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

"What is concerning you this morning?"

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

0800, 1200, 1600, 2000.

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

"It may hurt but we'll give you medicine to help you feel better."

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

"It's highly likely that she will recover and return to her pre-illness state."

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

"Tell me what you would like to see happen with your children in the future."

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

Active ROM exercises to both arms and legs two or three times a day.

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

Ask the client if this decision has been discussed with his healthcare provider.

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

As a tool to organize thinking and clinical decision-making about clients' healthcare needs.

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

Assault and battery with deliberate intent to deviate from the consent form.

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

Assist and support the client in establishing short-term goals.

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

Bend at the knees when lifting heavy objects.

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

Biofeedback allows the client to control involuntary responses to promote peripheral vasodilation.

Which intervention should the nurse include in the plan of care for a client who is being treated with compression dressings for leg ulcers due to chronic venous insufficiency? Check capillary refill of toes on the lower extremity with venous compression dressings. Apply dressing to the wound area before applying the venous compression dressings. Wrap the leg from the knee down towards the foot. Remove the venous compression dressings every 8 hours to assess wound healing.

Check capillary refill of toes on the lower extremity with venous compression dressings.

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

Combination of plant proteins to provide essential amino acids.

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

Consider the sterile field contaminated if it becomes wet during the procedure.

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

Continue gabapentin.

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

Continue the planned nursing interventions to restore the client's fluid volume.

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

Determine who is legally empowered to make decisions.

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

Discontinue the administration of the bolus feeding.

A client in hospice care develops audible gurgling sounds on inspiration. Which nursing action has the highest priority? Ensure cultural customs are observed. Increase oxygen flow to 4L/minute. Auscultate bilateral lung fields. Inform the family that death is imminent. Rationale An audible gurgling sound produced by a dying client is characteristic of an ineffective clearance of secretions from the lungs or upper airways, causing a rattling sound as air moves through the accumulated fluid. The nursing priority in this situation is to convey to the family that the client's death is imminent.

Inform the family that death is imminent.

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, which action should the nurse take next? Raise the bed to a comfortable working level. Bend the client's knee. Move the knee toward the chest as far as it will go. Cradle the client's heel.

Cradle the client's heel.

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

Document the events that occurred in the nurses' notes.

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

Document the presence and volume of the pulse palpated.

The nurse is preparing to give a dehydrated client IV fluid delivered at a continuous rate of 175 mL/hour. Which infusion device should the nurse use? Portable syringe pump. Electronic infusion device/smart pump. Volumetric controller. Nonvolumetric controller.

Electronic infusion device/smart pump.

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

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

The nurse assesses an immobile, older male client and determines that his blood pressure is 138/60 mmHg, his temperature is 95.8 °F (35.4 °C), 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, which nursing action is most important for the nurse to implement? Administer a PRN antihypertensive prescription. Provide the client with an additional blanket. Encourage additional fluid intake. Encourage the client to cough and deep breathe every 2 hours.

Encourage the client to cough and deep breathe every 2 hours.

The charge nurse assigns a nursing procedure to a new staff nurse who has not previously performed the procedure. Which action is most important for the new staff nurse to take? Review the steps in the procedure manual. Ask another nurse to assist while implementing the procedure. Follow the agency's policy and procedure. Inform the charge nurse that they have never done this procedure.

Inform the charge nurse that they have never done this procedure.

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. Which intervention should the nurse initiate? Review the client's medical record for an advance directive. Determine if a do-not-resuscitate prescription has been obtained. Document that the client is being discharged against medical advice. Evaluate the client's mental status for competence to refuse treatment.

Evaluate the client's mental status for competence to refuse treatment.

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

Examine the effectiveness of nursing interventions toward meeting client outcomes.

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

Fluid volume imbalance.

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

Flush the lumen with the saline solution and administer the medication through the lumen.

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

Foods and liquids consumed during the past 24 hours.

A middle-aged woman who enjoys being a teacher and mentor feels that she should pass down her legacy of knowledge and skills to the younger generation. According to Erickson's psychosocial developmental theory, she is involved in which developmental stage? Generativity. Ego integrity. Identification. Valuing wisdom.

Generativity.

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

Herbs should be obtained from manufacturers with a history of quality control of their supplements.

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

Increase in pulse rate.

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

Locate the perineum.

A client is admitted with a stage four pressure injury that has a black, hardened surface (eschar) that is stable. Which dressing is best for the nurse to use first? Hydrogel. Exudate absorber. No dressing. Transparent adhesive film.

No dressing.

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

Notify family members of the client's condition.

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

Notify the surgeon that the consent form has not been signed.

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

Obtain a prescription for removal of the catheter as soon as possible.

Which action should the nurse implement to mitigate the formation of a hip pressure injury for a client who is immobile? Maintain in a lateral position using protective wrist and vest devices. Partial side lying with hip elevated to 30 degrees (30-degree lateral position). Raise the head and knee gatch when lying in a supine position. Transfer into a wheelchair close to the nurse's station for observation. Rationale The partial side-lying position with hip elevation maintains alignment and provides the best pressure relief over the hip bony prominence. Raising the head and bed gatch may reduce shearing forces due to sliding down in bed, but it interferes with venous return from the legs and places pressure on the sacrum, predisposing to pressure injury formation. Sitting in a wheelchair places the body weight over the ischial tuberosities and predisposes it to a potential pressure point.

Partial side lying with hip elevated to 30 degrees (30-degree lateral position).

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

Premedicate the client with an analgesic. Inform the client of the plan for moving to the chair. Ask the client to push the IV pole to the chair. Assess the client's blood pressure.

How should the nurse handle linens that are soiled with incontinent feces? Put the soiled linens in an isolation bag, then place it in the dirty linen hamper. Place an isolation hamper in the client's room and discard the linens in it. Place the soiled linens in the designated fluid-resistant dirty linen bag and deposit them in the dirty linen hamper. Ask the housekeeping staff to pick up the soiled linen from the dirty utility room.

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

The nurse is completing the plan of care for a client who is admitted for benign prostatic hypertrophy. Which data should the nurse document as a subjective finding? Reports inability to empty bladder. Temperature of 99.8 °F (37.7 °C) and pulse of 108. Postvoided residual volume of 750 mL. Specimen collection for culture and sensitivity.

Reports inability to empty bladder.

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 and amitriptyline for pain control at home. During the admission assessment, which information is most important for the nurse to obtain? Sensory pattern, area, intensity, and nature of the pain. Trigger points identified by palpation and manual pressure of painful areas. Schedule and total dosages of drugs currently used for breakthrough pain. Sympathetic responses consistent with the onset of acute pain.

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

A client is admitted to the hospital with intractable pain. Which instruction should the nurse provide the unlicensed assistive personnel (UAP) who is preparing to assist this client with a bed bath? Take measures to promote as much comfort as possible. Report any signs of drug addiction to the nurse immediately. Wait until the client's pain is gone before assisting with personal care. This client's pain will be difficult to manage since the cause is unknown. Rationale Intractable pain is highly resistant to pain relief measures, so it is important to promote comfort during all activities.

Take measures to promote as much comfort as possible.

When assessing a client with an indwelling urinary catheter, which observation requires immediate intervention by the nurse? The drainage tubing is secured over the side rail. The clamp on the urinary drainage bag is open. There are no dependent loops in the drainage tubing. The urinary drainage bag is attached to the bed frame. Rationale Maintaining a closed urinary drainage system is important to prevent infection, so the most immediate priority is to close the clamp to reduce the risk of ascending microorganisms.

The clamp on the urinary drainage bag is open.

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

The client signs a document that designates another person to make legally binding healthcare decisions if the client is unable to do so.

The home health nurse visits an older female client who had a stroke three months ago and is now able to ambulate with the assistance of a quad cane. Which assessment finding has the greatest implications for this client's care? The husband, who is the caregiver, begins to weep when the nurse asks how he is doing. The client tells the nurse that she does not have much of an appetite today. The nurse notes that there are numerous scatter rugs throughout the house. The client's pulse rate is 10 beats higher than it was at the last visit one week ago. Rationale Scatter rugs pose a safety hazard because the client can trip on them when ambulating, so this finding has the greatest significance in planning this client's care. Psychological support of the caregiver is a less acute need than that of client safety. The other options are not safety priorities.

The nurse notes that there are numerous scatter rugs throughout the house.

Which statement correctly identifies a written learning objective for a client with peripheral vascular disease? The nurse will provide client instruction for daily foot care. The client will demonstrate proper trimming toenail technique. Upon discharge, the client will list three ways to protect the feet from injury. After instruction, the nurse will ensure the client understands the foot care rationale. Rationale An objective should contain four elements: who will perform the activity or acquire the desired behavior, the actual behavior that the learner will exhibit, the condition under which the behavior is to be demonstrated, and the specific criteria to be used to measure success. "Upon discharge, the client will list three ways to protect the feet from injury" is a concise statement that is a learning objective that defines exactly how the client will demonstrate mastery of the content.

Upon discharge, the client will list three ways to protect the feet from injury.

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

Use reflective listening techniques when the client expresses spiritual doubts.

To obtain the most complete assessment data for a client with chronic pain, which information should the nurse obtain? Can you describe where your pain is the most severe? What is your pain intensity on a scale of 1 to 10? Is your pain best described as aching, throbbing, or sharp? Which activities during a routine day are impacted by your pain? Rationale A client with chronic pain is more likely to have adapted physiologically to vital sign changes, localization, or intensity, so pain assessment should focus on any interference with daily activities, such as sleep, relationships with others, physical activity, and emotional well-being. Exacerbation of acute symptoms, such as pain distribution, patterns, intensity, and descriptors elicit specific assessment findings.

Which activities during a routine day are impacted by your pain?