NP1 Mock Final Exam

A nurse is caring for an 8-year-old client who is embarrassed about urinating in his/her bed at night. Which intervention should the nurse suggest to reduce the frequency of this occurrence? A."Drink your nightly glass of milk earlier in the evening." B."Set your alarm clock to wake you every 2 hours, so you can get up to void." C."Line your bedding with plastic sheets to protect your mattress." D."Empty your bladder completely before going to bed."

a (Rationale: Nightly incontinence and nocturia are often resolved by limiting fluid intake 2 hours before bedtime. Setting the alarm clock to wake does not correct the physiological problem, nor does lining the bedding with plastic sheets. Emptying the bladder may help with early nighttime urination, but will not affect urine produced throughout the night from late-night fluid intake.)

What intervention would the nurse use in the care of a client who is severely malnourished? A.Provide small, frequent nutrient-dense meals. B.Encourage intake of fatty foods to increase caloric intake. C.Prepare hot meals because they are more easily tolerated. D.Avoid salty foods and limit liquids to preserve electrolytes

a (Rationale: Small, frequent, nutrient-dense meals that limit fatty foods and overly sweet foods are easier to tolerate. Patients benefit from eating cold foods and drier or saltier foods with fluid in between)

Which fluid order should the nurse question for a patient with a traumatic brain injury? A.0.45% sodium chloride B.0.9% sodium chloride C.Lactated Ringer's D.Dextrose 5% in 0.9% sodium chloride

a (Rationale:0.45% sodium chloride is ahypotonic solution, and hypotonic solutions cause cells to swell, which can cause increased intracranial pressure. This can be life threatening for a patient with a traumatic brain injury. The other solutions are physiologically isotonic sodium-containingsolutions that will expand ECV but will not cause cell swelling. In the fluid container, dextrose 5% in 0.9% sodium chloride is hypertonic, but the dextrose enters cells rapidly, leaving isotonic 0.9% sodium chloride)

A nurse is providing care for a group of clients on a busy medical surgical unit. One of the client's family members tells the nurse, "You don't seem to care about my family member because it takes so long to answer the call light." Which action by the nurse best demonstrates caring towards the client? A.The nurse makes frequent rounds to check on the client. B.The nurse introduces the oncoming staff nurses to the client. C.The nurse instructs staff members to answer the client call light promptly. D.The nurse makes arrangements for the family member to stay with the client.

a (Rationale:Caring means the client matters to the nurse. This is best accomplished when the nurse is present for the client. Frequent rounds will serve two purposes. It shows caring towards the client. Also the nurse may be able to take of the client's needs so the call light is not necessary. The nurse should introduce the oncoming staff nurses as part of continuity of care. All staff members should answer call lights promptly. The nurse is accommodating the family by making arrangements for family members to stay with the client.)

During hospitalization, the nurse should encourage the parents of an 8-month-old infant to A.Provide as much care as possible. B.Not worry about attachments because the infant is too young to develop them. C.Remember that infants cannot differentiate a stranger from a familiar person. D.Relax and allow nursing staff to care for the child at all times

a (Rationale:Extended separations from parents complicate the attachment process and increase the number of caregivers with whom the infant must interact. Ideally, the parents provide most of the care during hospitalizations. Close attachment to the primary caregivers, most often parents, usually occurs by this age. Infants seek out these persons for support and comfort during times of stress. By 8 months, most infants are able to differentiate a stranger from a familiar person and respond differently to the two.)

The nurse is unable to locate the Point of Maximal Impulse (PMI) when assessing a client. Which position would be best for locating the PMI? A.Have the client turn onto his/her left side. B.Have the client lean back onto the bed. C.Have the client lie in the right Sims position. D.Have the client move to a high Fowler's position

a (Rationale:If palpating the PMI is difficult, turn the patient onto the left side. This maneuver moves the heart closer to the chest wall. Different positions help to clarify the types of sounds heard. Sitting position is best to hear high-pitched murmurs (if present). In the presence of serious heart disease, the PMI will be located to the left of the midclavicular line if related to an enlarged left ventricle. In chronic lungdisease, the PMI is often to the right of the midclavicular line as a result of right ventricular enlargement)

The nurse is using an interpreter in the care of a client who does not speak English. What factors are taken into consideration when using an interpreter? A.Questions are directed toward the client. B.The age and gender of the interpreter are not a factor. C.Questions are directed to interpreter and then redirected to the client. D.The interpreter is usually from the same culture as the client.

a (Rationale:If the client needs an interpreter, the nurse should ensure gender, age, and ethnic compatibility of the interpreter with the client's preference and the topic of discussion. The nurse should direct questions to the client and not to the interpreter and should have the interpreter ask the client for feedback and clarification at regular intervals, not only at the end. The interpretermay not be from the same culture as the client. This is not a requirement. The interpreteronly needs to speak the same language.)

The nurse monitors which priority lab value after administering Lasix (furosemide)? A.Potassium B.Sodium C.Hemoglobin D.Hematocrit

a (Rationale:Lasix causes the kidneys to excrete potassium along with water. Low potassium levels can cause lethal cardiac arrythmias. The nurse would also monitor sodium, but this is not the priority. Hematocrit levels are affected by Lasix but this is not the priority. Hemoglobin is not affected by Lasix)

The nurse is teaching the client with cardiac disease about dietary changes. Which intervention would be most effective? A.Assist the client to modify favorite recipes by using trans-fats instead of saturated fats. B.Provide the client with a list of high-sodium, low-cholesterol foods that should be included in the diet. C.Instruct the client that a diet containing no saturated fat and minimal sodium will be necessary. D.Emphasize the increased risk for cardiac problems unless the client makes the dietary changes

a (Rationale:Lifestyle changes are more likely to be successful when consideration is given to client's preference and giving them a list of foods to choose from may assist them with modifying their diet. The highest percentage of calories from fat should come from monounsaturated fats not saturated fats or trans-fats, these will increase blood cholesterol levels. Removing saturated fat from the diet completely is not a realistic expectation; up to 7% of calories in the therapeutic lifestyle changes (TLC) diet can come from saturated fat. Telling the patient about the increased risk without assisting further with strategies for dietary change is unlikely to be successful)

A client weighing less than 200 lbs who can partially assist with transfers requests assistance with moving up in the bed. Which method of transfer is best used to accomplish the transfer safely? A.Use a friction-reducing device and two caregivers. B.Use a ceiling lift with a sling and one caregiver. C.Use a stretcher, drawsheet and three caregivers. D.Assistance is not required, the client can complete the transfer independently.

a (Rationale:Moving the client in bed employs the of a transfer friction-reducing device, such as a transfer roller sheet or scoot sheet. Scoot sheets further reduce the risk of back and musculoskeletal injury. Two caregivers is also going to help move the client up in bed and is the safest approach for staff and client. The use of a stretcher would be appropriate if transferring a client from the bed to a stretcher, but this client is requesting to be moved up in bed. The client cannot transfer self independently. remember they can partially assist and are requesting assistance.)

A nurse is considering applying artificial nails. What does the nurse consider when making this decision? A.Artificial nails can lead to fungal and bacterial growth under the nail. B.Artificial nails are prohibited only in areas where sterile procedures are performed. C.Artificial nails can lower certain bacterial count on the hands because they cover the natural nail. D.Artificial can be worn in client care areas as long as the nurse uses an alcohol based hand hygiene product

a (Rationale:Numerous reports identify that fungal growth frequently occurs under artificial nails as a result of moisture becoming trapped between the natural nail and the artificial nail. Because of the risks for infection posed by artificial nail use, health care workers who have direct contact with patients at high risk (e.g., those in intensive care units or operating rooms) should not wear artificial nails. Health care workers who wear artificial nails or nail extenders are more likely to harbor gram-negative pathogens on their fingertips, both before and after handwashing. Many health care institutions have chosen to ban artificial nails and extenders in all clinical areas, with the rationale that all patients are at risk for infection)

What intervention would the nurse use for a client who reports abdominal cramping just after starting a new tube feeding? A.Slow the rate of tube feeding. B.Place the patient in a supine position. C.Change the tube feeding to a high-fat formula. D.Instill cold formula to decrease pain in the stomach.

a (Rationale:One possible cause of abdominal cramping is a rapid increase in rate or volume. Lowering the rate of delivery may increase tolerance. Another possible cause of abdominal cramping is use of cold formula. The nurse should warm the formula to room temperature. The nurse should maintain the head of the bed at least 30 degrees. High-fat formulas are also a cause of abdominal cramping.)

After visually inspecting the client's abdomen, which assessment technique would the nurse perform next? A.Auscultation. B.Percussion. C.Light palpation. D.Deep palpation.

a (Rationale:Palpation should always be performed last when performing an abdominal health assessment. Auscultation is done before palpation and percussion because palpation and percussion cause movement or stimulation of the bowel, which can increase bowel motility and thus heighten bowel sounds creating false results)

What instructionswould the nurse give the mother of a 6-month-old infant who has had vomiting and diarrhea for 2 days? A.Bring the infant to the clinic for evaluation. B.Give the infant at least 2 ounces of juice every 2 hours. C.Measure the infant's urine output for 24 hours. D.Provide the infant with 50 ml of glucose water.

a (Rationale:Parents and caregivers need to be taught the seriousness of vomiting or diarrhea in infants due to rapid fluid loss that can occur in this age group. They should also be caught the importance of bringing an infant in this situation to health care providers for evaluation. Encouraging fluids for an infant who is actively vomiting will not improve fluid balance status, nor is juice or glucose water the best choice of fluid. Simply monitoring the loss over the next 24 hours would increase the potential for the infant to become dehydrated.)

which documentation entry related to PRN medication administration is complete? a. 6/5/11 0900 morphine 4 mg IV given in right antecubital fossa for pain rated 8 on a 0-10 scale, J. Williams RN b. 0600 famotidine 20 mg IV given in right hand, S. Abraham RN c. 9/2/11 0900 levothyroxine 50 mcg PO given d. 1/6/11 furosemide 40 mg PO given, J. Smith RN

a (Rationale:The longest option, signed by J. Williams, is complete because it contains the date and time the medication was administered, the name of the medication, theroute of administration and injection site, and the name of the nurse administering the medication. Because the medication administered was a PRN order, the nurse also included the reason why the medication was administered. Other options are incomplete)

A client, who is one day post abdominal surgery, is having difficulty getting out of bed. The client reports a pain level of 7 on a scale of 1 to 10. The client declines pain medication and states "I can tough this out." What is the appropriate response by the nurse? A."Unrelieved pain can make your recovery more difficult." B."The side effects of pain medication will lessen over time." C."Very few clients become addicted to pain medication after surgery." D."There are numerous ways to manage post-operative pain without medication."

a (Rationale:This post op patient isn't moving much at all which decreases peristalsis and isn't using their incentive spirometer which would assist in moving air in and out of their lungs.Unrelieved pain can affect the respiratory system and the consequences of unrelieved pain on the respiratory system could lead to atelectasis and pneumonia. Unrelieved pain can also affect the gastrointestinal system and the consequences could lead to constipation, anorexia and paralytic ileus. Fear of addiction, tolerance, and side effects often makes patients reluctant to report painor comply with a regimen that involves opioid drugs. Explaining the harmful effects that unrelieved pain is an priority with a patient who has had extensive bowel surgery and is important not to impaired recovery from surgery. Explaining that the availability of multiple drug options is available may or may not encourage this patient to use pain medication.)

A client in labor refuses to receive any sort of anesthesia medication. Which alternative treatment is best for this patient? A.Epidural block B.Relaxation and guided imagery C.Herbal supplements with analgesic effects D.Transcutaneous electrical nerve stimulation (TENS)

b (Rationale: Some clients prefer nonpharmacological measures for pain control. In the case of a client in labor, relaxation with guided imagery is often an effective supplement for pain management because it provides women with a sense of control over their pain. Relaxation and guided imagery can be used during any phase of health or illness. TENS units are typically used to manage postsurgical and procedural pain. Herbal supplements need to be evaluated for safety during pregnancy. Additionally, some clients consider herbal supplements tobe another form of medication, and they are not typically used to control acute pain. A pudendal block is a type of regional anesthesia; use of it does not respect the client's wishes for nonpharmacological pain control.)

When assessing a client who is using axillary crutches, the nurse notes the client has numbness in both hands. What further assessment would the nurse perform? A.Assess the distancebetween the crutches when the client is standing. B.Assess the distance between the crutch pad and the axilla. C.Assess the angle of the client's wrist when standing with the crutches. D.Measure the distance between the handgrip and the client's heel.

b (Rationale: The nurse would measure the distance between the clients axilla and the crutch pad. This should be three to four finger widths. Pressure in the axilla can cause nerve damage. The distance between the crutches when the client is standing is important for safety but does not affect the client's hands. The nurse would measure the angle of the client's elbow but not the wrists. The distance between the handgrip and heel affects the length of the crutch andsafety.)

The nurse is gathering data fromthe parents of a 3-year-old child. The parents report the child stopped using the toilet a week ago after the grandparent died. What is the most accurate information the nurse can provide? A.This is an abnormal behavior and the child may need to see acounselor. B.This is a common, expected behavior for a child of this age and should improve. C.Often schedule changes surrounding a death will cause this type of problem. D.It is possible the child is having a physical problem rather than mourning the grandparent.

b (Rationale:A child's stage of development and chronological age will influence how he or she grieves.Young children can show grief through changes in their eating patterns, changes in their sleeping patterns, fussiness or irritability, and changes in their bowel and bladder habits. It is common for younger children to regress when under increased stress. This a normal response and does warrant assessment by the healthcare provider or counselor unless other problems develop or the problem does not stop on its own. Children in this age group mourn by changes in eating, sleeping and changes in bowel and bladder. There is no evidence of a physical problem at this point.)

The nurse is preparing to irrigate a wound infected with antibiotic resistant bacteria. Which pieces of personal protection equipment would the nurse wear? A.Gown and gloves B.Gloves, gown, eye protection, and surgical mask C.Gloves and surgical mask D.Gloves, gown, hair and shoe covers

b (Rationale:An infection requires transmission-based contact precautions. since the nurse will be irrigating the wound and splatters of body fluids or exudates are possible, eye protection and surgical mask should be worn to protect the mucous membranes of the eyes, nose, and mouth. A gown would be worn when the nurse is in direct contact with the client. Contact precautions require gloves.)

Which assessment finding(s) by the nurse should be reported as an early indication of hypoxia? A.Cyanosis around the lips and oral mucosa B.Anxiety and restlessness C.Decrease in the level of consciousness D.Decreased blood pressure and respiratory rate

b (Rationale:Anxiety, confusion, and restlessness are early signs of hypoxia. Cyanosis around the lips and mouth is a sign of hypoxia, but it is a late sign. Decreased level of consciousness, decreased respiratory rate, and decreased blood pressure are also late signs of hypoxia. The respiratory rate will increase as the body attempts to compensate for the decreased level of oxygen. As hypoxia worsens, the respiratory rate may decline. During early stages of hypoxia, blood pressure is elevated unless the condition is caused by shock)

A mother expresses concern because her 5-year-old child frequently talks about friends who don't exist. What is the nurse's best response to this mother's concern? A."Have you considered a child psychological evaluation?" B."It's very normal for a 5-year-old child to have imaginary playmates." C."You should stop your child from playing electronic games." D."Pretend play is a sign your child watches too much television."

b (Rationale:At age 5, some children have imaginary playmates. Imaginary playmates are a sign of health and allow the child to distinguish between reality and fantasy. The child does not need a psychological evaluation based on this information. Television, videos, electronic games, and computer programs help support development and the learning of basic skills. However, these should be only one part of the child's total play activities.)

The nurse is caring for a client with dark skin. Where would the nurse assess the client for hypoxia? A.Nailbeds B.Oral mucosa C.Earlobe D.Lower extremities

b (Rationale:Because of skin pigmentation, translucent areas of high blood flow such as mucous membranes are best to check for cyanosis, which is a sign of hypoxia. It is important to remember that cyanosis is a late sign of hypoxia)

A nurse provides care to six clients during the 7-3 shift. Which should the nurse do to ensure that documentation is complete and correct? A.Document the care before providing it. B.Document care after the intervention is completed. C.Delegate the documentation to the licensed practical nurse. D.Keep a worksheet andthen transcribe the data on the client chart

b (Rationale:Documentation should be done by the nurse providing the care, after providingcare. "If it wasn't documented, it wasn't done.")

The client is being treated with continuous positive airway pressure device (CPAP) for sleep apnea. What assessment data most indicates the therapy is effective? A.The client has decreased snoring during sleep. B.The client reports a decrease in morning headache. C.The client has lost seven pounds since treatment began.. D.The client reports improved fasting fingerstick blood glucose.

b (Rationale:During periods of apnea, the oxygen level in the blood drops, and the carbon dioxide level rises, causing the person to wake up. Many people with sleep apnea complain of fatigue and morning headache. The client that experiences a decrease in morning headache indicates that the client is sleeping better. Weight loss is not a direct result of CPAP therapy. Snoring is a sign of apnea, not sound sleeping. Successful treatment for sleep apnea would assist with the disease process of DM, but is not the only factor in controlling diabetes)

What interventions would the nurse use to promote a restraint free environment? A.Provide constraint activity for the client. B.Cover or camouflage tubes and drains. C.Change caregivers often to prevent fatigue. D.Reduce visiting hours and times in therapy

b (Rationale:Position intravenous (IV) catheters, urinary catheters, and tubes/drains out of patient view, or use camouflage by wrapping the IV site with bandage or stockinette, placing undergarments on patients with a urinary catheter, or covering abdominal feeding tubes/drains with a loose abdominal binder. This helps maintain medical treatment and reduces patient access to tubes/lines. Provide scheduled ambulation, chair activity, and toileting. Organize treatments so the patient has long uninterrupted periods throughout the day. Provide for sleep and rest periods. Constant activity may irritate the patient. Providethe same caregivers to the extent possible. This increases familiarity with individuals in the patient's environment, decreasing anxiety and restlessness. Encourage family and friends to stay with the patient. Sitters or companions may be used. In some institutions, volunteers can be effective companions. Patient anxiety is reduced and safety is increased when one person provides care and supervision is constant.)

A client who takesaspirin regularly reports increasing lower abdominal pain and loose stools. Which priority intervention would the nurse provide for this client? A.Perform fingerstick blood glucose B.Hemoccult (guaiac) the client's stools C.Assess the client's urine for signs of blood D.Assess the client's mouth for bleeding gums

b (Rationale:The client is reporting symptoms consistent with gastrointestinal bleeding. The client takes aspirin which increases the risk of bleeding. Aspirin is known to interact with hypoglycemic drugs to cause low blood glucose. However there is no indication the client is taking these medications. There is no indication the client is bleeding from the bladder. Aspirin is known to cause bleeding gums. However the client is reporting symptoms in the lower GI tract. Assessing the mouth is not a priority.)

A client is admitted to the hospital following a motor vehicle accident. On admission, the client's BP is 110/80 and heart rate 90. The nurse rechecks the vital signs 15 minutes later and the BP is now 90/60 and heart rate 140. What should the nurse suspect as the main cause of this client's vital sign changes? A.Fluid volume overload B.Fluid volume deficit C.Acute pain D.Hypoxia

b (Rationale:The decreasing blood pressure and increasing heart rate are indications of fluid loss, possibly hemorrhage. Fluid overload and acute pain would increase BP. The changes in BP would not be explained by hypoxia.)

The nurse is reviewing the client's plan of care which includes the nursing diagnostic statement: Impaired physical mobility related to tibial fracture as evidenced by the client's inability to ambulate to bathroom. Which part of the nursing diagnostic statement must be revised? A.Nursing diagnosis B.Etiology C.Patient chief complaint D.Defining characteristic

b (Rationale:The etiology, or related to factor, of tibial fracture is a medical diagnosis and needs to be revised. The nursing diagnosis is appropriate because the patient is unable to ambulate. The patient's chief complaint is what the patient subjectively states is the problem. No subjective data are included in the diagnostic statement. The defining characteristic (subjective and objective data that support the diagnosis) is appropriate for Impaired physical mobility)

The nurse suspects that the client has a hearing deficit; however, the client denies not being able to hear. What assessment technique will the nurse initially employ? A.Schedule a Weber and Rinne test. B.Observe the client's interaction with family. C.Use an otoscope to visualize the inner ear. D.Assess the clients hearing with an ophthalmoscope

b (Rationale:The most telling of these options would be to observe the client's interactions with the family. The nurse should assess for frequent requests to repeat, inattention to conversation, turning one ear to the conversation and lip-reading. The Weber and Rinne test and use of an otoscope may be part of the assessment, but will not yield much information as this simple observation. The client has already denied a hearing problem, soconfronting the client with the nurse's suspicion will probably only serve to alienate the client from the nurse.)

The nurse is preparing to remove medications from the medication dispensing machine. One of the medications has a name that is different from thename on the orders for the client. What is the initial action by the nurse? A.Inform the physician that the medication is unavailable B.Verify both the trade name and generic name for the medication. C.Hold the medication until the correct medication can be obtained. D.Request the pharmacist review the client's medications for accuracy.

b (Rationale:The nurse initially would verify both the trade name and generic name for the medication. This makes certain the medication is correct or there is an error that needs to be reported. There is no reason to hold the medication unless there is an actual problem with the medication. There is no need to contact either the pharmacist or physician until the nurse is certain there is a problem.)

A nurse is planning discharge for a client who has a nursing diagnosis of Impaired physical mobility. Before discontinuing the client's plan of care, what does the nurse need to do? A.Determine whether the client has transportation to get home. B.Evaluate whether client goals and outcomes have been met. C.Establish whether the client has a follow-up appointment scheduled. D.Ensure that the client's prescriptions have been filled

b (Rationale:The nurse needs to evaluate whether goals and outcomes have been met before revising, continuing, or discontinuing a plan of care. The client needs transportation, but that does not address the client's mobility status. Whether the client has a follow-up appointment and ensuring that prescriptions are filled do not evaluate the problem of mobility)

A client does not wish to take prescribed allergy medication at the scheduled morning time because it causes excessive daytime sleepiness. What is the appropriate response by the nurse? A."You must take your medications as ordered by the physician while you are in the hospital." B."I will contact the physician to retime the medication daily at bedtime." C."You can skip this medication on days when you need to be awake and alert." D."I will cluster your care in the morning, so you can sleep in the afternoon."

b (Rationale:The nurse should use knowledge about the medication to educate the patient about potential response to medications. Then the medication schedule can be altered based on that knowledge, after the physician has been notified. It is the patient's right to refuse her medication; however, the nurse should educate the patient on the importance and effects of her medication. Asking a patient to change her entire life schedule around a medication is unreasonable and will decrease compliance. Clustering care and encouraging the patient to nap in the afternoon does not address her concerns and is not a necessary or appropriate solution.)

After medication administration, the nurse realizes the wrong medication was administered. What is the initial action by the nurse? A.Notify the healthcare provider of the error. B.Return to the room to fully assess the client. C.Notifythe charge nurse and complete a variance report. D.Administer an antidote to the client to reverse the medication effects.

b (Rationale:The nurse's first priority is to establish the safety of the patient by assessing the patient. The nurse would notify the healthcare provider. Then the nurse would notify the charge nurse and fill out the necessary paperwork. The nurse administer an antidote only if indicated.)

A 67-year-old patient tells the nurse, I have problems with constipation now that I am older, so I use a suppository every morning. Which action should the nurse take first? A.Encourage the patient to increase oral fluid intake. B.Assess the patient about individual risk factors for constipation. C.Inform the patient that a daily bowel movement is unnecessary. D.Suggest that the patient increase dietary intake of high-fiber foods

b (Rationale:The nurses initial action should be further assessment of the patient for risk factors for constipation and for usual bowel pattern. The other actions may be appropriate but will be based on the assessment)

What would the nurse include when teaching an older adult about eyesight examinations? A.The client should see an optometrist every two years. B.The client should have a complete eye exam every year. C.The client should have a baseline screening by an ophthalmologist. D.The client should be screened during annual wellness office visits

b (Rationale:The older client needs to have complete eye examinations every year. The optometrist can screed for disease such as cataracts and glaucoma. The client can then be referred to the ophthalmologist if indicated. The client's primary provider does not have the equipment to properly screen the client foreye diseases)

The provider orders a maintenance dose of oral aminophylline, 3 mg/kg every 6 hour. The patient weighs 50 kg. How many mg should the nurse administer to the patient in a 24-hour period? A.150 mg B.600 mg C.300 mg D.900 mg

b (Rationale:The patients weight times the number of milligram/kilogram will provide daily dosage of medication: 50 kg 3 mg/kg = 150 mg per dose. The patient is to receive a dose every 6 hours. The number of hours in a day divided by the number of hours separating each dose supplies the number of dosages the patient receives per day: 24hours 6 hours between doses = 4 doses per day. If each dose is 150 mg and the patient receives 4 of these doses a day, the total amount of medication received is 150 mg 4 daily doses = 600 mg)

Where would the nurse auscultate for the pulmonic heart valve? A.Second intercostal space on the right side B.Second intercostal space on the left side C.Third intercostal space (Erb's point) D.Fourth intercostal space along the sternum

b (Rationale:The pulmonic area is at the second intercostal space on the left side. The aortic area is at the second intercostal space on the patient's right side. The second pulmonic area is found by moving down the left side of the sternum to the third intercostal space, also referred to as Erb's point.The tricuspid area is located at the fourth left intercostal space along the sternum)

The nurse is gathering information from a client who reports being obese for many years. The client has decided to go to a weight loss clinic. The nurse recognizes that the client is in which stage of the change process? A.Precontemplation B.Contemplation C.Preparation D.Action

b (Rationale:These stages range from no intention to change (precontemplation), to considering a change within the next 6 months (contemplation), to making small changes (preparation), to actively engaging in strategies to change behavior (action), to maintaining a changed behavior (maintenance). This patient is planning to make the change within the next 6 months and is in the contemplation stage)

The parent of a toddler asks a nurse at a well-child clinic how the child's frequent temper tantrums can best be handled. Which action should the nurse suggest to the parent? A.Restrain the child physically. B.Ignore the temper tantrums. C.Tell the child that temper tantrums are not acceptable. D.Distract the child by offering to playa game.

b (Rationale:This action may actually cause the behavior to intensify. This is the recommended approach, since it does not provide positive reinforcement for the unacceptable behavior. Ignoring a negative behavior is a basic concept in behavior modification. The parent should be instructed to make sure that the child is safe, and then appear to ignore the child or walk away. Without an audience, the behavior is more likely to extinguish itself quickly. This is the recommended approach, since it does not provide positive reinforcement for the unacceptable behavior. Ignoring a negative behavior is a basic concept in behavior modification. The parent should be instructed to make sure that the child is safe, and then appear to ignore the child or walk away. Without an audience, the behavior is more likely to extinguish itself quickly. This provides positive reinforcement for an unacceptable behavior.)

What would intervention would the home health nurse use in the care of a client with peripheral nerve damage from diabetes? A.Instruct the client to remove all throw rugs. B.Teach the client how to use a bath thermometer. C.Check smoke detectors and replace batteries regularly. D.Encourage the client to remove unheeded items from the home.

b (Rationale:This client is experiencing a tactile deficits with the peripheral nerve damage. Using a bath thermometer to monitor water temperature and prevent burns would address this specific deficit. Interventions for visual deficits would include removing throw rugs on any floor and keeping spaces uncluttered and organized. Interventions for olfactory and hearing deficits would include checking smoke detectors and replacing batteries regularly)

Which question should the nurse ask to best assess how visual alterations are affecting the client's self-care ability? A."Have you stopped reading books or switched to books on audiotape?" B."Are you able to prepare a meal or write a check?" C."How do you protect yourself from injury at work?" D."How does your vision impairment make you feel?"

b (Rationale:To best understand how vision is affecting self-care ability, the nurse wants to target questions to encompass what self-care tasks the patient has difficulty doing, such as preparing meals and writing checks. Switching to books on audiotape gives the nurse an idea of the severity of the deficit, but not its impact on activity of daily living. Assessing whether the patient is taking measures to protect himself is important, but this does not address self-care activities. Emotional assessment of a patient is also important but does not properly address the goal of determining the effect of visual alterations on self-care ability)

What intervention would the nurse use when providing personal care for a comatose client? A.Place the patient in a prone position for easier access. B.Use a different corner of the washcloth for each eye. C.Wipe each eye from outer to inner canthus. D.Use a sterile medicine cup to instill lubricant.

b (Rationale:Use a separate, clean cotton ball or corner of the washcloth for each eye. Place the patient in supine position. Gently wipe each eye from inner to outer canthus. Use an eyedropper to instill the prescribed lubricant (e.g., saline, methylcellulose, liquid tears) as ordered.)

The nurse on the inpatient rehabilitation unit is providing care for a client with arthritis. What pain management strategies would the nurse use in managing this client's pain? A.Administer pain medication after physical therapy. B.Administer pain medications regularly around the clock. C.Administer pain medication when the client states the pain levels are increasing. D.Administer pain medication only when nonpharmacological measures have failed

b (Rationale:When a patient with arthritis has chronic pain, the best way to manage pain is to take medication regularly throughout the day to maintain constant pain relief. The nurse would not wait to administer pain medications after therapy as this will interfere with therapies. If the patient waits until having pain to take the medication, pain relief takes longer. Nonpharmacological measures are used in conjunction with medications unless requested otherwise by the patient.)

A nurse is preparing to assist a client out of bed. What is the initial action by the nurse? A.Raise the height of the bed. B.Raise the headof the bed 30 degrees. C.Turn the client onto the side facing away from the nurse. D.Move the client's legs over the side of the bed

b (Rationale:With the patient in supine position, raise the head of the bed 30 degrees;this decreases the amount of work needed by the patient and the nurse to raise the patient to a sitting position.The bed should be in the low position. The patient is turned to face the nurse after the head of the bed is raised 30 degrees. The patient's legs are positioned over the edge of the bed after the head of the bed is raised and the patient is turned to face the nurse.)

Validation of a dying person's life would be demonstrated by which nursing action? A.Taking pictures of visitors B.Providing quiet visiting time C.Listening to family stories about the person D.Calling the organ donation coordinator

c (Rationale: Listening to family members' stories validates theimportance of the dying individual's life and reinforces the dignity of the person's life. Taking pictures of visitors does not address the value of a person's life. Calling organ donation and providing private visiting time are components of the dying process, but they do not validate a dying person's life.)

What response indicates that the nurse is attentively listening to the client's explanations during an admission interview? A."Can you explain what your symptoms are like?" while writing in the client's chart B."When was the last time you saw adoctor for this?" C."Go on.", while nodding his/her head. D."I'm sorry, say that again."

c (Rationale:A nurse can convey attentiveness in listening to patients in various ways. Common responses are nodding the head, uttering "uh-huh" or "mmm", repeating the words the patient has used or saying "I see what you mean." The other options are examples of open-ended questions or simply examples of clarifying techniques)

An appropriate principle of surgical asepsis is that: A.the entire sterile package is sterile once it is opened. B.all of the draped table, top to bottom, is considered sterile. C.an object held below the waist is considered contaminated. D.if the sterile barrier field becomes wet, the dry areas are still sterile.

c (Rationale:A sterile object or field out of the range of vision or an object held below a person's waist is contaminated. Once a sterile package is opened, a 2.5-cm (1-inch) border around the edgesis considered unsterile. Tables draped as part of a sterile field are considered sterile only at table level. A sterile barrier that has been permeated by punctures, tears, or moisture must be considered contaminated)

The nurse is helping an obese adolescent modify their diet to meet increased energy needs due to a new moderate exercise program. Which modification is most appropriate for the nurse to recommend? A.Decreasing carbohydrates to 10% to 25% of total intake. B.Decreasing protein intake to 0.5 g/kg/day. C.Adequately hydrating with water before and after exercise. D.Elimination of cholesterol from all dietary sources

c (Rationale:Adequate hydration is very important for all athletes. They need to ingest water before and after exercise to prevent dehydration, especially in hot, humid environments. Carbohydrates, both simple and complex, are the main source of energy, providing 55% to 60% of total daily kilocalories. Protein needs increase to 1.0 to 1.5 g/kg/day. Intake of iron-rich foods is required to prevent anemia, and protein is a high source of energy. High cholesterol sources should be avoided, but eliminating cholesterol is unhealthy for any age group.)

The nurse is preparing to administer an enema to an adult client who has normal sphincter control. For administration of the enema, the client is placed in which position? A.Right side-lying B.Dorsal recumbent C.Sims' D.Prone

c (Rationale:Assist the client into left side-lying (Sims') position with the right knee flexed. Additionally, place a child in dorsal recumbent position. This allows enema solution to flow downward by gravity along the natural curve of the sigmoid colon and rectum, thus improving retention of solution.)

The nurse is caring for a client who has a wound drain with a collection device. The nurse notices that thecollection device has a sudden decrease in drainage even though the drain is compressed. What is the correct intervention by the nurse? A.Request an order to remove the drain. B.Compress the device again to activate it. C.Request the healthcare provider inspect the drain. D.No action is needed because is there no drainage to be removed.

c (Rationale:Because a drainage system needs to be patent, look for drainage flow through the tubing, as well as around the tubing. A sudden decrease in drainage through the tubing may indicate a blocked drain, and you will need to notify the physician. The health care provider determines the need for drain removal and removes drains. Notifying the charge nurse, although important for communication, is not the next step in providing care for this patient. The evacuator may be compressed when a blockage is present.)

The nurse is teaching a client with fluid volume excess about food choices. Which food choices by the client indicates the teaching has been effective? A.Bologna sandwich on whole wheat bread with lettuce and tomatoes and iced tea B.Spaghetti with pork meatballs, salad and milk C.Grilled chicken breast, corn and milk D.Lean steak, broccoli with cheese sauce and hot tea

c (Rationale:Bologna, pork and cheese sauce are all high in sodium. This client is experiencing a fluid volume excess an high sodium level and will most likely be placed on a sodium restricted diet. The grilled chicken breast with corn and milk are the best choices for this client)

The nurse is caring for a client who has been on bed rest for several weeks. The nurse notes that the client is continually seeping liquid stool rectally. What is the initial intervention by the nurse? A.Hold the client's antibiotics. B.Recommend high fiber foods. C.Perform a digital rectal examination. D.Administer a laxative

c (Rationale:Continual seepage of diarrhea may occur with an impaction, and a digital rectal examination can verify its presence. If an impaction is present the nurse would remove it and administer a laxative. Diarrhea is often due to diet or antibiotic use, which alters the normal flora in the gastrointestinal tract. However, a physician's order is required to change these, and continual seepage of stool is more likely the result of impaction; this should be ruled out first.)

What should the nurse do first if a patient is unable to void on demand for a clean-voided specimen? A.Perform Credé's procedure for the suprapubic area. B.Catheterize the patient to obtain the specimen. C.Offer fluids, if allowed, and wait about 30 minutes. D.Notify the physician that the test cannot be completed

c (Rationale:If the patient is unable to urinate on demand, offer fluids if permitted. Allow more time for urine to accumulate in the bladder. Try obtaining a specimen after 30 minutes. If the patient has no urine in the bladder, Credé's would not be useful. The riskfor infection precludes the use of catheterization simply to obtain a specimen. If the patient is unable to void after several hours, the physician may need to be called to obtain an order for catheterization.)

During a follow-up visit, a woman is describing new onsetof marital discord with her terminally ill spouse. Using the Kübler-Ross behavioral theory, the nurse recognizes that the spouse is in which stage of dying? A.Denial B.Bargaining C.Anger D.Depression

c (Rationale:Kübler-Ross' traditional theory involves five stages of dying. The anger stage of adjustment to an impending death can involve resistance, anger at God, anger at people, and anger at the situation. Denial would involve failure to accept a death. Bargaining is an action to delay acceptance of death by bartering. Depression would present as withdrawal from others.)

The nurse is concerned a client may have tissue ischemia in the legs when making which assessment finding? A.The client has peripheral edema. B.The client has a widened pulse pressure. C.The client has leg pain while walking. D.The client has brownish discoloration to the lower legs

c (Rationale:Leg pain (also called intermittent claudication) is a primary manifestation of peripheral arterial disease. Intermittent claudication is muscle pain caused by interruption in arterial flow, resulting in tissue hypoxia (tissue ischemia). Peripheral edema and brownish discoloration to the skin on the leg would be consistent with venous disease, not arterial disease. Widened pulse pressure would be an unrelated finding.)

What steps should the nurse take to conduct an assessment of a possible pulse deficit? A.A nurse measures the pulse after the patient exercises. B.Two nurses check the same pulse on opposite sides of the body. C.Two nurses assess the apical and radial pulses and determine the difference. D.The current pulse is compared with previous pulse measurements for differences

c (Rationale:Locate apical and radial pulse sites. One nurse auscultates the apical pulse, and one nurse palpates the radial pulse. Both nurses count the pulse rate for 60 seconds simultaneously. Subtract the radial rate from the apical rate to obtain the pulse deficit. The pulse deficit reflects the number of ineffective cardiac contractions in 1 minute. If a pulse deficit is noted, assess for other signs and symptoms of decreased cardiac output.)

The nurse anticipates what type of oxygen therapy for a client who needs oxygen at 3 liters per minute? A.Venturi mask B.Simple face mask C.Nasal cannula D.Nonrebreather mask with reservoir bag

c (Rationale:Oxygen can be administered per nasal cannula at 1-6 liters. . The simple face mask is used for short-term oxygen therapy. It fits loosely and delivers oxygen concentrations from 40% to 60%. The simple face mask delivers 5-8 liters of oxygen. When used as a nonrebreather, the plastic face mask with a reservoir bag delivers 60% to 100% oxygen at appropriate flow rates. A Venturi mask delivers 4-12 liters oxygen)

When taking the blood pressure of a client, what would be the most accurate means of estimating the systolic pressure? A.Checking previous blood pressure readings. B.Estimating according to body build and age. C.Palpating for obliteration of the radial pulse. D.Using 20mm Hg as the usual systolic pressure

c (Rationale:Palpating for obliteration of the radial pulse allows for the nurse to be in the range of the systolic pressure. All other answers should never be used at anytime.)

The nurse is assisting a client sitting in a wheelchair to a standingposition. What should the nurse do to improve the base of support? A.Rock with the client until they are in a standing position. B.Tighten the back muscles while lifting. C.Place the feet further apart. D.Lean slightly backward.

c (Rationale:Placing the feet further apart will increase the base of support)

Which assessment question should the nurse ask if stress incontinence is suspected? A."Does your bladder feel distended?" B."Do you empty your bladder completely when you void?" C."Do you experience urine leakage when you cough or sneeze?" D."Do your symptoms increase with consumption of alcohol or caffeine?"

c (Rationale:Stress incontinence can be related to intra-abdominal pressure causing urine leakage, as would happen during coughing or sneezing. Asking the patient about the fullness of his bladder would rule out retention and overflow. An inability to void completely can refer to urge incontinence. Physiological causes and medications can effect elimination, but this is not related to stress incontinence)

The nurse is assisting the client with personal hygiene. Which nursing action would best provide activerange of motion? A.Provide a wash cloth and instruct the client to wash his/her face. B.Move the wash basin farther toward the end of the bed so the client must reach. C.Encourage the client to bathe and brush her hair with minimal assistance. D.Move each of the client's hand and arm joints through range of motion

c (Rationale:The best range of motion is the natural movement of the client's joints in normal activity. Brushing the hair and teeth includes more of the joints of the hands and the arms than does washing the face. The wash basin should be close to the client to avoid overreaching and possible falls. Passive range of motion is the second best choice after normal use of the joints)

The nurse is developing a plan of care for a critical care unit client experiencing signs and symptoms of disorientation, slurred speech and daytime sleepiness. Which intervention is appropriate to include on the plan? A.Provide personal care per hospital routine. B.Visit with the client during rounds. C.Decrease conversation outside the clients room. D.Encourage family members to visit in the early evening.

c (Rationale:The client is experiencing signs and symptoms of sleep deprivation. Decreasing conversation outside the clients room is the best answer. Keep the noise level down. Be aware that activities, conversation, and equipment, even outside the patient's room, can disrupt sleep. The nurse should schedule nursing care to avoid interrupting the clients sleep rather than strictly following hospital routine. If the nurse visits with the client each hour, the client will not get sufficient sleep. The nurse would allow the client to sleep when making rounds. Visits from family members can cause the client to become over stimulated just before bedtime.)

What would the nurse include when teaching a female client about obtaining a clean catch urine specimen? A.Cleanse the urethral meatus from the area of most contamination to least. B.Initiate the first part of the urine stream directly into the collection cup. C.Hold the labia apart while voiding into the specimen cup. D.Drink fluids 5 minutes before collecting the urine specimen

c (Rationale:The client should hold the labia apart to reduce bacterial levels in the specimen. The urethral meatus should be cleansed from the area of least contamination to greatest contamination (or front-to-back). The initial steam flushes out microorganisms in the urethra and prevents bacterial transmission in the specimen. Drink fluids 30 to 60 minutes before giving a specimen.)

The nurse is teaching a patienthow to use a flow-oriented incentive spirometer (IS) the night before abdominal surgery. Which statement by the patient indicates an understanding of the procedure? A."I should blow slowly into the mouthpiece." B."The balls must be elevated to be effective." C."I need to keep the balls elevated as long as possible." D."Quick rapid breaths are the most effective way to expand my lungs."

c (Rationale:The goal is to keep the balls elevated for as long as possible to ensure maximal sustained inhalation, not to snap the balls to the top of the chamber quickly with a rapid, brief, low-volume breath. Even if very slow inspiration does not elevate the balls, this pattern helps to improve lung expansion.)

According to Maslow's Hierarchy of Needs, which nursing diagnosis has the highest priority? A.Acute Pain B.Risk for Aspiration C.Impaired Gas Exchange D.Risk for Fluid Volume Deficit

c (Rationale:The highest priority would be Impaired Gas Exchange as it relates to the client's airway and oxygenation status. Next ranked is Risk for Aspiration (airway maintenance), Acute pain and Risk for fluid volume deficit.)

Which task can the nurse safely delegate to a nurse assistant? A.Palpating the bladder of a patient who is unable to void B.Administering a continuous bladder irrigation C.Providing indwelling urinary catheter care D.Obtaining the patient's history

c (Rationale:The nurse can safely delegate indwelling urinary catheter care to a nurse assistant who is adequately trained to do so. Palpating the bladder and obtaining the patient's history require assessment skills of a trained professional nurse. Administering a continuous bladder irrigation requires critical thinking skills of a professional nurse.)

The client's son requests to view the documentation in his mother's medical record. What is the nurse's best response to this request? A."I'll be happy to get that for you." B."You will have to talk to thephysician about that." C."You will need your mother's permission." D."You are not allowed to see it."

c (Rationale:The nurse understands that sharing health information is governed by HIPAA legislation, which defines rights and privileges of patients for protection of privacy. Private health information cannot be shared without the patient's specific permission. The other three responses either are outright false and/or use poor communication techniques)

The nurse is planning care for a client who is a single parent. The client is experiencing lack of sleep related to anxiety from financial issues. What is the expected outcome for this client? A.The client will report decreased anxiety within 3 days. B.The client will verbalize a plan to improve finances within 2 days. C.The client will report feeling rested upon awakening within 1 day. D.The client will verbalize a plan to manage children as a single parent within 4 days

c (Rationale:The nurse would set the expected outcome as related to the problem which is lack of sleep. The client would awaken feeling rested. The anxiety is the R/T part. The financial issues is a contributing factor. Being a single parent is part of the assessment data)

The client shows signs and symptoms of hypoxia. What nursing diagnosis problem statement is most appropriate for this client? A.Ineffective BreathingPattern B.Ineffective Airway Clearance C.Impaired Gas Exchange D.Ineffective Oxygenation

c (Rationale:The only nursing diagnosis supported by hypoxia as the only finding is Impaired Gas Exchange.The patient may have other nursing diagnoses such as Ineffective Breathing Patternor Ineffective Airway Clearance, but those diagnoses are not supported by the finding in this scenario. Ineffective Oxygenation is not a NANDA diagnosis.)

What is one of the differences between a leader and a manager? A.A leader has legitimate authority. B.A manager motivates and inspires others. C.A manager focuses on coordinating resources. D.A leader focuses on accomplishing goals of the organization.

c (Rationale:The terms leadership and management are often used interchangeably. However these roles have specific traits. The manager is the coordinator of resources (time, people and supplies). Authority is the right to direct others that is given to a person by the organization through assignment to an authorized position such asa nurse manager. It is the nurse leader who has the ability to guide or influence, as well as to motivate and inspire others on the team. Managers are assigned responsibility for accomplishing the goals of the organization)

A nurse and patient take action to meet health-related goals. The nurse is in which phase of the helping relationship? A.Pre-interaction B.Orientation C.Working D.Termination

c (Rationale:The working phase occurs when the nurse and the patient work together to solve problems and accomplish goals. Pre-interaction occurs before the nurse meets the patient. Orientation occurs when the nurse and the patient meet and get to know each other. Termination occurs during the ending of the relationship)

How does the nurse assess that a hearing aid is operating correctly? A.Speaking very softly behind the client B.Covering the client's unaffected ear and speaking C.Determining the clients response to a normal tone of voice D.Removing the hearing aid and sending it to be checked by an audiologist

c (Rationale:To determine whether the client can hear clearly using the hearing aid, turn your back to the client and ask a question slowly and clearly in a normal tone of voice. Depending on your position, the client may be ableto read your lips. The prostheses are limited by the function of the ear structures. The hearing aid may not be the problem in this case.)

A toddler is going to have surgery on the right ear. Which teaching method is most appropriate for this developmental stage? A.Encourage independent learning. B.Use discussion throughout the teaching session. C.Apply a bandage to a doll's ear. D.Develop a problem-solving scenario.

c (Rationale:Use play to teach a procedure or activity (e.g., handling examination equipment, applying a bandage to a doll) to toddlers. Encouraging independent learning is for the middle-aged adult. Use of discussion is forolder children, adolescents, and adults, not for toddlers. Use problem solving to help adolescents make choices. Problem solving is too advanced for a toddler.)

A nurse is giving discharge instructions to a client. On the client's admission data his educational level is marked as 3rd grade. What would be the most important action by the nurse when providing information to this client? A.Give written information. B.Involve a family member. C.Use multiple teaching methods. D.Use only short teaching periods.

c (Rationale:Using multiple teaching methods for this client would be more beneficial since their educational level is 3rdgrade. Educational materials should be written at 5th or 6th grade reading levels, which would probably not assist this client. Using drawings, photographs, videos, demonstration, discussion and one-to-one teaching methods are some of the multiple methodsyou may use. Involving a family member could be appropriate, but the nurse would need to do an assessment and find out if this client lives alone or with family member and if this client would even want the family involved. Using short teaching periods may be appropriate for this client, but ONLY using this one method of teaching would not necessarily benefit this client.)

The nurse finds it difficult to care for a client whose advance directive states that no extraordinary resuscitation measures should be taken. Which step may help the nurse to find resolution in this assignment? A.Call for an ethical committee consult. B.Decline the assignment on religious grounds. C.Scrutinize his/her own personal values. D.Convince the family to challenge the directive.

c (Rationale:Values develop over time and are influenced by family, schools, religious traditions, and life experiences. The nurse must recognize that no two humans have the same set of experiences, and so differences in values are more likely the norm than the exception. Closer inspection of one's values may be a step in gaining understanding of another person's perspective. Calling for a consult, declining the assignment, and convincing the family to challenge the patient's directive are not ideal resolutions because they do not address the reason for the nurse's discomfort, which is the conflict between the nurse's values and those of the patient.)

The nurse is assessing several clients who have recently returned to the unit from surgery.. Which client most likely has a need for suctioning? A.A client who reports pain when breathing B.A client who has a cough producing thick yellow mucus C.A client with clear but diminished lung sounds and O2 sat level of 88% D.A client who is drowsy and has a respiratory rate of 10

c (Rationale:When a patient's oxygen saturation falls below 90%, this is a good indicator of the need for suctioning. Pain with breathing is probably related to the surgery. If a cough is productive, suctioning is not necessary. Drowsiness and a decreased respiratory rate may be due to administration of pain medications such as opioids.)

Which statement best demonstrates the use of assertive communication when a nurse is addressing another member of the healthcare team? A."You need to check the laboratory results of the client in room 423." B."You should visit with the client's family about the upcoming procedure." C."I am concerned that the client does not have adequate pain management." D."We need to be more aware of the situation among the client and the client's family."

d (Rationale:An important characteristic of assertive communication includes the use of "I" statements versus "you" statements. "You" statements place blame and put the listener in a defensive position. "I" statements encourage discussion.)

A nurse is preparing to administer routine medications for a group of clients. An unlicensed personnel (UAP) reports to the nurse a client is experiencing pain. What is the appropriate action by the nurse? A.Ask the UAP for more information about the client's pain. B.Prepare the prescribed pain medication and take it to the client's room. C.Assess the client's pain when administering the client's routine medications. D.Perform a pain assessment on the client prior to preparing the medications.

d (Rationale:Assessment is not within the scope of practice for the UAP. The nurse cannot accept this information without assessing the client. The nurse would not delay addressing the client's pain. The nurse would prioritize the client's pain)

The patient has a calculated body mass index (BMI) of 34. How would the nurse classify this client? A.Unclassifiable. B.Normal weight. C.Overweight. D.Obese

d (Rationale:BMI greater than 30 is defined as obesity. BMI between 25 and 30 is classified as overweight. BMI less than 25 is considered normal or underweight. All patients can be classified by dividing their weight in kilograms by their height in meters squared.)

A client has been using continuous positive airway pressure (CPAP), and now the health care provider is recommending bi-level positive airway pressure (BiPAP). The client is asking the nurse to explain the difference again. Which response is appropriate? A."CPAP maintains a set positive airway pressure during inspiration only." B."CPAP opens the airways during inspiration and allows them to close during expiration." C."BiPAP maintains a set pressure that is the same for inspiration and expiration." D."BiPAP delivers sufficient expiratory pressure to keep the airways open."

d (Rationale:BiPAP uses two modes of pressure: one for inspirationand one for expiration. During expiration, BiPAP delivers sufficient pressure to keep the airways open. CPAP maintains a set positive airway pressure during inspiration and expiration. It keeps the airways open and prevents upper airway collapse.)

A client with a hemoglobin of 7 gm/dL is at risk for developing pressure ulcers as a result of which of the following? A.Increased sedation B.Edematous tissues C.Low blood glucose D.Low oxygen to the tissues

d (Rationale:Decreased hemoglobin reduces the oxygen-carrying capacity of the blood and the amount of oxygen available to the tissues, thus increasing the risk for pressure ulcers. Anemia does not cause increased sedation, edematous tissue, or lowblood glucose.)

A client climbed over the siderails and fell. After meeting the client's needs and assessing that the client was not harmed, what action would the nurse take? A.Do nothing because the client was not harmed. B.Complete an incident report and put it in the medical record. C.Chart what happened and state that an incident report has been filled out. D.Document what happened in the client record without mentioning the incident report

d (Rationale:Document in the client's record an objective description of what you observed and follow-up actions taken without reference to the incident report. Incident reports are not a part of the permanent medical record but are an important source of risk management data for identifying and addressing the causes of errors made in health care organizations. You complete the report even if an injury does not occur or is not apparent.)

When is healing by primary intention expected? A.When the wound is left open and is allowed to heal B.When a surgical wound is left open for 3 to 5 days C.When connective tissue development is evident D. when the edges of a clean incision remain close together

d (Rationale:Healing by primary intention occurs when the edges of a clean surgical incision remain close together. The wound heals quickly, and tissue loss is minimal or absent. The skin cells quickly regenerate, and the capillary walls stretch across under the suture line to form a smooth surface as they join. Wounds that are left open and are allowed to heal by scar formation are classified as healing by secondary intention. Connective tissue development is evident during healing by secondary intention. Healing by tertiary intention occurs when surgical wounds are not closed immediately but are left open for 3 to 5 days to allow edema or infection to diminish.)

The nurse is caring for an adult client who's family does not want to tell him that he is dying. According to these wishes what is the best initial action by the nurse? A.Arrange an encounter with the client and tell him the truth. B.Change the subject when the client asks about his impending death. C.Tell the family that the client has the right to know he is dying. D.Talk to the family about the situation and their concerns

d (Rationale:In this situation, the best and first thing the nurse should do is talk with the family about what is happening and what their concerns are. The nurse should investigate religious, cultural, and family traditions regarding telling the client about impending death. The nurse should have this discussion with the family before offering such advice as the client has the right to know. The nurse should not change the subject if the client asks about impending death, but should not encourage such an encounter before discussing the situation withthe family.)

A nurse is preparing to administer a flu vaccine, which technique should the nurse use to locate the deltoid muscle? A.By locating the center of the arm between the elbow and the shoulder. B.By locating the midpoint of the lateral aspect of the upper arm. C.By palpating the lower edge of the acromion process and measuring 4 inches below to the center of the lateral aspect of the upper arm. D.By palpating the lower edge of the acromion process and measuring 4 finger-widths below to the midpoint and center of the lateral aspect of the upper arm.

d (Rationale:Locatingthe center of the arm and between the elbow and does not give the nurse specific location of where to administer the medication. Locating the midpoint of the lateral aspect of the upper arm does not give the nurse specific location of where to administer the medication. Palpating the lower edge of the acromion process and measuring 4 inches below the center of the lateral aspect of the upper arm would be too low to administer the medication. Palpating the lower edge of the acromion process and measuring 4 finger-widths below the midpoint and the center of the lateral aspect of the upper arm would be the correct location to administer the medication)

An older adult asks the nurse why he/she doesn't feel as rested in the morning as he/she used to. What would be the appropriate response by the nurse? A."Older adults have more dream type sleep." B."Adding a daily nap will help you feel more rested." C."You should be getting more sleep now that you are older." D."Older adults usually spend less time in deep, restful sleep at night."

d (Rationale:Older adults experience significantly less REM sleep (dream type sleep) and sleep less at an average of 5-7 hours. The key word in this question is why. Adding a daily nap is an intervention not an explanation of why she doesn't feel rested)

While walking in the hallway with the nurse, a client complains of feeling faint. Which nursing action would be most appropriate? A.Instruct the patient to increase his pace so they can quickly return to his room. B.Leave the patient in order to find a second nurse to help them. C.Advise the patient to look down at his feet to maintain balance. D.Guide the patient to the closest place to sit down.

d (Rationale:Sitting allows him to sit and rest as a safety factor.Picking up the pace does not ensure safety. Leaving the client alone does not assure safety. Looking at the feet does not promote balance.)

A nurse is preparing to have a client sign a consent form. The client is Native American. The client states he/she wants to consult the Shaman before signing the consent form. The Shaman is also to be present when the consent is signed. What is the best action by the nurse? A.Allow the Shaman to participate in the consent process and witness the form. B.Tell the client the Shaman must leave the room when the consent form is signed. C.Inform the client having the Shaman present when the consent is signed violates confidentiality. D.Allow the Shaman to be present when the consent form is signed but not participate in the consent process

d (Rationale:The client has the right to have the Shaman present in the room when the consent form is signed. The Shaman cannot participate in the consent process. The nurse would not ask the Shaman to leave the room)

A client who has recently begun working the night shift reports feelings of irritability and malaise. What will the nurse explain to the client regarding the symptoms? A.This is a sign of sleep deprivation and most likely will not improve. B.The symptoms are stress related and may be relieved by medication. C.This is a symptom of sleep apnea and the client should seek treatment for this. D.The symptoms are not uncommon and may resolve asthe client adjusts to the schedule

d (Rationale:The client is experiencing some mild symptoms of sleep deprivation, which are affecting circadian rhythm. Hypersomnia may result from sleep deprivation. Medication will not adjust circadian rhythms. The symptoms are not stress related in this case.)

Which action by the nurse demonstrates holism in the care of a client? A.The nurse administers all medications and treatments on time. B.The nurse makes sure to do complete teaching regarding pharmacological interventions. C.The nurse is able to prioritize the needs of the client assigned according to Maslow's hierarchy. D.The nurse considers how the loss of the client's job will affect the client manages his/her diabetes.

d (Rationale:The concept of holism emphasizes that nurses must keep the whole person in mind and strive to understand how one area of concern relates to the whole person. In this situation, the stress from a job loss will affect the person's chronic condition. The nurse must also consider the relationship of the individual to the external environment and to others.The rest of the options are only focused on the physiology of the person's condition, not the rest of the situation.)

What is the optimal position for a female client when providing peri-care? A.Prone. B.Side-lying. C.High-Fowler's. D.Dorsal recumbent

d (Rationale:The dorsal recumbent position provides full exposure of the female genitalia. The side-lying, prone, and high-Fowler's positions do not allow adequate exposure of the female genitalia)

A patient is given furosemide 40 mg orally at 0900. The duration of action for this drug is approximately 6 hours after oral administration. At which time in military hours should the nurse no longer expect to see the effects of this drug? A.0930 B.1000 C.1100 D.1500

d (Rationale:The nurse should no longer see the effects of furosemide around 1500 hours (3:00 p.m.). The effects of oral furosemide should be seen 30 to 60 minutes after administration, which is 0900 (9:30 a.m. in this case). Peak diuresis should occur in 1 to 2hours, which is 1000 hours (10:00 a.m.) to 1100 (11:00 a.m.) in the scenario above)

The nurse is providing diabetic diet teaching to a Hispanic man and his wife. When the nurse is discussing foods that are acceptable, the wife continues to interrupt with statements like, "Oh, he doesn't eat that," or, "All he eats is rice and beans." What should the nurse do? A.Ask the wife to leave the room so he/she can focus on teaching the client. B.Explain how "rice and beans" are not acceptable foods on a diabetic diet. C.Provide a diet plan with only food alternatives selected by the client. D.Refer the client and his wife to a dietitian familiar with Hispanic food choices

d (Rationale:The nurse should refer the client to speakwith a dietitian who is familiar with cultural food choices. If possible, he/she should develop a diet plan that includes the client's cultural diet preferences and can provide culturally sensitive teaching brochures that describe healthy food choices. Rice and beans may be acceptable alternatives in a balanced diet. The nurse should include people in the family who help shop for and prepare food in the home, along with the wife)

Where would the nurse place his/her hands when assisting a client from the sitting position to standing? A.Place hands around the client's shoulders. B.Place arms under the client's axillae. C.Place both hands around the closest arm. D.Place hands around the client's waist

d (Rationale:The nurse would place both hands at the client's waist because this is the center of gravity. The nurse would never lift the client from under the client's axilla because this can harm the client. Placing the hands on the client's arm or the shoulders will not provide sufficient support.)

The nurse is caring for a client who recently had surgery. The client's pain was 7 out of 10 before receiving pain medication. One hour after receiving an oral opioid, the client ranks his/her pain at 3 out of 10. The client asks the nurse why he/she isn't receiving more pain medication. Which is the nurse's best response? A."It's too early to give you any more pain medication right now." B."It is possible you are developing a tolerance to the pain medication." C."I will notify the health care if your pain doesn't improve in a few minutes." D."Let try getting you more comfortable in bed until time for your next dose of medication."

d (Rationale:The patient is responding well to the oral pain medication and it can take up to 2 hours for oral medications to relieve pain. Trying nonpharmacological interventions as an addition to opioid medications is appropriate at this time. If nonpharmacological interventions combined with the oral opioid are ineffective, the nurse needs to notify the health care provider and ask for a change in the medication or for additional pain medication. Saying that the patient has to wait 4 hoursfor additional pain medication is inaccurate because the nurse needs to provide further nursing interventions if pain is not relieved at an acceptable level for the patient. Admission to an intensive care unit is not typically necessary to manage pain following surgery for a hernia)

The nurse is preparing to transfer a client from the bed to the wheelchair. What is the priority action by the nurse? A.Place a gait (transfer) belt on the client. B.Place the wheelchair parallel to the bed. C.Lower both siderails on the same side as the wheelchair. D.Lock the brakes on both the wheelchair and the bed.

d (Rationale:The priority action is to lock the brakes on both the bed and the wheelchair. This helps prevent a fall. The nurse would lower the bottom siderail but not necessarily both side rails. The client may or may not need a gait or transfer belt. The nurse would place the chair at a slight angle facing the bed)

The nurse answers the client's call light to find the client agitated and stating that he/she "felt something pop." The nurse finds the client's abdominal surgical wound is open with intestines protruding. What isthe initial action by the nurse? A.Notify the surgeon using SBAR. B.Cover the wound with a dry sterile dressing. C.Try to reinsert the abdominal contents. D.Cover the wound with a moist saline dressing

d (Rationale:This is a surgical emergency, and the nurse needs to cover the wound with a moist saline dressing, immediately notify the surgeon, and prepare the patient for emergency surgery.)

The nurse is preparing medication for a 30-month-old child with otitis media in the right ear. The child weighs 33 pounds. The physician has ordered Keflex, 50 mg/kg/d in equally divided doses every 8 hours. The medication concentration is 250 mg/5 mL. How many milliliters should the nurse give the toddler for each dose? A.20 mL B.15 mL C.10 mL D.5 mL

d (Rationale:To calculate the correct dosage, the nurse first converts the child'sweight from pounds to kilograms by dividing weight in pounds by 2.2 (2.2 lb.= 1 kg). 33 pounds 2.2 pounds/kg = 15 kg. The child is to receive 50 mg for every kilogram. To determinethis child'sdosage multiply weight times daily dose (15 kg 50 mg/kg = 750 mg). Thus, 750 mg is to be administered in equally divided dosages every 8 hours, or 3 times a day. 750 mg 3 = 250 mg/dose. There is 250 mg in 5 mL of medication so the patient would be given 5 mL)

After instructing a mother about nutrition for a preschool-age child, which statement by the mother indicates a correct understanding of the topic? A."I usually give dessert only as a reward for eating other foods." B."I will serve more casseroles and stews to get my child to eat vegetables." C."I do not give my child snacks; children this age should eat only at mealtime." D.I know that lifelong food habits are developed during this stage of life."

d (rationale: Lifelong food habits are developed during the preschool stage of life. Therefore, the mother should widen the variety of foods she introduces to her child. Desserts should not be used as rewards for eating other foods as this encourages over-consumption. Preschool-age children often refuse combined foods (casseroles/stews). Because they are active, preschoolers require nutritious between meal snacks)