Midterm

A nurse is performing an admission assessment on a client. The nurse determines the client's radial pulse rate is 68/min and the simultaneous apical pulse is 84/min. What is the client's pulse deficit?

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

A nurse observes an assistive personnel (AP) reprimanding a client for not using the urinal properly. The AP tells the client that diapers will be used next time the urinal is used improperly. Which of the following torts is the AP committing? A. Assault B. Battery C. False imprisonment D. Invasion of privacy

A. CORRECT. By threatening the client, the AP is committing assault. The AP's threats could make the client become fearful and apprehensive.

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

A. CORRECT. To reduce the risk of injury, at least two staff members should reposition clients. B. CORRECT. Twisting the spine or bending at the waist (flexion) increases the risk for injury. D. CORRECT. Using smooth movements instead of sudden or jerky muscle movements help to prevent injury.

A nurse is preparing to perform denture care for a client. Which of the following actions should the nurse plan to take? A. Pull down and out at the back of the upper denture to remove. B. Brush dentures with a toothbrush and denture cleaner C. Rinse the dentures with hot water after cleaning them D. Place the dentures in a clean, dry storage container after cleaning them

B. CORRECT. Brushing the dentures thoroughly with a tooth brush and denture cleaner removes debris that accumulate on and between the teeth.

A nurse is caring for a client who was transferred to the surgical unit by stretcher from the PACU. Which of the following actions should the nurse perform immediately following the transfer? A. Administer pain medication B. Check the client's vital signs C. Instruct the client to use the incentive spirometer every 1 hr. D. Provide ice chips as per provider prescription.

B. CORRECT. The greatest risk to this client is an injury from unstable vital signs (e.g. hypotension and respiratory depression) after receiving anesthesia and medication. Therefore, the first action the nurse should take is to check the client's vital signs and compare them with the readings during the PACU stay.

A nurse is measuring a client's vital signs. The client's heart rate is 105/min. The nurse should document this finding as which of the following alterations? A. Palpitation B. Bradycardia C. Tachycardia D. Dysrhythmia

C. CORRECT. Tachycardia is a heart rate over 100/min in adults.

A nurse manager is providing teaching to a group of newly licensed nurses about ways that clients acquire health care-associated infections (HAIs). Which of the following routs of infection should the manage identify as an iatrogenic HAI? A. Infections acquired from improper hand hygiene B. Infection acquired by drug resistance C. Infection acquired by inappropriate waste disposal D. Infection acquired from a diagnostic procedure

D. CORRECT. Iatrogenic HAIs directly result from diagnostic or therapeutic procedures.

A nurse is caring for a client who states that she does not want to get out of bed to pain from arthritis. Which of the following actions should the nurse take? A. Tell the client the provider does not want her to remain in bed B. Allow the client to remain in bed until her pain subsides C. Instruct the family to perform ADLs for the client D. Advise the client to perform range-of-motion exercises while in bed

D. CORRECT. Performing range-of-motion exercises will help the client maintain until her pain is under control and she is able to ambulate without excessive discomfort.

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

D. CORRECT. The temporal artery route, while not as accurate as the rectal route for obtaining a precise body temperature, is noninvasive and can be used to obtain a temperature in a toddler who might have an ear infection and who is having diarrhea. The nurse should place the probe behind the ear if the client is diaphoretic but should avoid placing it over an area covered in hair.

A home health nurse enters a client's home and finds a used syringe without a cap on the table. Which of the following actions should the nurse take? A. Recap the needle on the syringe. B. Schedule a nurse to administer future injections for this client C. Explain to the client that the syringe should be disposed of in the bathroom trash can. D. Place the syringe in a puncture-proof disposal container

D. CORRECT. The nurse should place the uncapped syringe in a puncture-proof sharps disposal or rigid plastic container to prevent a needle-stick injury. The nurse should keep the syringe uncapped to prevent a needle-stick injury while placing the cap on the needle. Then, the nurse should provide client education on safety and proper disposal of syringes.

A nurse is instructing a client who has diabetes mellitus about foot care. Which of the following guidelines should the nurse include? (SELECT ALL THAT APPLY) A. Inspect feet daily B. Use moisturizing lotion on the feet C. Wash the feet with warm water and let them air dry D. Use over-the-counter products to treat abrasions E. Wear cotton socks

A. CORRECT. Clients who have diabetes mellitus are at increased risk for infection and diminished sensitivity in the feet, so they should inspect them daily. B. CORRECT. The client should use moisturizing lotions (but not between the toes) to help keep their skin smooth and supple. E. CORRECT. The client should wear clean cotton socks each day.

A nurse is planning care for a client who is on bed rest. Which of the following interventions should the nurse plan to implement? A. Encourage the client to perform anti-embolic exercises every 2 hr. B. Instruct the client to cough and deep breathe every 4 hr. C. Restrict the client's fluid intake D. Reposition the client every 4 hours

A. CORRECT. Encourage the client to perform anti embolic exercises every 1 to 2 hr to promote venom return and reduce the risk of thrombus formation.

A nurse is acquainting a group of newly licensed nurses with the roles of the various members of the health care team they will encounter on a medical‑surgical unit. When she gives examples of the types of tasks certified nursing assistants (CNAs) may perform, which of the following client activities should she include? (SELECT ALL THAT APPLY) A. Bathing B. Ambulating C. Toileting D. Determining pain level E. Measuring vital signs

A. CORRECT. It is within the range of function for a CNA to provide basic care to clients (bathing). B. CORRECT. It is within the range of function for a CNA to provide basic care to clients (assisting with ambulation). C. CORRECT. It is within the range of function for a CNA to provide basic care to clients (assisting with toileting). E.CORRECT. It is within the range of function for a CNA to provide basic care to clients (measuring and recording vital signs).

A nurse is planning care for a client who develops dyspnea and feels tired after completing morning care. Which of the following actions should the nurse include in the clients plan of care? A. Schedule rest periods during morning care B. Discontinue morning care for 2 days C. Perform all care as quickly as possible D. Ask a family member to come in to bathe the client

A. CORRECT. Planning for rest periods during morning care will prevent fatigue and continue to foster independence.

A nurse is performing mouth care for a client who is unconscious. Which of the following actions should the nurse take? A. Turn the client's head to the side B. Place two fingers in the client's mouth to open it C. Brush the client's teeth once per day D. Inject a mouth rinse into the center of the client's mouth

A. CORRECT. Position the client's head on the side unless, there is a contraindication for this position, to reduce the risk of aspiration.

A nurse in a provider's office is documenting findings following an examination performed for a client new to the practice. Which of the following parameters should the nurse include as part of the general survey? (SELECT ALL THAT APPLY) A. Posture. B. Skin lesions C. Speech D. Allergies E. Immunization status

A. CORRECT. Posture is part of the body structure or general appearance portion of the general survey. B. CORRECT. Skin lesions is part of the body structure or general appearance portion of the general survey. C. CORRECT. Speech is part of the body structure or general appearance portion of the general survey.

A nurse is instructing a client, who has an injury of the left lower extremity, about the use of a cane. Which of the following instructions should the nurse include? (SELECT ALL THAT APPLY) A. Hold the cane on the right side B. Keep two points of support on the floor C. Place the can 38 cm (15in) in front of the feet before advancing D. After advancing the cane, move the weaker leg forward E. Advance the stronger leg so that it aligns evenly with the cane

A. CORRECT. The client should hold the cane on the uninjured side to provide support support for the injured left leg. B. CORRECT. The client should keep two points of support on the ground at all times for stability. D. CORRECT. The client should advance the weaker leg first, followed by the stronger leg.

A nurse is preparing to administer medication to a client who has gout. The nurse discovers that an error was made during the previous shift in which the client received atenolol instead of allopurinol. Which of the following interventions is the nurse's priority. A. Measure the client's apical pulse B. Administer the allopurinol to the client C. Inform the nurse manage D. Complete an incident report

A. CORRECT. The first action of the nurse should take using the nursing process is to assess the client by measuring the client's apical pulse. Atenolol is a beta blocker and can decrease the client's heart rate.

A nurse is caring for a client who has a history of falls. Which of the following actions is the nurse's priority? A. Complete a fall-risk assessment B. Educate the client and family about fall risks. C. Eliminate safety hazards from the client's environment. D. Make sure the client uses assistive aids in their possession.

A. CORRECT. The first action to take using the nursing process is to assess or collect data from the client. Therefore, the priority action is to determine the client's fall risk. This will work as a guide in implementing appropriate safety measures.

A nurse is caring for a client who asks what their Snellen eye test results mean. The client's vital acuity is 20/30. Which of the following responses should the nurse make? A. "Your eyes see at 20 feet what visually unimpaired eyes see at 30 feet." B. "Your right eye can see the chart clearly at 20 feet, and your left eye can see the chart clearly at 30 feet." C. "Your eyes see 30 feet what visually unimpaired eyes see at 20 feet." D. "Your left eye can see the chart clearly at 20 feet, and your right eye can see the chart clearly at 30 feet."

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

A nurse is beginning a complete bed bath for a client. After removing the client's gown and placing a bath blanket over the body, which of the following areas should the nurse wash first? A. Face B. Feet C. Chest D. Arms

A. CORRECT. The greatest risk to a client during bathing is the transmission of pathogens from one area of the body to another. Begin with the cleanest area of the body and proceed to the the least clean area. The face is generally the cleanest area, and washing it first follows a systematic head-to-toe approach to client care.

A nurse is planning to administer pain medication to a client following abdominal surgery. Which of the following actions should the nurse take first? A. Use the pain scale to determine the client's pain level B. Discuss the adverse effects of pain medication with the client C. Obtain the client's vital signs D. Check the client's allergies

A. CORRECT. The nurse should consider Maslow's hierarchy of needs, which includes 5 levels of priority. The levels are as follows: physiological needs, safety and security needs, love and belonging needs, personal achievement and self-esteem needs, and achieving full potential and the ability to problem-solve and cope with life situations. When applying Maslow's hierarchy of needs priority-setting framework, the nurse should review physiological needs first and then address the client's needs by following the remaining hierarchal levels. The nurse should also consider all contributing client factors, as higher levels of the pyramid can compete with those at the lower levels, depending on the specific client situation. To meet the client's physiological needs, the nurse should begin the pain management by asking the client to describe her pain.

A nurse is caring for a client who has cancer and is experiencing pain. The nurse should implement which of the following interventions to assist the client with pain relief? A. Encourage the client to listen to soft music B. Instruct the client to practice tai chi C. Place a jasmine-scented air freshener in the client's room D. Offer the client ginger tea

A. CORRECT. The nurse should encourage the client to use music therapy to reduce anxiety, provide a distraction, and relieve pain.

A community health nurse is conducting a class about body mechanics for county office workers. Which of the following instructions should the nurse include? (SELECT ALL THAT APPLY) A. "Sit with your back supported." B. "Keep your knees at hip level." C. "Use an ergonomically designed computer keyboard." D. "Keep your elbows away from your body." E. "Adjust the monitor screen so that you have to tilt your head slightly to look at it."

A. CORRECT. Using lumbar support in a straight-back chair helps maintain good posture and prevent back pain. B. CORRECT. Keeping the knees at the level of the hip or higher helps reduce the risk of lordosis, which is an exaggeration of the curve of the lumbar spine. C. CORRECT. Using a keyboard that maintains ergonomic positioning of the wrists can help prevent carpal tunnel syndrome.

A nurse discovers a small paper fire in a trash can in a client's bathroom. The client has been taken to safety and the alarm has been activated. Which of the following actions should the nurse take? A. Open the windows in the client's room to allow smoke to escape. B. Obtain a class C fire extinguisher to extinguish the fire. C. Remove all electrical equipment from the client's room. D. Place wet towels along the base off the door to the client's room.

D. CORRECT. Place wet towels along the base of the door to the client's room to contain the fire and smoke in the room.

A nurse is taking a client's vital signs. Which of the following findings should the nurse identify as outside the expected reference range? A. Pulse rate 90/min B. Rectal temperature 38 C (100.4 F) C. Pulse oximetry 95% D. BP 145/90 mmHm

D. CORRECT. The blood pressure is greater than the expected reference range and should be reported to the provider.

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

D. CORRECT. The first action that should be taken using the nursing process is to assess or collect data from the client. Determine the client's ability to help with transfers than proceed with a safe transfer.

A nurse is caring for a client who has major fecal incontinence and reports irritation in the perianal area. Which of the following actions should the nurse take first? A. Apply a fecal collection system. B. Apply a barrier cream. C. Cleanse and dry the area. D. Check the client's perineum

D. CORRECT. The nurse should apply the nursing process priority-setting framework to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with an assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's status, the nurse must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with the knowledge to make an appropriate decision. The priority nursing action is for the nurse to collect more data by assessing the area of irritation.

A nurse is assessing postoperative circulation of the lower extremities for a client who had knee surgery. The nurse should test which of the following? (SELECT ALL THAT APPLY) A. Range of motion B. Skin color C. Edema D. Skin lesions E. Skin temperature

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

A nurse is preparing to perform a comprehensive physical examination of an older adult client. Which of the following interventions should the nurse use in consideration of the client's age? (SELECT ALL THAT APPLY) A. Expect the session to be shorter than that for a younger client. B. Plan to allow plenty of time for position changes. C. Make sure the client has any essential sensory aids in place. D. Tell the client to take their time answering questions. E. Invite the client to use the bathroom before beginning the examination.

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

A nurse educator is reviewing proper body mechanics during employee orientation. Which of the following statements should the nurse identify as an indication that an attendee understands the teaching? (SELECT ALL THAT APPLY) A. "My line of gravity should fall outside my base of support." B. "The lower my center of gravity the more stability I have." C. "To broaden my base of support, I should spread my feet apart." D. "When I lift an object, I should hold it as close to my body as possible." E. "When pulling an object, I should move my front foot forward."

B. CORRECT. Being closer to the ground lowers the center of gravity, which leads to greater stability and balance. C. CORRECT. Spreading the feet apart increases and widens the base of support. D. CORRECT. Holding an object as close to the body as possible helps avoid displacement of the center of gravity and thus prevents injury and instability.

A nurse manager is reviewing with nurses on the unit in the care of a client who has had a seizure. Which of the following statements by a nurse requires further instruction? A. "I will place the client on their side." B. "I will go to the nurses' station for assistance." C. "I will not the time that the seizure begins." D. "I will prepare to insert an airway."

B. CORRECT. During a seizure, stay with the client an Duse the call light to summon assistance.

A nurse is caring for a client who is postoperative. Which of the following interventions should the nurse take to reduce the risk of thrombus development? (SELECT ALL THAT APPLY) A. Instruct the client not to perform the Valsalva maneuver B. Apply elastic stockings C. Review laboratory values for total protein level D. Place pillows under the client's knees and lower extremities E. Assist the client to change positions often

B. CORRECT. Elastic stockings promote venous return and prevent thrombus formation. E. CORRECT. Frequent position changes prevents venous stasis.

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

B. CORRECT. In the semi-flower's position, the client lies supine with the head of the bed elevated 15 to 45 degrees (typically 30). This position helps prevent regurgitation and aspiration by clients who have difficulty swallowing. This is the safest position for clients receiving enteral tube feedings.

A nurse is preparing a client for discharge and providing instructions about performing dressing changes at home. Which of the following statement should the nurse identify as an indication that the client understands medical asepsis? A. "I'll wrap the old dressing in a paper bag and put it in the trash." B. "I'll was my hands before I remove the old dressing and again before putting on the new one." C. "I'll need to take a pain pill 30 minutes before I change the dressing." D. "I'll wear sterile gloves when I apply the new dressing."

B. CORRECT. It is essential that the client understands the importance of hand hygiene before, during, and after any handling of the wound or its dressing.

A nurse is evaluating a client's understanding of the use of a sequential compression device. Which of the following client statements indicates client understanding? A. "This device will keep me from getting sores on my skin." B. "This device will keep the blood pumping through my leg." C. "With this device on my, leg muscles won't get weak." D. "This device is going to keep my joints in good shape."

B. CORRECT. Sequential pressure devices promote venous return in the deep veins of the legs and thus help prevent thrombus formation

A nurse on a medical-surgical unit observes smoke billowing from a client's room. Which of the following actions should the nurse take first? A. Close the door to the client's room B. Evacuate the client from the room C. Sound the fire alarm D. Activate the fire extinguisher

B. CORRECT. The acronym RACE can help nurses remember the order of the actions to take in the event of a fire. The components of RACE are rescue, activate, confine, and extinguish. The first priority is rescuing or removing the client from immediate danger. The second action is activation of the fire alarm system. The third action is confining the fire by closing doors and windows. The final action is extinguishing the fire, if possible using an available fire extinguisher. If attempts to extinguish a fire could compromise the safety of clients or staff members, the nurse should await the arrival of emergency fir personnel.

A nurse is teaching an assistive personnel (AP) about proper hand hygiene. Which of the following statements by the AP indicates an understanding of the teaching? A. "There are times I should use soap and water rather than an alcohol-based rub to clean my hands." B. "I will use cold water when I wash my hands to protect my skin from becoming too dry." C. "I will apply friction for at least 10 seconds while washing my hands." D. "After washing my hands, I will dry them from the elbows down."

B. CORRECT. While alcohol-based hand rubs are as effective as soap and water in providing proper hand hygiene, the Centers for Disease Control and Prevention recommend washing hands with soap and water at certain times, such as when the hands are visibly soiled with dirt or body fluids.

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

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

A nurse is caring for a client who fell at a nursing home. The client is oriented to person, place, and time and can follow direction. Which of the following actions should the nurse take to decrease the risk of another fall? (SELECT ALL THAT APPLY) A. Place a belt restraint on the client when they are sitting on the bedside commode. B. Keep the bed in its lowest position with all side rails up. C. Make sure that the client's call light is within reach. D. Provide the client with nonskid footwear. E. Complete a fall-risk assessment.

C. CORRECT. Making sure that the call light is within reach enables the client to contact the nursing staff to ask for assistance and prevents the client from falling out of bed while reaching for the call light. D. CORRECT. Nonskid footwear keeps the client from slipping. E. CORRECT. A fall-risk assessment serves as the basis for a plan of care that can then individualize for the client.

A nurse is using the Braden scale to predict the pressure ulcer risk of a client in a long-term care facility. Using this scale, which of the following parameters should the nurse evaluate? A. Incontinence B. Mental state C. Nutrition D. General physical condition

C. CORRECT. Nutrition, sensory perception, moisture, activity, and friction and shear are the parameters on the Braden scale for determine a client's risk of developing pressure ulcers.

A nurse is inserting an IV catheter for a client that results in a blood spill on her gloved hand. The client has no documented bloodstream infection. Which of the following actions should the nurse take? A. Was the gloved hands and then throw the gloves away B. Prepare an incident report to document the event C. Carefully remove the gloves and proceed with hand hygiene D. Ask the provider to order a blood culture to determine the risk of infection

C. CORRECT. Standard precautions require the use of gloves and hand hygiene in the care of all clients.

A nurse is caring for a client who has been sitting in a chair for 1 hr. Which of the following complications is the greatest risk to the client? A. Decreased subcutaneous fat B. Muscle atrophy C. Pressure injury D. Fecal ipaction

C. CORRECT. The greatest risk to this client is injury from skin breakdown due to unrelieved pressure over a bony prominence from prolonged sitting in a chair. Instruct the client to shift his weight every 15 min and reposition the client after 1 hr.

A nurse is preparing to insert an NG tube for a client who has a bowel obstruction. Which of the following actions should the nurse take first? A. Give the client a glass of water B. Assist the client into a sitting position C. Explain the procedure to the client D. Measure the length of tubing to be inserted

C. CORRECT. The nurse should apply the least invasive priority-setting framework when caring for this client, which assigns priority to nursing interventions that are least invasive to the client, as long as those interventions do not jeopardize client safety. The nurse should take interventions that are not invasive to the client before interventions that are invasive. This reduces the number of organisms introduced into the body, decreasing the number of facility-acquired infections. Informing the client about the procedure reduces fear and assists in gaining the client's cooperation, which is important for NG insertion and is the priority nursing intervention.

A nurse is instructing a client who has COPD about using the orthopedic position to relive shortness of breath. Which of the following statements should the nurse make? A. "Lie on your back with your head and shoulders supported by a pillow." B. "Have your head turned to the side while you lie on your stomach." C. "Have a table beside your bed so you can sit on the bedside and rest your arms on the table." D. "Lie on your side with your top arm resting on the bed and your weight on your hip."

C. CORRECT. This is an accurate description for the orthopedic position. This position allows for chest expansion and is especially beneficial for clients who have COPD.

While making rounds, the nurse finds a patient on the floor in the hall. What should be the nurse's first response? A. Inspect the patient for injury. B. Transfer the patient back to bed. C. Move the patient to the closest chair. D. Complete the notification report.

A. CORRECT (Powerpoint - no explanation)

A nurse is performing a neurological assessment of a client. To promote safety during the examination, the nurse stands nearby as the client follows the instructions for which of the following tests? A. Romberg B. Kinesthetic sensation C. 2-point discrimination D. Weber

A. CORRECT. A Romberg test evaluates standing balance, first with the client's eyes open and then with them closed. The nurse should remain nearby because the client could fall during this test.

A nurse on a medical unit is caring for a client who has been coughing intermittently during meals, attempting to clear her throat repeatedly, and eating only a small portion of each meal. The nurse should recommend a referral to which of the following members of the inter professional team to evaluate the client for dysphagia? A. Speech-language pathologist B. Social worker C. Physical therapist D. Occupational therapist

A. CORRECT. A speech-language pathologist can perform a thorough evaluation of the client for dysphagia and help the client learn to eat safely. For example, a speech-language pathologist can instruct the client in learning the supraglottic swallow: take a breath, hold the breath while swallowing, cough after swallowing, and swallow again to clear the mouth.

A nurse is planning to perform passive range-of-motion exercises for a client. Which of the following actions should the nurse take? A. Repeat each joint motion 5 times during each session B. Move the joint to the point of considerable resistance C. Sit approximately 2 ft from the side of the best closest to the joint being exercised D. Exercise the smaller joints first

A. CORRECT. To maintain the client's joint mobility, the nurse should repeat each motion 3 to 5 times.

A nurse manager is assigning care of a client who is being admitted from the PACU following a thoracic surgery. The nurse manager should assign the client to which of the following staff members? A. Charge nurse B. Registered nurse (RN) C. Practical nurse (PN) D. Assistive personnel (AP)

B. CORRECT. A client who is postoperative following thoracic surgery requires professional nursing knowledge, skills, and judgment of an RN to provide safe and effective client care.

A nurse is performing an integumentary assessment for a group of clients. Which of the following findings should the nurse recognize as requiring immediate intervention? A. Pallor B. Cyanosis C. Jaundice D. Erythema

B. CORRECT. The priority finding when using the airway, breathing, circulation (ABC) approach to care is cyanosis, which is an indication of hypoxia (inadequate oxygenation). Therefore, immediately report this finding to the provider.

A nurse is preparing an in-service program about delegation. Which of the following are components of the five rights of delegation? (SELECT ALL THAT APPLY) A. Right place B. Right supervision and evaluation C. Right direction and communication D. Right documentation E. Right circumstance

B. CORRECT. The right supervision and evaluation is one of the five rights of delegation. They also include the right task and right person. C. CORRECT. The right direction and communication is one of the five rights of delegation. They also include the right task and right person. E. CORRECT. The right circumstance is one of the five rights of delegation. They also include the right task and right person.

A nurse enters a client's room and finds the client sitting on the floor and leaning against the side of the bed. The client states she slipped while getting out of bed. Which of the following actions should the nurse take first? A. Complete an incident report B. Check the client for injuries C. Make sure the client has skid-free footwear D. Remind the client to ask for help when getting out of bed

B. CORRECT. Using the nursing process, the nurse should first evaluate the client for any injury or physiological changes. The nurse should also notify the provider to determine the need for any further examination or intervention.

A nurse has noticed several occasions in the past week when another nurse on the unit seemed drowsy and unable to focus on the issue at hand. Today, the nurse was found asleep in a chair in the break room not during a break time. Which of the following actions should the nurse take? A. Alert the American Nurses Association B. Fill out an incident report. C. Report the observations to the nurse manage on the unit. D. Leave the nurse alone to sleep.

C. CORRECT. Any nurse who notifies behavior that could jeopardize client care or could indicate a substance use disorder has a duty to report the situation immediately to the nurse manager.

A nurse is caring for a client with stage 4 ovarian cancer who has decided to stop treatment and enter hospice care. Which of the following ethical principles is the nurse displaying by supporting the client in her decision? A. Responsibility B. Accountability C. Advocacy D. Confidentiality

C. CORRECT. By following the ethical principle of advocacy, the nurse supports the client in the decisions she makes about her own health care.

A nurse observes smoke coming from under the door of the staff's lounge. Which of the following actions is the nurse's priority? A. Extinguish the fire. B. Activate the fire alarm. C. Move clients who are nearby. D. Close all open doors on the unit.

C. CORRECT. The greatest risk to this client is injury from the fire. Therefore, the priority intervention is to rescue the clients. Protect and move clients in close proximity to the fire.

A nurse is caring for a client who has a BMI of 29 and expresses a desire to lose weight. Which of the following actions should the nurse take first? A. Refer the client to a nutritionist B. Discuss eating strategies with the client C. Determine the client's intention to change current eating habits D. Instruct the client to perform 30 min of vigorous exercise daily

C. CORRECT. When using the nursing process, the nurse should first assess the client's readiness to commit a change in behavior.

Although the patient refused the procedure, the nurse insisted and inserted a nasogastric tube in the right nostril. The administrator of the hospital decides to settle the lawsuit because the nurse is likely to be found guilty of which of the following? A. An unintentional tort B. Assault C. Invasion of privacy D. Battery

D. Battery (Powerpoint - no explanation)

A nurse is assessing a client who is unconscious. Family members are present and answer the nurse's questions about the client's medical history. The nurse should document this information as which of the following types of data? A. Secondary-source data B. Experiential data C. Primary-source data D. Quantitative data

A. CORRECT. Information provided by someone other than the client is secondary data.

A nurse is caring for a competent adult client who tells the nurse, " I am leaving the hospital this morning whether the doctor discharges me or not." The nurse believes that this is not in the client's best interest, and prepares to administer a PRN sedative medication the client has not requested along with the scheduled morning medication. Which of the following types of tort is the nurse committing? A. Assault B. False imprisonment C. Negligence D. Battery

B. CORRECT. Administering a medication as a chemical restraint to keep the client from leaving the facility against medical advice is false imprisonment., because the client neither requested nor consented to receiving the sedative.

A nurse is caring for a client who had a stroke and requires assistance performing ADLs. The nurse should collaborate with which of the following members of the inter professional care team? A. Speech-language pathologist B. Occupational therapist C. Social worker D. Dietitian

B. CORRECT. An occupational therapist can help clients who have physical limitations or disabilities gain an optimal level of independence in performing ADLs, such as bathing, dressing, grooming, and eating

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

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

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

D. CORRECT. According to evidence-based practice, the nurse should first perform hand hygiene before touching the client or performing any skills, such as tracheostomy care. This is vital because contamination of the nurse's hands is a primary source of infection.

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

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

A charge nurse is conducting an in-service training session on ethics to a group of newly licensed nurses. Which of the following situations should the charge nurse include as an example of the ethical principle of veracity? A. A nurse truthfully answers the client's questions about upcoming chemotherapy. B. A nurse stops inserting an NG tube when the client refuses the procedure. C. A nurse provides the same amount of time to all clients regardless of condition. D. A nurse reports an assistive personnel who transfers a client without using a gait belt.

A. CORRECT. A nurse who truthfully answers the client's questions about treatment, such as chemotherapy, is demonstrating the ethical principle of veracity. Veracity refers to telling the truth and being straightforward and clear with clients about the treatment being delivered.

A nurse in a provider's office is preparing to assess a client's skin as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (SELECT ALL THAT APPLY) A. Capillary refill less than 3 seconds. B. 1+ pitting edema in both feet C. Pale nail beds in both hands D. Thick skin on the soles of the feet E. Numerous macule on the face darker than the surrounding skin color.

A. CORRECT. Expect capillary refill in less than 3 seconds as an expected finding. D. CORRECT. Expect thicker skin on the palms of the hands and the soles of the client's feet. E. CORRECT. Macules on the face are darker than the skin color indicates freckles, which are an expected finding.

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

A. CORRECT. For a client who has decreased circulation in the leg, evaluating pedal pulses is critical in order to determine adequate blood supply to the foot. The nurse should apply the safety and risk reduction priority-setting framework. This framework assigns priority to the factor posing the greatest risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting framework, and/or nursing knowledge to identify which risk poses the greatest threat to the client.

A nurse is performing a neurologic examination for a client. Which of the following assessments should the nurse perform to test the client's balance? (SELECT ALL THAT APPLY) A. Romberg test B. Heel-to-toe walk C. Snellen test D. Spinal accessory function E. Rosenbaum test

A. CORRECT. For the Romberg test, the clients stands with their eyes closed, arms at both sides, and feet together. The nurse verifies balance if the client can stand with minimal swaying for at least 5 seconds.

A nurse is talking with a client during her initial prenatal visit. The client reports a history of trisomy 13 syndrome in her family and is concerned her fetus might be at risk. Which of the following statements should the nurse provide? A. "If you sign an informed consent form, we can perform genetic screening to see if your baby has this disorder." B. "If the genetic screening shows that your baby has this disorder, I can provide you with information about an abortion clinic." C. "Screening for trisomy 13 syndrome and other chromosomal disorders is done automatically for clients at increased risk." D. "I can provide you with information about sterilization so that the disorder is not passed to your future children."

A. CORRECT. Genetic screening has multiple legal and ethical considerations that must be addressed prior to testing. The client will need to sign an informed consent form prior to the screening.

A nurse is instructing a group of assistive personnel in measuring a client's respiratory rate. Which of the following guidelines should the nurse include? (SELECT ALL THAT APPLY) A. Place the client in a semi-fowlers position. B. Have the client rest an arm across the abdomen. C. Observe on full respiratory cycle before counting the rate. D. Count the rate for 30 seconds if irregular. E. Count and report any sighs the client demonstrates.

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

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

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

A nurse is caring for a group of clients on a medical-surgical unit. For which of the following needs should the nurse initiate a referral for a social worker? (SELECT ALL THAT APPLY) A. A client who has terminal cancer requests hospice care in the home. B. A client asks about community resources available for older adults. C. A client states, "I would like to have my child baptized before surgery." D. A client requests an electric wheelchair for use after discharge. E. A clients states, "I do not understand how to use a nebulizer."

A. CORRECT. Initiate a referral for a social worker to provide information and assistance in coordinating hospice care for a client. B. CORRECT. Initiate a referral for a social worker to provide information and assistance in coordinating care for community resources available for clients. D. CORRECT. Initiate a referral for a social worker to assist the client in obtaining medical equipment for use after discharge.

A nurse is caring for a client who is about to undergo an elective surgical procedure. The nurse should take which of the following legal actions regarding informed consent? (SELECT ALL THAT APPLY) A. Make sure the surgeon obtained the client's consent. B. Witness the client's signature on the consent form. C. Explain the risks and benefits of the procedure. D. Describe the consequences of choosing not to have the surgery. E. Tell the client about alternatives to having the surgery.

A. CORRECT. It is the nurse's responsibility to verify that the surgeon obtained the client's consent and that the client understands the information the surgeon gave them. B. CORRECT. It is the nurse's responsibility to witness the client's signing of the consent form, and to verify that they are consenting voluntarily and appear to be competent to do so. The nurse also should verify that the client understands the information the surgeon has provided.

A nurse is caring for a client who has emphysema. The client has not stopped smoking cigarettes and states, "It's too late for me to quit." Which of the following actions should the nurse take? A. Assist the client in finding local smoking-cessation assistance programs. B. Tell the client that she will be all right after receiving medical care. C. Inform the client that she must stop smoking or the provider will not be able to care for her. D. Advocate for the client by supporting her statement about not quitting.

A. CORRECT. Smoking cessation slows the progression of chronic obstructive pulmonary disease (COPD). It is not "too late" for this client to stop smoking, and the nurse should encourage the client to do so.

A nurse is instructing a assistive personnel (AP) about caring for a client who has low platelet count. Which of the following instructions is the priority for measuring vital signs for this client? A. "Do not measure the client's temperature rectally." B. "Count the client's radial pulse for 30 seconds and multiply it by 2." C. "Do not let the client know you are counting their respirations." D. "Let the client rest for 5 minutes before you measure their blood pressure."

A. CORRECT. The greatest risk to a client who has a low platelet count is an injury the results in bleeding. Using a thermometer rectally poses a risk of injury to the rectal mucosa. The low platelet count contraindicates the use of the rectal route for this client.

A nurse is using the I-SBAR communication tool to give a client's provider information about the client. The nurse should convey this client's pain status in which portion of the report? A. Assessment B. Background C. Situation D. Recommendation

A. CORRECT. The nurse provides information about assessment in this portion of the report, including vital signs, pain assessment, and changes in assessment findings.

A nurse is conducting an admission interview with a client. Which of the following pieces of assessment information should the nurse collect during the introductory phase of the interview? A. Client's level of comfort and ability to participate in the interview. B. Previous Illnesses and surgeries C. Events surround the client's recent illness D. Sociocultural history

A. CORRECT. The nurse should assess the client's level of comfort and establish a rapport during the introductory or orientation phase. The nurse should engage in active listening and present a relaxed attitude to place the client at ease and encourage client participation. This will assist the nurse in gaining the necessary data to formulate appropriate nursing diagnoses and outcomes.

A nurse is planning to administer pain medication to a client following abdominal surgery. Which of the following actions should the nurse take first? A. Use the pain scale to determine the client's pain level B. Discuss the adverse effects of pain medication with the client C. Obtain the client's vital signs D. Check the clients allergies

A. CORRECT. The nurse should consider Maslow's hierarchy of needs, which includes 5 levels of priority. The levels are as follows: physiological needs, safety and security needs, love and belonging needs, personal achievement and self-esteem needs, and achieving full potential and the ability to problem-solve and cope with life situations. When applying Maslow's hierarchy of needs priority-setting framework, the nurse should review physiological needs first and then address the client's needs by following the remaining hierarchal levels. The nurse should also consider all contributing client factors, as higher levels of the pyramid can compete with those at the lower levels, depending on the specific client situation. To meet the client's physiological needs, the nurse should begin with pain management by asking the client to describe her pain.

A nurse is admitting a client who will undergo a craniotomy. During the planning phase of the nursing process, which of the following actions should the nurse take? A. Establish client outcomes. B. Collect information about past health problems C. Determine whether the client has met specific goals D. Identify the client's specific health problems

A. CORRECT. The planning phase of the nursing process includes developing goals and outcomes that help the nurse create the client's plan of care.

A nurse is caring for a client in the emergency department who has an oral body temperature of 38.3 C (101 F), pulse rate 114/min, and respiratory rate 22/min. The client is restless with warm skin. Which of the following interventions should the nurse take? (SELECT ALL THAT APPLY) A. Obtain culture specimens before initiating antimicrobials. B. Restrict the client's oral fluid intake. C. Encourage the client to rest and limit activity. D. Allow the client to shiver to dispel excess heat. E. Assist the client with oral hygiene frequently.

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

A client who is postoperative following knee arthroplasty is concerned about the adverse effects of the medication prescribed for pain management. Which of the following members of the interprofessional care team can assist the client in understanding the medication's effects? (SELECT ALL THAT APPLY). A. Provider B. Certified nursing assistant C. Pharmacist D. Registered Nurse E. Respiratory therapist

A. CORRECT. The provider must be knowledgeable about any medication prescribed for the client, including its actions, effects, and interactions. C. CORRECT. A pharmacist must be knowledgeable about any medication prescribed for the client, including its actions, effects, and interactions. D. CORRECT. A registered nurse must be knowledgeable about any medication prescribed for the client, including its actions, effects, and interactions.

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

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

A nurse is collecting data from an older adult client as part of a neurologic examination. Which of the following findings should the nurse expect as changes associated with aging? (SELECT ALL THAT APPLY) A. Slower light touch sensation B. Some vision and hearing decline C. Slower fine finger movement D. Some short-term memory decline E. Decreased risk of depression

A. CORRECT. Touch sensation decreases for the client who is aging. B. CORRECT. Losses in vision, hearing, taste, and smell decline for the client who is aging. C. CORRECT. Fine finger movement slows, along with some reflex and motor responses, for the client who is aging. D. CORRECT. Minimal decline in short-term memory is an expected finding for the client who is aging.

A nurse is caring for a client who has a terminal illness. The client is restless and reports sever pain but refuses the prescribed opioid pain medication. Which of the following actions should the nurse take first? A. Ask why the client is refusing the pain medication B. Administer a PRN anti-anxiety medication C. Help the client change positions D. Offer the client a heat or cold pack to place on painful areas

A. CORRECT. Using the nursing process, the nurse should first assess the reason for the client's refusal of the opioid pain medication.

A nurse on a medical-surgical unit is admitting a client. Which of the following information should the nurse document in the client's record first? A. Assessment B. Plan of care C. Nursing interventions performed D. Evaluation of progress

A. CORRECT. When caring for a client, the nurse should apply the nursing process priority-setting framework. The nursing process is used to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with an assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's status, he or she must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with the knowledge to make an appropriate decision.

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

B. CORRECT. Because palpation and percussion can alter the frequency and intensity of bowel sounds, auscultate the abdomen next and before using those two techniques.

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

B. CORRECT. In this situation, the client is exercising their right to make their own personal decisions about surgery, regardless of others' opinions of what is "best" for them.

A nurse is discussing with a newly licensed nurse about how to obtain informed consent from a client who is scheduled to undergo an epidural procedure. Which of the following ethical principles should the nurse include in the teaching? A. Beneficence B. Autonomy C. Paternalism D. Justice

B. CORRECT. Informed consent is based on the ethical principle of autonomy, which is the right to self-determination, independence, and freedom of choice.

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

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

A nurse is administering medications to a client who is recovering from a stroke and has right-sided paralysis. The nurse places the client's medications on the left side of the mouth and administers pills one at a time. Which of the following ethical principles is the nurse displaying? A. Autonomy B. Nonmaleficence C. Fidelity D. Justice

B. CORRECT. Nonmaleficence is the duty to do no harm and to protect clients from harm by eliminating threats. These actions taken by the nurse are important for the safety of the client by preventing aspiration.

A nurse provides an introduction to a client as the first step of a comprehensive physical examination. Which of the following strategies should the nurse use with this client? (SELECT ALL THAT APPLY) A. Address the client with the appropriate title and their last name. B. Use a mix of open- and closed-ended questions. C. Reduce environmental noise. D. Have the client complete a printed history form. E. Perform the general survey before the examination.

B. CORRECT. Open-ended questions help the client tell a story in their own words. Closed-ended questions are useful for clarifying and verifying information gathered from the client's story. C. CORRECT. A quiet, comfortable environment eliminates distractions and helps the client focus on the important aspects of the interview. E. CORRECT. The general survey is noninvasive and, along with the health history and vital sign measurement, can help put the client at ease before the more sensitive parts of the process (the examination).

A nurse is assessing an older adult client who has significant tenting of skin over the forearm. Which of the following factors should the nurse consider as a cause for this finding? (SELECT ALL THAT APPLY) A. Think, parchment-like skin B. Loss of adipose tissue C. Dehydration D. Diminished skin elasticity E. Excessive wrinkling

B. CORRECT. Tenting is a delay in the skin returning to its normal place after pinching. Tenting is a manifestation of aging skin and loss of subcutaneous tissue that provides recoil in younger skin. C. CORRECT. Tenting is a delay in the skin returning to its normal place after pinching. Dehydration can cause the skin to tent, which can easily develop in the older adult client. D. CORRECT. Tenting is a delay in the skin returning to its normal place after pinching. Tenting in the older adult client is a manifestation of aging skin and loss of elasticity.

A nurse is measuring the blood pressure of a client who has a fractured femur. The blood pressure reading is 140/94 mmHg, and the client denies any history of hypertension. Which of the following actions should the nurse take first? A. Request a prescription for an antihypertensive medication. B. Ask the client if they are having pain. C. Request a prescription for an anti-anxiety medication. D. Return in 30 min to recheck the client's blood pressure.

B. CORRECT. The firs action that should be taken using the nursing process is to assess the client for pain which can cause multiple complications, including elevated blood pressure. Therefore the priority is to perform a pain assessment. If the client's blood pressure is still elevated after pain interventions, report the finding to the provider.

A nurse is measuring a client's vital signs. The client's radial pulse rate is 55/min. Which of the following actions should the nurse take next? A. Document the finding B. Measure the client's apical pulse rate C. Talk with the client about factors that can affect the pulse rate D. Notify the provider about the client's radial pulse rate

B. CORRECT. The first action the nurse should take using the nursing process is to assess or collect data from the client. This pulse rate is below the expected reference range for an adult. The nurse and a coworker should measure the apical pulse and radial pulse rates simultaneously to determine if there is a pulse deficit. If the client's radial pulse rate is lower than the apical pulse rate, the client might have a cardiovascular disorder.

A nurse is called away for an emergency while conversing with a client who is concerned about his medical diagnosis. The nurse returns to the client promptly, as promised. Which of the following ethical principles is the nurse demonstrating? A. Autonomy B. Fidelity C. Nonmaleficence D. Justice

B. CORRECT. The nurse is demonstrating the ethical principle of fidelity by keeping a promise that was made.

A client who reports shortness of breath requests the nurse's help in changing positions. After repositioning the client, which of the following actions should the nurse take next? A. Encourage the client to take deep breaths B. Observe the rate, depth, and character of the client's respirations C. Prepare to administer oxygen D. Give the client a back rub to promote relaxation

B. CORRECT. The nurse should apply the nursing process priority-setting framework to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with an assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider go a change in client's status, the nurse must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with the knowledge needed to make an appropriate decision; therefore, the nurse should first assess the client's respiratory status.

A nurse is performing an admission assessment for a client who has asthma and reports several food allergies. Which of the following actions should the nurse take? A. Document the client's food allergies in the medical record B. Ask the client to identify the specific food allergies C. Monitor the client for indications of anaphylaxis D. have epinephrine available for administration

B. CORRECT. The nurse should apply the nursing process priority-setting framework to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with an assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify the provider of a change in the client's status, the nurse must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with the knowledge to make an appropriate decision. Therefore, the nurse should first assess the client's allergies and identify the specific allergens to ensure the specific foods are not offered to the client during meals.

A nurse in a provider's office is preparing to assess a young adult client's musculoskeletal system as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (SELECT ALL THAT APPLY) A. Concave thoracic spine posteriorly B. Exaggerated lumbar curvature C. Concave lumbar spine posteriorly D. Exaggerated thoracic curvature E. Muscles slightly larger on the dominant side

C. CORRECT. Expect the client to have a concave lumbar spine posteriorly. E. CORRECT. Expect the client to have muscle size equal on both sides or slightly larger on the dominant side.

A nurse on an oncology unit receives report at the beginning of her shift about four clients who are postoperative. Which of the following clients should the nurse see first? A. A client who is 1 day postoperative following a lobectomy for small-cell carcinoma and has a chest tube with 35 mL/hr of bright red, bloody drainage. B. A client who is 2 days postoperative following a colectomy due to colorectal cancer and has an stony bag fill of bright red, bloody drainage. C. A client who is 2 days postoperative following the excision of an abdominal mass and has a portable wound suction device with 20 mL/hr of serosanguinous drainage. D. A client who is 1 day postoperative following the excision of a bladder wall tumor and prostate and has continuous bladder irrigation with 300 mL/hr reddish-pink urine.

B. CORRECT. The nurse should apply the unstable vs. stable priority-setting framework when caring for clients. Using this framework, unstable clients are prioritized due to needs that threaten survival. The nurse should first address problems involving the airway, breathing, or circulatory status that are life-threatening. Clients whose vital signs or laboratory values indicate a risk of becoming unstable are also a higher priority than clients who are stable. The nurse may need to use nursing knowledge to determine which option describes the most unstable client. An ostomy bag full of blood indicates that the client's bowel is hemorrhaging. The client may require fluid replacement, transfusion, and additional surgery to repair the bleeding vessel. This finding poses an immediate threat to the client's situation.

A nurse if preparing to attend a care plan conference for a client who has severe burns. Which of the following criteria should the use identify as part of an effective conference? A. The planning process for the conference is centered on the nursing staff. B. Other health care professionals are in attendance at the conference. C. Controversial opinions regarding the plan of care are not tolerated during the conference. D. The conference is focused on a discussion of the client's health care issues with minimal attention to resolving them.

B. CORRECT. The nurse should identify that an effective conference should consist of other health care professionals who contribute to the plan of care for goal setting and seek to establish positive client outcomes. The members of the conference consist of the nursing team who should invite other health professionals (e.g. physical therapists, dietitians, and occupational therapists) to contribute to the plan of care.

A charge nurse is discussing ethics with a newly licensed nurse. Which of the following actions should the charge nurse include as an example of beneficence? A. Taking a continuing education course about recognizing risk factors of suicide? B. Spending extra time reorienting a client who is experiencing command hallucinations. C. Acknowledging and accepting a client's refusal of a psychotropic medication. D. Describing the purpose, action, and side effects of a psychotropic medication.

B. CORRECT. The nurse should include this action as an example of beneficence, which is the duty to act to promote the good of others. Reorienting a client who is experiencing command hallucinations is in the best interest of the client and can protect the client from harm.

A nurse on a medical-surgical unit is caring for a client. Which of the following actions should the nurse prioritize when using the nursing process? A. Identify goals for client care B. Obtain client information C. Document nursing care needs D. Evaluate the effectiveness of care

B. CORRECT. The nursing process is based on the scientific process. The first step in the scientific process is collecting data. Therefore, the first step in the nursing process is assessing and obtaining information about the client.

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

B. CORRECT. To auscultate the closure of the mitral valve, place the diaphragm of the stethoscope over the apex, or apical/mitral site, which is on the left midclavicular line at the fifth intercostal space. D. CORRECT. To auscultate the apical heart rate, place the diaphragm of the stethoscope over the apex of the heart, which is on the left midclavicular line at the fifth intercostal space.

A nurse is delegating the ambulation of a client who had knee arthroplasty 5 days ago to an AP. Which of the following information should the nurse share with the AP? (SELECT ALL THAT APPLY) A. The roommate ambulates independently. B. The client ambulates wearing slippers over anti embolic stockings. C. The client uses a front-wheeled walker when ambulating. D. The client had pain medication 30 min ago. E. The client is allergic to codeine. F. The client at 50% of breakfast this morning.

B. CORRECT. To complete this assignment safely, the AP should make sure the client wears stockings and slippers. C. CORRECT. To complete this assignment safely, the AP should make sure the client uses a front-wheeled walker. D. CORRECT. To complete this assignment safely, the AP should know that the client should be feeling the effects of the pain medication.

A nurse in a provider's clinic is taking a client's age, height, weight, and vital sings. The nurse should identify this action as part of which of the following components of the nursing process? A. Planning B. Evaluation C. Assessment D. Implementation

C. CORRECT. Collecting this data is included in the assessment portion of the nursing process. In addition, the nurse should explore the client's health history and perform a physical examination.

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

D. Nonmaleficence is a commitment to do no harm. In this situation, administering the medication could harm the client. By questioning it, the nurse is demonstrating this ethical principle.

A nurse is assisting a client who is eating at mealtime. Suddenly, the client grabs her neck with both hands and appears frightened. Which of the following actions should the nurse take first? A. Place an oxygen mask on the client B. Check the client's pulse C. Determine whether the client is able to breath D. Wrap arms around client from behind

C. CORRECT. Caring for this client requires the application of the nursing process priority-setting framework. The nurse can use the nursing process to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with an assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider go a change in client's status, the nurse must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with the knowledge to make an appropriate decision. This client is demonstrating a universal choking gesture. If the client is unable to move air in or out, sever airway obstruction is present. The client would need emergency interventions to clear a partial obstruction, as indicated by stridor or minimal airway passage. As long as there is good air exchange and the client can cough and breath spontaneously, the nurse should stay with the client and monitor her condition.

A nurse is caring for a client who reports pain with internal rotation of the right shoulder. This discomfort can affect the client's ability to perform which of the following actions? A. Exercising the deltoid muscle when using hand weights. B. Brushing the hair on the back of the head. C. Fastening or zipping closures on the back while dressing. D. Reaching into a cabinet above the sink

C. CORRECT. Fastening closures on the back while dressing requires internal rotation of the shoulder, so this activity will elicit pain.

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

C. CORRECT. If the peripheral pulse is irregular, the nurse should auscultate the apical pulse for 60 seconds to obtain an accurate rate. Then, the nurse should document the irregularity in the client's medical record.

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

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

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

C. CORRECT. Resonance is the expected percussion sound over the thorax. It is a hollow sound that indicates air inside the lungs. E. CORRECT. Bronchovesicular sounds are expected breath sounds of medium pitch and intensity and of equal inspiration and expiration time. The nurse can expect to hear them over larger airways.

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

C. CORRECT. Testing cranial nerve V, the trigeminal nerve, involves testing the strength of muscle contraction by asking the client to clench their teeth while the nurse palpates the master and temporal muscles, and then the temporomandibular joint. E. CORRECT. Testing cranial nerve V, the trigeminal nerve, involves testing light touch by having the client tell the nurse when they feel a gentle touch on the face from a wisp of cotton.

A nurse on a medical-surgical unit has received change-of-shift report and will care for four clients. Which of the following tasks should the nurse assign to an assistive personnel (AP)? A. Updating the plan of care for a client who is postoperative. B. Reinforcing teaching with a client who is learning to walk using a quad cane. C. Reapplying a condom catheter for a client who has urinary incontinence. D. Applying a sterile dressing to a pressure injury.

C. CORRECT. The application of a condom catheter is a noninvasive, routine procedure that can be delegated to an AP.

A nurse in a surgeon's office is providing preoperative teaching for a client who is scheduled for surgery the following week. The client tells the nurse that "I plan to prepare my advance directives before I come to the hospital." Which of the following statements made by the client should indicate to the nurse an understanding of advance directive? A. "I'd rather have my brother make decisions for me, but I know it has to be my wife." B. "I know they won't go ahead with the surgery unless I prepare these forms." C. "I plan to write down that I don't want them to keep me on a breathing machine." D. "I will get my regular doctor to approve my plan before I hand it in at the hospital."

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

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

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

A nurse is assessing a client's peripheral pulses. Which of the following descriptions should the nurse use to document the findings? A. Peripheral pulses equal bilaterally at a rate of 60/min B. Radial, brachial, and pedal pulses bilaterally weak C. Peripheral pulses bilaterally symmetric, equal, and strong in all 4 extremities D. Brachial, radial, popliteal, and dorsalis pedis pulses regular, 58, and bilaterally palpable.

C. CORRECT. The nurse does not evaluate the peripheral pulses routinely when measuring vital signs. Peripheral pulse evaluation is for specific clinical indications such as circulatory impairment to an extremity or during a comprehensive physical examination. A full evaluation of peripheral pulses typically includes palpation of the radial, brachial, ulnar, femoral, popliteal, tibial, and dorsalis pedal pulses. Documentation of peripheral pulse evaluation should include the strength of pulsations as well as their equality and symmetry in all 4 extremities.

A charge nurse is teaching adult pulmonary resuscitation (CPR) to a group of newly licensed nurses. Which of the following actions should the charge nurse teach as the first response in CPR? A. Call for assistance B. Begin chest compressions C. Confirm unresponsiveness D. Give rescue breaths

C. CORRECT. The nurse should apply the nursing process priority-setting framework to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with an assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider go a change in client's status, he or she must first collect adequate data from the client to obtain the knowledge needed to make an appropriate decision. Establishing unresponsiveness is required before beginning CPR. If a client is unresponsive, the nurse should activate the emergency response team.

A nurse is caring for a client who has a stage III pressure ulcer on the heel. When preparing to irrigate the wound, which of the following actions should the nurse take first? A. Obtain the prescribed irritation solution B. Don personal protective equipment C. Check the client's pain level D. Place a waterproof pad under the client's extremity

C. CORRECT. The nurse should apply the nursing process priority-setting framework to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with an assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider go a change in client's status, the nurse must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with the knowledge to make an appropriate decision. Therefore, the nurse should determine the client's level of pain prior to the procedure to evaluate the need for administration of an analgesic. Medicating the client approximately 30 minutes prior to would care will decrease pain and increase comfort.

A nurse is assessing a client's thyroid gland. Which of the following instructions should the nurse give the client before inspecting and palpating this gland? A. "Tilt your head slightly forward." B. "Keep your head straight and look ahead of you." C. "Tilt your head back and swallow." D. "Turn your head to the side against my hand."

C. CORRECT. To examine the thyroid gland, the nurse should instruct the client to extend her head backward and to swallow. The nurse should be able to feel the thyroid gland ascend as the client swallows and observe any enlargement of the gland.

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

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

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

C. CORRECT. With flatus, the profusion is mainly midline, and there is no change in the flanks.

A charge nurse is assigning client care for four clients. Which of the following should the nurse assign to the a PN? A. Creating a plan of care for a client who is recovering from a stroke. B. Assessing pressure injury on a client who is on bed rest. C. Providing a nasopharyngeal suctioning for a client who has pneumonia. D. Teaching a client who has asthma to use a metered-dose inhaler.

C. Providing nasopharyngeal suctioning is within the scope of care for a PN.

A nursing student is employed and working as an unlicensed assistive personnel (UAP) on a busy surgical unit. The nurses know that the UAP is enrolled in a nursing program and will be graduating soon. A nurse asks the UAP if he has performed a urinary catheterization on patients while in the nursing program. When the UAP says, "Yes," the nurse asks him to help her out by doing a urinary catheterization on a post surgical patient. What is the best response by the UAP? A. "Let me get permission from the patient first." B. " Sure. Which patient is it?" C. "I can't do it unless you supervise me." D. "I can't do it. Is there something else I can help you with?"

D. CORRECT. (Powerpoint - no explanation)

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

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

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

D. CORRECT. Beneficence is action that promotes good for others, without any self-interest. By administering pain medication before the client attempts a potentially painful exercise like ambulation, the nurse is taking a specific and positive action to help the client.

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

D. CORRECT. If the nurse questions the reliability of the monitoring equipment, a manual process should be used. Also, malfunctioning equipment can pose a safety risk for the client, so it must be tagged and removed.

A nurse who is assessing a client's neurological system, should ask the client to close their eyes and identify which of the following items? A. A word the nurse whispers 30 cm from the ear. B. A number the nurse traces on the palm of the hand. C. The vibration of a tuning fork the nurse places on the foot. D. A familiar object the nurse places in the hand.

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

A nurse is working with an assistive personnel (AP) in a long-term care facility. According to the 5 rights of delegation, which of the following determinations should the nurse make prior to assigning tasks? A. Whether the AP has consented to the performance of delegated tasks. B. The client's willingness to consent to care from the AP C. Whether the task can be more efficiently completed by the nurse. D. The degree of supervision that the AP will require to complete the task.

D. CORRECT. Successful delegation involves assigning the right task to the right person under the right circumstances. The person who will perform the task must be given adequate direction and specification regarding the amount of supervision that will be provided. The right communication of expectations and the right feedback about performance must also be supplied.

A charge nurse is reviewing the Cod of Ethics for Nurses during a staff meeting. Which of the following should the charge nurse include in the teaching? A. "The Code of Ethics for Nurses is legally binding." B. "The Code of Ethics for Nurses is mandatory for the practice of nursing." C. "The Code of Ethics for Nurses is a description of licensure requirements." D. "The Code of Ethics for Nurses is a guide for professional actions."

D. CORRECT. The American Nurses Association Code of Ethics for Nurses is a guide for fulfilling nursing responsibilities in a way that reflects quality in nursing care and upholds the ethical obligations of the nursing profession. It provides a guide for professional actions.

A nurse in an emergency department is caring for a client who reports developing right eye pain with a gritty sensation while sawing wood. Which of the following actions should the nurse take first? A. Install proparacaine hydrochloride eye drops B. Perform ocular irrigation of the right eye C. Place the client in a supine position with the head turned toward the affected side D. Ask the client about first aid performed at the scene

D. CORRECT. The nurse should apply the nursing process priority-setting framework to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with an assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify the provider of a change in the client's status, the nurse must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with the knowledge to make an appropriate decision. Therefore, the first action the nurse should take is to assess the first aid that was performed at the scene to determine if eye irrigation was administered.

A nurse is administering an oral sedative to a client who is receiving care following an involuntary admission. The client states, "I'm not taking any more medication." Which of the following actions should the nurse perform? A. Administer the medication by another route. B. Refer the client's refusal to the facility's ethics committee. C. Inform the client that, due to her involuntary admission, she cannot refuse a sedative. D. Document the client's refusal of the medication in the medical record.

D. CORRECT. The nurse should respect the client's right to refuse medication, even if the client is receiving treatment due to an involuntary admission. The nurse should document this refusal in the medical record and assess the reasons for the client's refusal.