the medication as ordered by the doctor. D) Document the client's choice and re-assess pain in 1 hour.

D) Document the client's choice and re-assess pain in 1 hour.

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

D) Emptying the urinary catheter drainage bag for a client with Alzheimer's disease.

During the initial morning assessment, a male client denies dysuria but reports that his urine appears dark amber. Which intervention should the nurse implement? A) Provide additional coffee on the client's breakfast tray. B) Exchange the client's grape juice for cranberry juice. C) Bring the client additional fruit at mid-morning. D) Encourage additional oral intake of juices and water.

D) Encourage additional oral intake of juices and water. Dark amber urine is characteristic of fluid volume deficit, and the client should be encouraged to increase fluid intake (D). Caffeine, however, is a diuretic (A), and may worsen the fluid volume deficit. Any type of juice will be beneficial (B), since the client is not dysuric, a sign of an urinary tract infection. The client needs to restore fluid volume more than solid foods (C).

An elderly client with a fractured left hip is on strict bedrest. Which nursing measure is essential to the client's nursing care? A) Massage any reddened areas for at least five minutes. B) Encourage active range of motion exercises on extremities. C) Position the client laterally, prone, and dorsally in sequence. D) Gently lift the client when moving into a desired position.

D) Gently lift the client when moving into a desired position. To avoid shearing forces when repositioning, the client should be lifted gently across a surface (D). Reddened areas should NOT be massaged (A) since this may increase the damage to already traumatized skin. To control pain and muscle spasms, active range of motion (B) may be limited on the affected leg. The position described in (C) is contraindicated for a client with a fractured left hip.

A client is in the radiology department at 0900 when the prescription levofloxacin (Levaquin) 500 mg IV q24h is scheduled to be administered. The client returns to the unit at 1300. What is the best intervention for the nurse to implement? A) Contact the healthcare provider and complete a medication variance form. B) Administer the Levaquin at 1300 and resume the 0900 schedule in the morning. C) Notify the charge nurse and complete an incident report to explain the missed dose. D) Give the missed dose at 1300 and change the schedule to administer daily at 1300.

D) Give the missed dose at 1300 and change the schedule to administer daily at 1300. To ensure that a therapeutic level of medication is maintained, the nurse should administer dose as soon as possible, and revise the administration schedule accordingly to prevent dangerously increasing the level of medication in the bloodstream (D). The nurse should document the reason for the late dose, but (A and C) are not warranted. (B) could result in increased blood levels of the drug.

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

D) Move the chair parallel to the right side of the bed, and stand the client on the right foot.

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

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

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

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

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

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

When caring for a client with a 3-cm stage I pressure ulcer on the coccyx, which action may the nurse institute independently? A) Applying an antibiotic cream to the area three times per day. B) Massaging the area with an astringent every 2 hours. C) Using a povidone-iodine wash on the ulceration three times per day. D) Using normal saline solution to clean the ulcer and applying a protective dressing as necessary.

D) Using normal saline solution to clean the ulcer and applying a protective dressing as necessary. The nurse may wash the area with normal saline solution and apply a protective dressing. These interventions will protect the area and are within the nurse's scope of practice. A nurse must obtain a physician's order to use a povidone-iodine wash or an antibiotic cream. Massaging with an astringent can further damage the skin.

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

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

An older woman with end stage heart disease is hospitalized for severe heart failure. She is alert, oriented, and requests that no heroic measures are implemented if her breathing stops. What action should the nurse take first? A) Discuss with the client her meaning of heroic measures. B) Obtain a "do not resuscitate" (DNR) prescription. C) Set up a family conference to discuss the client's. D) Consult the palliative care team about client's care.

A) Discuss with the client her meaning of heroic measures.

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

C) Consult with the staff chaplain and ask that the chaplain visit with the client.

The nurse observes a newly admitted older adult female take short steps and walk very slowly while pushing a walker in front of her. What action should the nurse take in response to these observations? A) Complete a full fall risk assessment of the client. B) Teach the client to take longer steps at faster pace. C) Suggest that the the client use a wheelchair instead of a walker. D) Place client on bedrest until the healthcare provider is notified.

A) Complete a full fall risk assessment of the client.

A client diagnosed with primary open-angle glaucoma received a prescription for biotic eye drops, pilocarpine HCl (Pilocarpine). What instruction should the nurse plan to include in this client's teaching? A) "Do not allow the dropper bottle to touch the eye." B) "Administer the medication directly on the cornea." C) "Squeeze your eye closed after administering the drops." D) "Wash your hands after each administration of eye drops."

A) "Do not allow the dropper bottle to touch the eye."

A postoperative client has three different PRN analgesics prescribed for different levels of pain. The nurse inadvertently administers a dose that is not within the prescribed parameters. What actions should the nurse take first? A) Assess for side effects of the medication. B) Document the client's responses. C) Complete a medication error report. D) Determine if the pain was relieved.

A) Assess for side effects of the medication.

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

B) "I don't understand why I'm so weak and tired."

A male client is on contact precautions due to an infected draining wound and is being discharged home. The client lives at home with his wife and their adolescent daughter. What discharge instruction should the nurse include for the client? A) Use disposable plates and utensils. B) Stay in a room with the door closed. C) Dispose of soiled dressings in plastic bags that are securely closed. D) Others who are in the same room with the client should wear a mask.

C) Dispose of soiled dressings in plastic bags that are securely closed.

The nurse is providing wound care to a client with stage 3 pressure ulcer that has a large amount of eschar. The wound care prescription states "clean the wound and then apply collagenase." Collagenase is a debriding agent. The prescription does not specify a cleaning method. Which technique should the nurse cleanse the pressure ulcer? A) Lightly coat the wound with povidone-iodine solution. B) Irrigate the wound with sterile normal saline. C) Flush the wound with sterile hydrogen peroxide. D) Remove the eschar with a wet-to-dry dressing.

B) Irrigate the wound with sterile normal saline.

When evaluating a client's plan of care, the nurse determines that a desire outcome was not achieved. Which action should the nurse implement first? A) Establish a new nursing diagnosis. B) Note which actions were not implemented. C) Add additional nursing orders to the plan. D) Collaborate with the HCP to make changes.

B) Note which actions were not implemented. First, the nurse should review which actions in the original plan were not implemented (B) in order to determine why the original plan did not produce the desired outcome. Appropriate revisions can then be made, which may include revising the expected outcome, or identifying a new nursing diagnosis (A). (C) may be needed if the nursing actions were unsuccessful, or were unable to be implemented. (D) other members of the healthcare team may be necessary to collaborate changes once the nurse determines why the original plan did not produce the desired outcome.

During shift change report, the nurse receives report that a client has abnormal heart sounds. Which placement of the stethoscope should the nurse use to hear the client's heart sounds?

B) Use the stethoscope bell over the valvular areas of the anterior chest.

What should the nurse do to prevent pressure ulcers in an older adult? A) Clean the skin daily using mild soap and hot water. B) Encourage the client to sit in a chair as much as possible. C) Perform a systematic skin assessment at least once a day. D) Massage bony prominences gently every shift.

C) Perform a systematic skin assessment at least once a day. Daily skin inspection is essential in preventing pressure ulcers. Hot water is irritating to skin and should be avoided. Massaging bony prominences is contraindicated and may actually promote skin breakdown. Prolonged, uninterrupted chair sitting should be avoided; the client's position should be adjusted at least every hour.

When performing blood pressure measurement to assess for orthostatic hypotension, which action should the nurse implement first? A) Apply the blood pressure cuff securely. B) Record the client's pulse rate and rhythm. C) Position the client supine for a few minutes. D) Assist the client to stand at bedside.

C) Position the client supine for a few minutes.

The nurse is performing a routine dressing change for a client with a stage 3 pressure ulcer that is red with significant grandution. The wound has a gauze dressing covering the area. What action should the nurse implemented? A) Apply a hydro gel (Duaderm) dressing. B) Increase the frequency of the dressing changes. C) Replace the gauze with transparent dressing. D) Leave the dressing off until consulting with the healthcare provider.

C) Replace the gauze with transparent dressing.

A client is in contact isolation due to stage IV coccyx wound infected with methicillinresistant staphylococcus aureus (MRSA). The nurse plans interventions to prevent multiple reentries to the client's room. In which order should the nurse perform the interventions? A) Change coccyx dressing, perform tracheostomy care, restart the IV. B) Perform tracheostomy care, change coccyx dressing, restart the IV. C) Restart the IV, perform tracheotomy care, change coccyx dressing. D) Change coccyx dressing, restart the IV, perform tracheostomy care.

C) Restart the IV, perform tracheotomy care, change coccyx dressing.

During the admission interview, which technique is most efficient for the nurse to use when obtaining information about signs and symptoms of a client's primary health problem?

Close-ended questions. Lay descriptors of health problems can be vague and nonspecific. To efficiently obtain specific information, the nurse should use close-ended questions (C) that focus on common signs and symptoms about the client's health problem. (A, B, and D) are used when therapeutically interacting and should be used after specific information is obtained from the client.

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

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

Which would be most helpful when coaching a client to stop smoking? A) Review the negative effects of smoking on the body. B) Explain how smoking worsens high blood pressure. C) Discuss the effects of passive smoking on environmental pollution. D) Establish the client's daily smoking pattern.

D) Establish the client's daily smoking pattern. A plan to reduce or stop smoking begins with establishing the client's personal daily smoking pattern and activities associated with smoking. It is important that the client understands the associated health and environmental risks, but this knowledge has not been shown to help clients change their smoking behavior.

A client who has been diagnosed with terminal cancer tells the nurse, "The doctor told me I have cancer and do not have long to live." Which response is best for the nurse to provide? A) "That's correct, you do not have long to live." B) "Would you like me to call your minister?" C) "Don't give up, you still have chemotherapy to try." D) "Yes, your condition is serious."

D) "Yes, your condition is serious."

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

D) A 55- year- old woman who has had moderate low back pain for three months.

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

D) Altered tissue perfusion.

Which instruction should the nurse include in the discharge teaching plan for an adult client with hypernatremia? A) Monitor daily urine output volume. B) Drink plenty of water whenever thirsty. C) Use salt tablets for sodium content. D) Review food labels for sodium content.

D) Review food labels for sodium content.

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

A) Administer a PRN antihypertensive prescription.

A student nurse requires additional teaching if which of the following factors is identified as contributing to a client's risk for infection? A) Proper nutrient intake. B) Impairment of primary body system defenses. C) Chronic disease. D) Inadequate secondary defenses.

A) Proper nutrient intake. Malnutrition, rather than proper nutrient intake, would put the client at risk for infection. Inadequate secondary defenses, impaired primary defenses, and chronic disease put the client at risk by lowering the body's ability to fight infection.

An elderly client fractured his hip as a result of a fall at home. Because of his extensive cardiac history and chronic obstructive pulmonary disease, surgery isn't an option. The client tells the nurse he doesn't know how he's going to get better. Which response is best? A) "You're doing fine." B) "What is your biggest concern right now?" C) "Give it some time and you'll be OK." D) "You don't believe you're doing well?"

B) "What is your biggest concern right now?" Open-ended questions allow a client to control what he wants to discuss and help a nurse determine care needs. Telling the client that he's fine or that he just needs more time doesn't encourage him to verbalize his concerns. Reiterating the client's concerns may not encourage him to verbalize his feelings.

At 0100 on a male client's second postoperative night, the client states he is unstable to sleep and plans to read until feeling sleepy. What action should the nurse implement? A) Leave the room and close the door to the client's room. B) Assess the appearance of the client's surgical dressing. C) Bring the client a prescribed PRN sedative-hypnotic. D) Discuss symptoms of sleep deprivation with the client.

C) Bring the client a prescribed PRN sedative-hypnotic.

When assessing a male client, the nurse finds that he is fatigue, and is experiencing muscle weakness, leg cramps, and cardiac dysrhythmias. Based on these findings, the nurse plans to check the client's laboratory values to validate the existence of which? A) Hyperphosphatemia. B) Hypocalcemia. C) Hypermagnesemia. D) Hypokalemia.

D) Hypokalemia.

A client with pneumonia has a decrease in oxygen saturation from 94% to 88% while ambulating. Based on these findings, which intervention should the nurse implement first? A) Assist the ambulating client back to the bed. B) Encourage the client to ambulate to resolve pneumonia. C) Obtain a prescription for portable oxygen while ambulating. D) Move the oximetry probe from the finger to the earlobe.

A) Assist the ambulating client back to the bed. An oxygen saturation below 90% indicates inadequate oxygen. First, the client should be assisted to return to bed (A) to minimize oxygen demands. Ambulation increases aeration of the lungs to prevent pooling of respiratory secretions, but the client's activity at this time is depleting oxygen saturation of the blood, so (B) is contraindicated. Increased activity increases respiratory effort, and oxygen may be necessary to continue ambulation (C), but first the client should return to the bed to rest. Oxygen saturation levels at different sites should be evaluated AFTER the client returns to bed (D).

A nurse reports to the hospital occupational health nurse (OHN) that he/she was splashed with blood during the resuscitation of an HIV-positive client. The nurse asks the OHN when he/she will know whether he/she is positive or negative for HIV infection. Which of the following is the most appropriate response by the OHN? A) "The test results will vary during the first year of testing for the disease." B) "We will test you in 4 weeks, and then we will have a definitive answer." C) "Accurate results will be obtained by testing at 3 months and again at 6 months." D) "Most nurses who have been splashed do not test positive if they wash immediately."

C) "Accurate results will be obtained by testing at 3 months and again at 6 months." Ninety-five percent of exposed individuals will seroconvert within 3 months; 99% will convert by 6 months. The other options do not accurately reflect the timeline for seroconversion following exposure.

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

C) One-inch pressure sore draining serous fluid.

Which intervention is most important for the nurse to implement for a male client who is experiencing urinary retention? A) Apply a condom catheter. B) Apply a skin protectant. C) Encourage increased fluid intake. D) Assess for bladder distention.

D) Assess for bladder distention. Urinary retention is the inability to void all urine collected in the bladder, which leads to uncomfortable bladder distention (D). (A and B) are useful actions to protect the skin of a client with urinary incontinence. (C) may worsen the bladder distention.

A client has a wound with a drain. When performing wound cleansing around the drain, the nurse should cleanse in which direction? A) Laterally, from one side of the wound to the opposite side. B) Laterally, from the distal area to the center. C) From the superior portion of the wound to the inferior. D) In a widening circle around the drain, outward from the center.

D) In a widening circle around the drain, outward from the center.

When assessing a client who starts to wheeze related data should obtain? A) Presence of radiation. B) Heart sounds. C) Body temperature. D) Precipitating factors.

D) Precipitating factors.

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

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