PassPoint - Basic Physical Care

The nurse has been teaching a client about a high-protein diet. The teaching is successful if the client identifies which meal as high in protein? 1. Baked beans, hamburger, and milk 2. Spaghetti with cream sauce, broccoli, and tea 3. Bouillon, spinach, and soda 4. Chicken cutlet, spinach, and soda

Correct response: Baked beans, hamburger, and milk Explanation: Beans, hamburger, and milk are all excellent sources of protein. The spaghetti-broccoli-tea choice is high in carbohydrates. The bouillon-spinach-soda choice provides liquid and sodium as well as some iron, vitamins, and carbohydrates. Chicken provides protein but the chicken-spinach-soda combination provides less protein than the beans-hamburger-milk selection.

A client rings a call bell to request pain medication. Upon performing the pain assessment, the nurse informs the client that the nurse will return with the pain medication. The nurse's promise to return with the pain medication is an example of which principle of bioethics? 1. fidelity 2. autonomy 3. nonmaleficence 4. justice

Correct response: fidelity Explanation: Fidelity is keeping one's promises and never abandoning a client entrusted to care without first providing for the client's needs. Autonomy respects the rights of clients or their surrogates to make healthcare decisions. Nonmaleficence is avoiding causing harm. Justice involves giving each his or her due and acting fairly.

A nurse is helping a client with meal choices for a low-potassium diet. Which breakfast selection indicates to the nurse that the client understands the diet? 1. scrambled eggs, toast, and tea 2. bacon, toast, and orange juice 3. cantaloupe, raisin bran, and skim milk 4. banana, toast, and whole milk

Correct response: scrambled eggs, toast, and tea Explanation: Eggs, bread, and tea are foods that have low potassium content. The other foods are high in potassium.

When receiving a client assignment, which assignment should the licensed practical nurse (LPN) recognize as being outside of the LPN scope of practice? Select all that apply. 1. initiating a blood transfusion 2. completing an initial admission assessment 3. reinforcing teaching about insulin administration 4. performing wound care on a surgical wound 5. suctioning a client with a tracheostomy

Correct response 1. initiating a blood transfusion 2. completing an initial admission assessment Explanation: Initiating blood transfusions and completing initial admission assessments are under the scope of practice for registered nurses. Wound care, reinforcing teaching about insulin administration, and suctioning are within the scope of practice for LPNs.

The nurse is performing her morning assessment when the client says, "I had trouble sleeping last night." Which action should the nurse take first? 1. Recommending warm milk or a warm shower at bedtime 2. Gathering more information about the sleep problem 3. Determining whether the client is worried about something 4. Finding out whether the client is taking medication that may impede sleep

Correct response: Gathering more information about the sleep problem Explanation: The nurse first should determine what the client means by "trouble sleeping." The nurse lacks sufficient information to recommend warm milk or a warm shower or to make inferences about the cause of the sleep problem, such as worries or medication use

During discharge teaching, a client with a fractured toe asks the emergency department nurse why ice should be applied to the fracture site. The nurse should explain that ice application has which effect? 1. Maintains proper bone alignment 2. Relieves swelling by reducing blood flow to the injury site 3. Helps prevent skin maceration at the injury site 4. Reduces pain by promoting vasodilation at the injury site

Correct response: Relieves swelling by reducing blood flow to the injury site Explanation: Applying ice to the injury site soon after an injury causes vasoconstriction, helping to relieve or prevent swelling and bleeding. The other options are inaccurate descriptions of the effects of ice application.

A nurse is caring for a client with a history of falls. Which interventions take priority in this client's care? Select all that apply. 1. Place the call light within the client's reach. 2. Keep the bed in the lowest possible position. 3. Implement neurological checks every 4 hours. 4. Encourage the client change positions frequently while in bed. 5. Provide immediate response to the client's toileting needs. 6. Assign security personnel to sit outside of the client's door.

Correct response: 1. Place the call light within the client's reach. 2. Keep the bed in the lowest possible position. 5. Provide immediate response to the client's toileting needs. Explanation: Keeping the bed in the lowest possible position, placing the call light within reach, instructing the client not to get out of bed, and responding to the client toileting needs promptly are all fall reduction/prevention measures. Neurological checks and security personnel placed outside the door are not fall reduction/prevention measures.

A nurse is assisting with developing a care plan for a client with Hepatitis A. What is the main route of transmission of this virus? 1. sputum 2. feces 3. blood 4. urine

Correct response: feces Explanation: The hepatitis A virus is transmitted by the fecal-oral route, primarily through ingestion of contaminated food or liquids. It isn't transmitted via sputum, blood, or urine.

Which guidelines define and regulate what the nurse may and may not do as a professional? 1. state legislature 2. facility policies and procedures 3. standards of care 4. nurse practice act

Correct response: nurse practice act Explanation: Each state legislature has enacted a nurse practice act. These statutes outline the legal scope of nursing practice within a particular state. State boards of nursing oversee the statutory law. State legislatures create boards of nursing within each state; the state legislature itself doesn't regulate the scope of nursing. Facility policies govern the practice within a particular facility. Nurse practice acts set educational requirements for the nurse, distinguish between nursing practice and medical practice, and define the scope of nursing practice in that state. Standards of care, criteria that serve as a basis for evaluating the quality of nursing practice, are established by federal organizations, accreditation organizations, state organizations, and professional organizations.

A train accident sends a large number of injured passengers to the hospital. The hospital's disaster plan is put into effect. Which nursing action would best serve the hospital in this disaster situation? 1. perform duties as outlined in the disaster plan 2. volunteer to help where assistance is most needed 3. offer advice about how to run the facility smoothly 4. implement tasks that are beyond the scope of practice

Correct response: perform duties as outlined in the disaster plan Explanation: Before a disaster occurs, the nurse should know how the hospital's disaster plan works and what he or she will be required to do. During a disaster, the charge nurse will assign staff to areas where they are needed; therefore, a nurse could be required to perform tasks outside of the usual duties. This practice is permitted if the nurse has the knowledge, skill, and comfort level to perform the assigned tasks. However, the nurse should never perform medical procedures outside of the scope of practice as outlined in the state's Nurse Practice Act.

A licensed practical nurse (LPN) is assisting with the admission of a client to the medical-surgical unit. While gathering data about the client, the LPN asks the client if an advance directive has been prepared. The client responds, "I don't know what you mean." Which response by the nurse would be most appropriate? 1. "An advance directive is a document that states your wishes about health care." 2. "An advance directive tells us your wishes should you die during hospitalization." 3. "An advance directive explains how you want your finances used should you become disabled." 4. "An advance directive states your wishes concerning what to do with your personal items."

Correct response: "An advance directive is a document that states your wishes about health care." Explanation: An advance directive is a written document that states a client's health care wishes regarding withdrawing treatment, resuscitation measures, life support, and end-of-life care. Wishes related to dying, finances, and personal items pertain to a last will and testament, not an advance directive.

The licensed practical nurse is teaching a client with right-sided weakness proper cane use. Which instruction should the nurse include in her teaching? 1. "Hold the cane on the same side as the injury." 2. "Hold the cane on the opposite side from the injury." 3. "Don't use the cane when climbing stairs." 4. "Use the cane when walking further than 50 feet."

Correct response: "Hold the cane on the opposite side from the injury." Explanation: The nurse should instruct the client to hold the cane in the hand opposite the affected extremity; the only exception is when the client is physically unable to hold the cane in that hand. A cane helps maintain balance; so the client should be encouraged to use the cane when navigating stairs. The cane should be used when walking any distance to prevent injury from falls.

A nurse enters a client's room and finds a pillowcase on fire where it was placed over a table lamp. Which action should the nurse perform first? 1. Call for help. 2. Use the fire extinguisher. 3. Remove the client from the room. 4. Put a heavy blanket over the lamp.

Correct response: Remove the client from the room. Explanation: The acronym RACE promotes the safest sequence of response to fire. The letters stand for Remove the client from the scene, Activate the alarm, Contain the fire, and Extinguish the blaze.

The nurse needs to pick up a large object that is sitting on the floor in a client's room. Which action most increases the nurse's risk of a back injury? 1. moving close to the object 2. leaning forward toward the object 3. using the arms and legs to lift the object 4. bringing the body close to the level of the object

Correct response: leaning forward toward the object Explanation: Leaning forward causes the line of gravity to fall outside the base, encouraging the development of a back injury. Actions to reduce the development of a back injury include moving close to the object, using the large muscles of the arms and legs to lift the object, and bringing the body close to the level of the object.

A nurse places a client who is suspected of having tuberculosis in isolation. Which part of the chain of infection do isolation techniques interfere with? 1. transmission mode 2. agent 3. susceptible host 4. portal of entry

Correct response: transmission mode Explanation: Isolation techniques attempt to break the chain of infection by interfering with the transmission mode. These techniques do not affect the agent, host, or portal of entry.

The nurse observes the unlicensed assistive personnel (UAP) delivering a food tray to the client prescribed a clear liquid diet. The nurse would intervene when which food product is seen on the food tray? 1. cranberry juice 2. vanilla yogurt 3. iced coffee 4. chicken broth

Correct response: vanilla yogurt Explanation: Yogurt is found in full liquid diets. A clear liquid diet includes clear juices, such as cranberry juice, coffee, tea, water, and broth.

A client, age 43, has no family history of breast cancer or other risk factors for this disease. The nurse should instruct her to have a mammogram how often? 1. Once, to establish a baseline 2. Once per year 3. Every 2 years 4. Twice per year

Correct response: Once per year Explanation: The American Cancer Society (Canadian Cancer Society) recommends having a mammogram every year starting at age 40. Women at increased risk (those with a family history, genetic tendency, or history of breast cancer) should talk to their physicians about beginning screening earlier than age 40.

A client who's scheduled for surgery asks the nurse to keep $50 for him until he returns from surgery. How should the nurse respond? 1. "I'll put your money in an envelope and keep it in my locker until you return from surgery." 2. "I'll notify your physician about the money." 3. "I'll notify the business office to make arrangements for your money to be placed in the hospital safe." 4. "You can place your the money in your bedside drawer; it will be safe there."

Correct response: "I'll notify the business office to make arrangements for your money to be placed in the hospital safe." Explanation: It's the nurse's obligation to keep the client's belongings safe, but she shouldn't personally keep the money for the client. Instead, the nurse should notify the business office and make arrangements for the client's money to be placed in the hospital safe. The physician doesn't require notification that the client has money in his possession. Placing the client's money in the bedside drawer doesn't keep the money secure.

An LVN/LPN working on a busy unit decides to delegate some tasks to the unlicensed assistive personnel (UAP). Which client tasks can be delegated to the UAP? Select all that apply. 1. positioning a client 2. vital signs on critical clients 3. pharyngeal suctioning 4. intake and output measurement 5. ambulation of a client

Correct response: 1. positioning a client 4. intake and output measurement 5. ambulation of a client Explanation: The nurse cannot delegate tasks that require nursing judgment. Vital signs on critical clients and suctioning require nursing judgment. Positioning, intake and output, and ambulation do not require nursing judgment.

A nurse, assigned to a client with emphysema, is providing shift report. Which nursing interventions would be appropriate to include? Select all that apply. 1. The nurse should reduce fluid intake to less than 850 mL per shift. 2. The nurse should teach diaphragmatic, pursed-lip breathing. 3. The nurse should administer low-flow oxygen. 4. The nurse should keep the client in a supine position as much as possible. 5. The nurse should encourage alternating activity with rest periods. 6. The nurse should teach the use of postural drainage and chest physiotherapy.

Correct response: 2. The nurse should teach diaphragmatic, pursed-lip breathing. 3. The nurse should administer low-flow oxygen. 5. The nurse should encourage alternating activity with rest periods. 6. The nurse should teach the use of postural drainage and chest physiotherapy. Explanation: Diaphragmatic, pursed-lip breathing strengthens respiratory muscles and enhances oxygenation in clients with emphysema. Low-flow oxygen should be administered because a client with emphysema has chronic hypercapnia and a hypoxic respiratory drive. Alternating activity with rest allows to perform activities without excessive distress. If the client has difficulty mobilizing copious secretions, the nurse should teach the client and family members how to perform postural drainage and chest physiotherapy. Fluid intake should be increased to 3,000 mL/day, if not contraindicated, to liquefy secretions and facilitate their removal. The client should be placed in high Fowler's position to improve ventilation.

A client has a prescription for a low-fat diet. When reviewing the client's food diary, which food items would the nurse suggest that client eliminate from their diet? Select all that apply. 1. steamed broccoli 2. broiled haddock 3. cream cheese 4. beef sausage 5.Milk chocolate

Correct response: 3. cream cheese 4. beef sausage 5.Milk chocolate Explanation: Creamed cheese, processed meats (beef sausage), and chocolate are high in fats. Fruits and vegetables (broccoli) and broiled haddock are low in fats.

A client with renal failure is placed on a potassium-restricted diet. For lunch, the client consumed 6 oz (168 g) of hamburger on a bun, one cup of cooked broccoli, a rawpear, and iced tea. Using the chart provided, calculate how many milliequivalents of potassium were in this meal. 1. 24.4 2. 30 3. 31.4 4. 37

Correct response: 37 Explanation: According to the chart, 4 oz of beef contains 11.2 mEq of potassium. Add 5.6 mEq for the additional 2 oz for a total of 16.8 mEq of potassium in the beef. The amount of potassium in one cup of broccoli is 14 mEq. A pear has 6.2 mEq. Thus, the total amount of potassium in this meal is 37 mEq. The iced tea and bun do not contain significant amounts of potassium and, therefore, are not listed on the chart

The nurse is recording the intake and output for a client with the following: D5NSS 1,000 mL; urine 450 mL; emesis 125 mL; Jackson Pratt drain #1 35 mL; Jackson Pratt drain #2 32 mL; and Jackson Pratt drain #3 12 mL. How many milliliters should the nurse document as the client's output? Record your answer using a whole number.

Correct response: 654 Explanation: The nurse must add all the output volumes together: 450 mL + 125 mL + 35 mL + 32 mL + 12 mL = 654 mL. D5NSS 1,000 mL is considered input, not output.

A nurse-manager is reviewing incidents that occurred recently. For which event will the manager need to make a report to the board of nursing? 1. A client falls from bed when the nurse did not raise the side rails after providing care. 2. A nurse documents administering narcotics to a client while personally using the medication. 3. A home health nurse notifies a primary care provider of a decline in client health. 4. A client develops a urinary tract infection after several days with an indwelling catheter.

Correct response: A nurse documents administering narcotics to a client while personally using the medication. Explanation: Nurse practice/health profession acts regulate nursing licensure and practice. Each state, province, or territory has its own legislation. Violations of criminal law, such as possession of controlled substances, assault, battery, negligence, and rape, must be reported to the board of nursing as well as the police. Most cases of malpractice fall within the realm of civil law.

A nurse is working within the managed care delivery model. Which is true regarding managed care? 1. All plans have the same values underlying the delivery of care. 2. Their values are not reflected in the decision making. 3. All systems reflect the values of efficiency and effectiveness. 4. There are no conflicts between cost-effectiveness and respectful care.

Correct response: All systems reflect the values of efficiency and effectiveness. Explanation: All systems in the managed care delivery model reflect the values of efficiency and effectiveness. Different plans may have different values underlying the delivery of care. However, they all reflect the business plan values of efficiency and effectiveness. Their values are reflected in the decision making and the policy development of the organization. Value conflicts between cost-effectiveness and respectful care may be seen.

A client recovering from a stroke has slid down in bed and needs to be repositioned. Which action should the nurse take to ensure safety for both the client and the nurse? 1. Roll the client side to side. 2. Ask for assistance from the lift team. 3. Raise the head of the bed before repositioning. 4. Stand at the head of the bed and slide the client toward the pillow.

Correct response: Ask for assistance from the lift team. Explanation: A safe and effective approach to client repositioning is the use of a lift team. When using a team, a group of care providers share the weight of the client, reducing the risk of personal injury, and providing a safe method of repositioning the client. Rolling the client side to side is not a correct action to reposition a client in bed. The bed should be flat when repositioning a client. Raising the head of the bed will cause the client to slide further down in the bed. Any attempts at repositioning will be difficult because of the client's angle in the bed. Standing at the head of the bed and sliding the client toward the pillow is also not an appropriate method to reposition a client in bed.

A client is prescribed acetaminophen by mouth every 4 hours as needed for headache. Which factor in the client's medical history would cause the nurse to question this order? 1. Duodenal ulcer 2. Cirrhosis 3. Allergy to salicylates 4. Bleeding disorder

Correct response: Cirrhosis Explanation: Acetaminophen can cause liver failure, so the nurse should question its use in a client with a history of cirrhosis. An order for aspirin should be questioned in a client with a history of duodenal ulcer, salicylate allergy, or bleeding disorder.

The nurse is aware that Standard Precautions represent the first tier of Centers for Disease Control guidelines for isolation precautions. Which is the nurse's primary responsibility when following Standard Precautions? 1. Wear gloves for all contact with the client. 2. Consider all body substances potentially infectious. 3. Place a body substance isolation sign on the client's door. 4. Wear gloves and a gown whenever caring for the client.

Correct response: Consider all body substances potentially infectious. Explanation: Standard precautions are based on the concept that all body substances are potentially infectious and direct contact with them must be avoided. The nurse should wear gloves when contact with body substances — not unsoiled articles or intact skin — is anticipated. Because all body substances from all clients are considered potentially infectious, signs on doors are unnecessary. Gloves and gowns are necessary only when contact with body fluids is likely.

Two nurses are working the night shift on a medical unit. The first nurse completes an initial shift assessment on assigned clients. One hour later, the second nurse finds the first nurse asleep in the lounge. The first nurse remains asleep for the next 4 hours and then wakes up to do client rounds. What should the second nurse do in this situation? 1. Cover by assessing the first nurse's patients hourly. 2. Nothing; the first nurse's patients did not call for assistance. 3. Discuss the situation with the first nurse, including the safety implications of sleeping on the job. 4. Ask the nurse on the day shift to report the situation to the nurse manager.

Correct response: Discuss the situation with the first nurse, including the safety implications of sleeping on the job. Explanation: The second nurse is responsible for immediately discussing this behavior and its safety implications with the first nurse. The other options do not demonstrate behavior representative of advocating for safe and competent care.

The nurse is assisting a healthcare provider in debriding a necrotic skin wound. The healthcare provider is using a plastic basin to collect the bloody supplies. When cleaning the area on completion of debridement, which nursing action is done after placing the supplies in a hazardous material bag? 1. Wash the basin in hot, soapy water. 2. Dispose of the plastic basin. 3. Spray the basin with a disinfectant agent. 4. Clean the basin with an antiseptic agent.

Correct response: Dispose of the plastic basin. Explanation: The plastic basin would be disposed of. Hot water causes the protein materials to stick to the basin. The basin does not need to be disinfected. An antiseptic is used to limit bacteria on the skin. Plastic emesis basins are disposable. The nurse would obtain a new one for the room.

A client is scheduled for a bronchoscopy. Pre-procedure, the nurse should instruct the client to avoid which activity? 1. Walking 2. Coughing 3. Talking 4. Eating

Correct response: Eating Explanation: Bronchoscopy involves visualization of the trachea and bronchial tree. To prevent aspiration of stomach contents into the lungs, the nurse should instruct the client not to eat or drink anything for approximately 6 hours before the procedure. It isn't necessary for the client to avoid walking, talking, or coughing.

Which nursing action best addresses the outcome: The client will be free from falls? 1. Use large muscle group when transferring client from bed to chair. 2. Encourage use of grab bars and railings in the bathroom and halls. 3. Limit use of the stairs. 4. Install a monitoring system to help the client in an emergency situation.

Correct response: Encourage use of grab bars and railings in the bathroom and halls. Explanation: To address the client outcome of being free from falls, it is best to place assistive devices of grab bars especially in the bathroom and railings in the halls and on the stairs to promote balance. Focusing on how to transfer a client is a nursing-focused action, not a client-focused action. It is important to place an emergency contact number close by and have an emergency monitoring system; however, they will not prevent falls. Although limiting the use of stairs decreases the potential of falls, any time that stairs are used creates a fall possibility.

A nurse is caring for a client who is receiving a lumbar epidural anesthetic block to control labor pain. Which action would be most appropriate for the nurse to do to prevent hypotension? 1. Assist with monitoring when client receives ephedrine to raise blood pressure. 2. Administer oxygen at 3 L/minute using a nasal cannula. 3. Place the client flat on her back with her legs raised. 4. Ensure adequate hydration before the anesthetic is administered.

Correct response: Ensure adequate hydration before the anesthetic is administered. Explanation: For the client in a state of relative hypovolemia, administering IV fluids before the epidural anesthetic is given may prevent hypotension. An epidural anesthetic may lead to hypotension because blocking the sympathetic fibers in the epidural space reduces peripheral resistance. Ephedrine may be administered after an epidural block if a client becomes hypotensive and shows evidence of cardiovascular decompensation; however, it is not administered to prevent hypotension. Oxygen is administered to a client who becomes hypotensive, but it does not prevent hypotension. Placing a pregnant client in the supine position can contribute to hypotension because it leads to uterine pressure on the great vessels.

A nurse is caring for a client who underwent a retinal detachment repair using an air bubble. The nurse is informed by the health care provider to "Keep client in prone position." Which action should the nurse take? 1. Call the health care provider to report that the prescription is in error and must be reviewed. 2. Follow the prescription because this position will help keep the retinal repair intact. 3. Instruct the client to maintain this position while awake but to sleep lying flat. 4. Assume the dressing should be changed at bedtime and allow the client to lie flat.

Correct response: Follow the prescription because this position will help keep the retinal repair intact. Explanation: During retinal detachment repair, an air bubble is typically injected into the eye to provide added pressure. Postoperative positioning of the client is critical because the injected bubble must float into position over the area of detachment. The client must maintain a prone position which allows the bubble to act as a tamponade for the retinal detachment. The position should be maintained until the health care provider evaluates how well the retina is adhering to the choroid.

A nursing instructor is instructing a group of new nursing students. The instructor reviews that surgical asepsis will be used for which procedure? 1. instilling eye drops 2. nasogastric tube irrigation 3. IV catheter insertion 4. colostomy irrigation

Correct response: IV catheter insertion Explanation: Caregivers must use surgical asepsis when performing wound care or any procedure that involves entering a sterile body cavity or breaking skin integrity. To achieve surgical asepsis, objects must be sterilized or kept free of all pathogens. Because inserting an IV catheter disrupts skin integrity and involves entry into a sterile cavity (a vein), surgical asepsis is required. Medical asepsis is used when instilling eye drops. The GI tract isn't sterile; therefore, irrigating a nasogastric tube or a colostomy requires only clean technique.

A client on prolonged bed rest has developed a pressure ulcer. The wound shows no signs of healing even though the client has received appropriate skin care and has been turned every two hours. Which factor would the nurse assume is most likely responsible for the failure to heal? 1. Inadequate vitamin D intake 2. Inadequate protein intake 3. Inadequate massaging of the affected area 4. Low calcium level

Correct response: Inadequate protein intake Explanation: Clients on bed rest suffer from a lack of movement and a negative nitrogen balance. Therefore, inadequate protein intake impairs wound healing. Inadequate vitamin D intake and low calcium levels are not factors in poor healing for this client. A pressure ulcer should never be massaged.

A client is admitted to the emergency department with a closed head injury after being found unconscious. Based on information from the client's neighbor, the staff suspects intimate partner violence. The client has a restraining order against the spouse, but the spouse repeatedly attempts to visit the client. Which action should the nurse take? 1. Place the client in a room near the nursing station with a sign on the door restricting visitors. 2. Assign security personnel to be at the client's bedside at all times. 3. Admit the client to under an assumed name and post sign on door restricting visitors. 4. Inform hospital security personnel of the restraining order and description of spouse.

Correct response: Inform hospital security personnel of the restraining order and description of spouse. Explanation: The nurse should inform hospital security personnel about the restraining order and formulate an action plan with security that protects the client. The nurse does not have the authority to assign security personnel to be at the client's bedside. Measures should be in place to stop the spouse before he enters the unit, and a sign on the client's door could actually alert the spouse to the client's location. Admitting the client under an assumed name would require the client's consent and additional supervisor approval.

The nurse must apply a wet-to-dry dressing over an ulcer on a client's left ankle. How should the nurse proceed? 1. Apply the saturated fine-mesh gauze dressings over the wound. 2. Apply an occlusive dressing over the saturated fine-mesh gauze dressings. 3. Cover the saturated fine-mesh gauze dressings with an elastic bandage. 4. Lightly pack the moistened fine-mesh gauze dressings into all depressions and grooves of the wound.

Correct response: Lightly pack the moistened fine-mesh gauze dressings into all depressions and grooves of the wound. Explanation: The nurse should lightly pack the moistened fine-mesh gauze dressings into all depressions and grooves of the wound because necrotic tissue usually is more prevalent in those areas. Wound packing facilitates wound healing. The nurse should wring out excess moisture from saturated fine-mesh gauze dressings because saturated dressings won't dry properly. The nurse shouldn't apply an occlusive dressing or elastic bandage because they can prevent air circulation and hinder drying of the fine-mesh gauze.

The nurse is caring for a client who has a history of falling at home. Which intervention by the nurse reduces the risk of falling while the client is hospitalized? 1. Leaving the bed elevated after changing linens 2. Keeping all side rails up when the client is in bed 3. Applying a vest restraint when the client is in bed 4. Placing the call bell close to the client and reminding the client to call for assistance with ambulation

Correct response: Placing the call bell close to the client and reminding the client to call for assistance with ambulation Explanation: The nurse can help reduce the risk of falls by placing the call bell within the client's reach and reminding the client to call for assistance with ambulation. Leaving the bed elevated increases the risk of injury from falls. Keeping all side rails up also places the client at risk because the client may attempt to get out of bed unassisted by climbing over the side rails. The nurse should keep one side rail down to control this risk. Restraints haven't been shown to reduce the risk of falls and should be used only as a last resort.

A client is admitted to the health care facility with active tuberculosis (TB). The nurse should include which intervention in the plan of care? 1. Putting on an individually fitted N95 respiratory or high-efficiency particulate air (HEPA) respirator when entering the client's room 2. Instructing the client to wear a mask at all times 3. Wearing a gown and gloves when providing direct care 4. Keeping the door to the client's room open to observe the client

Correct response: Putting on an individually fitted N95 respiratory or high-efficiency particulate air (HEPA) respirator when entering the client's room Explanation: Because TB is transmitted by droplet nuclei from the respiratory tract, the nurse should put on an N95 respirator or a HEPA respirator when entering the client's room. Occupation Safety and Health Administration standards require an individually fitted respirator. Having the client wear a mask at all times would hinder sputum expectoration and make the mask moist from respirations. If no contact with the client's blood or body fluids is anticipated, the nurse need not wear a gown or gloves when providing direct care. A client with TB should be in a room with laminar airflow, and the room's door should be closed at all times.

The nurse is caring for a client with a nasogastric tube and in mitt restraints. Which nursing action is required every 1 to 2 hours? 1. Assist the client to the bathroom. 2. Assess cognitive status. 3. Offer the client sips of clear liquids. 4. Remove restraints and assess skin and circulation.

Correct response: Remove restraints and assess skin and circulation. Explanation: Placing a client in any type of restraint is a controversial issue. Strict guidelines exist. The client in restraints must have the skin integrity and circulation assessed every 1-2 hours. It is also appropriate to massage the area and provide range of motion exercises. On a regular basis, the client would be offered to use a bedpan or ambulate to the bathroom and the nurse would assess the cognitive status. A client with a nasogastric tube would not be offered fluids.

The infection control nurse is making rounds to ensure that airborne precautions are being observed while caring for clients with tuberculosis. Which action by the staff nurse requires further education? 1. The nurse double-bags respiratory secretions. 2. The nurse dons a surgical isolation mask when entering the client's room. 3. The nurse gathers disposable client care items. 4. The client's meals are served on disposable trays.

Correct response: The nurse dons a surgical isolation mask when entering the client's room. Explanation: When entering the room of a client with tuberculosis, the nurse should wear an N95 particulate respirator mask because surgical isolation masks allow tubercle bacilli to pass through. All trash and waste should be disposed of as infectious waste. All client care items and meal trays should be disposable.

A nurse prepares to transfer a client from a bed to a chair. Which principle demonstrates safe body mechanics? 1. The nurse stands an arm's length away from the client. 2. The nurse uses a rocking motion while helping the client to stand. 3. The nurse keeps knees straight and stiff and bends at the waist. 4. The nurse keeps feet as close together as possible.

Correct response: The nurse uses a rocking motion while helping the client to stand. Explanation: Rocking provides extra force when pushing or pulling. The nurse should keep any weight as close to the nurse's body as possible when lifting — not at arm's length. The nurse should keep knees slightly bent and feet spread apart to provide a wide base of support. Keeping the knees straight and stiff and bending at the waist and keeping the feet close together aren't examples of safe body mechanics. These positions could result in injury to the nurse or to the client.

The nurse finds the family member of a client in the nutrition room standing in a puddle of water holding the microwave door, shaking. What should the nurse do first? 1. Pull client from the pool of water. 2. Activate the emergency response team. 3. Obtain vital signs. 4. Unplug the microwave.

Correct response: Unplug the microwave. Explanation: For the safety of the nurse and to prevent further injury to the client, the first action is to unplug the microwave. Pulling the client from the pool without removing the source of the electricity endangers the nurse as well. The emergency response system can be activated after the source of electricity is unplugged. Vital signs can be obtained after all the other activities are done. The priority here is the safety of the nurse and the client.

A client with a history of heart failure is at risk for fluid volume excess. Which nursing intervention would ensure the most accurate monitoring of the client's fluid status? 1. Measuring and recording fluid intake and output 2. Weighing the client at the same time each day 3. Assessing vital signs every 4 hours 4. Checking the lungs for crackles every shift

Correct response: Weighing the client at the same time each day Explanation: Increased fluid volume leads to rapid weight gain — 2.2 lb (1 kg) for each liter of fluid retained. Weighing the client daily at the same time and with the client wearing similar clothing provides more objective data than measuring fluid intake and output, which may be inaccurate because of omitted measurements such as insensible losses. Changes in vital signs are less reliable because they usually are subtle during early stages of fluid retention. Although crackles indicate fluid accumulation in the lungs, weight gain is an earlier sign than crackles, which represent pulmonary edema. The nurse should plan to detect fluid accumulation before pulmonary edema occurs.

The nurse is caring for a client who required chest tube insertion for a pneumothorax. To assess a client for pneumothorax resolution after the procedure, the nurse can anticipate that he'll require: 1. monitoring of arterial oxygen saturation (SaO2). 2. arterial blood gas (ABG) studies. 3. chest auscultation. 4. a chest X-ray.

Correct response: a chest X-ray. Explanation: Chest X-ray confirms whether the chest tube has resolved the pneumothorax. If the chest tube hasn't resolved the pneumothorax, the chest X-ray will reveal air or fluid in the pleural space. SaO2values may initially decrease with a pneumothorax but typically return to normal in 24 hours. ABG levels may show hypoxemia, possibly with respiratory acidosis and hypercapnia not related to a pneumothorax. Chest auscultation will determine overall lung status, but it's difficult to determine if the chest is re-expanded sufficiently.

A nurse working in the postanesthesia care unit is caring for multiple postoperative clients . Which task could be delegated to unlicensed assistive personnel (UAP)? 1. monitor vital signs 2. assess level of consciousness 3. check surgical site for bleeding 4. apply sequential compression device to the client's leg

Correct response: apply sequential compression device to the client's leg Explanation: The nurse cannot delegate a task that requires nursing judgment. Vital signs in the immediate postoperative period and assessment requires nursing judgment. Checking the surgical site postoperatively is also considered an assessment. Application of a venous compression device does not require nursing judgment and can be safely delegated to the UAP.

A nurse is caring for a client who's receiving enteral feedings through a feeding tube. Before each tube feeding, the nurse checks for tube placement in the stomach as well as for residual volume. The purpose of the nurse's actions is to prevent which life-threatening complication? 1. gastric ulcers 2. aspiration 3. abdominal distention 4. diarrhea

Correct response: aspiration Explanation: Protecting the client who's receiving enteral feedings through a feeding tube from aspiration is essential because aspiration can cause pneumonia, a potentially life-threatening condition. Gastric ulcers aren't a common complication of tube feedings in clients with endotracheal or tracheostomy tubes. Abdominal distention and diarrhea are both associated with tube feedings, but neither is immediately life-threatening.

A client who's a member of Jehovah's Witnesses refuses a blood transfusion based on religious beliefs and practices. The client's decision must be followed based on which ethical principle? 1. the right to die 2. advance directive 3. autonomy of the client 4. substituted judgment

Correct response: autonomy of the client Explanation: The right to refuse treatment is grounded in the ethical principle of respect for the autonomy of the individual. The client has the right to refuse treatment as long as they are competent and aware of the risks and complications associated with that refusal. The right to die is a difficult decision involving whether to initiate or withhold life-sustaining treatment for a client who is irreversibly comatose, vegetative, or suffering with end-stage terminal illness. The client may have signed an advance directive, making their wishes known. An advance directive is a document that provides guidelines for starting or continuing life-sustaining medical care, generally for a client who has a terminal disease or disability and can't indicate their own wishes. Substituted judgment is an ethical principle used when a nurse makes a decision based on what's best for an incapacitated client.

While hospitalized, a child develops a Clostridium difficileinfection. The nurse can anticipate adding which type of precautions for this client? 1. standard precautions 2. airborne precautions 3. droplet precautions 4. contact precautions

Correct response: contact precautions Explanation: Contact precautions are used for serious illnesses that are easily transmitted by direct client contact or by contact with items in the client's environment. Clostridium difficile infection is an example of an infection that is spread in this manner. Droplet precautions are used for serious illnesses transmitted by large particle droplets. Standard precautions are used for all clients. Airborne precautions are used for suspected illnesses transmitted by airborne nuclei.

A nurse is faxing client information to a nursing home. Which action should the nurse take to maintain client confidentiality? 1. determining that the client has authorized release of the information 2. making sure the client's name and date of birth are displayed on the fax cover sheet 3. reading all information to the client before faxing 4. obtaining a written order from the client's primary physician to fax the information

Correct response: determining that the client has authorized release of the information Explanation: A nurse must obtain client authorization before sending any confidential information to a nursing home or other facility. A client's name and other protected information should never appear on a fax cover sheet. It isn't necessary to read the information to the client before sending it. A physician's order doesn't give a nurse the right to send confidential information without the client's permission.

A nurse is removing an indwelling urinary catheter. Which nursing action reflects the best technique? 1. wear sterile gloves 2. cut the lumen of the balloon 3. document the time of removal 4. position the client on his left side

Correct response: document the time of removal Explanation: The client should void within 8 hours of the removal of an indwelling urinary catheter. Documenting the time of removal allows the nurse and health care provider to verify the duration of elapsed time since removal, thus contributing to continuity of care. Clean, disposable gloves are required because it isn't a sterile procedure. If the balloon is cut from the lumen and the catheter isn't secured, the catheter may retrograde into the bladder, requiring surgical removal. The client should be positioned comfortably on his back, and privacy should be provided.

A nurse is preparing a client with Crohn's disease for a barium enema. What should the nurse do the day before the test? 1. allow the client to have a full liquid diet 2. obtain a high-fiber diet for the client 3. encourage increased oral fluid intake 4. offer the client high calorie foods

Correct response: encourage increased oral fluid intake Explanation: Adequate fluid intake is necessary to avoid dehydration, which may be caused by the barium enema bowel preparation, and to prevent fecal impaction after the procedure. The client may be placed on a low-residue diet 1 to 2 days before the procedure to reduce the contents in the GI tract. Fiber intake is limited in a low-residue diet. Only clear liquids are allowed the evening prior to a barium enema. High caloric foods are foods that are high in carbohydrate and fat content, which leaves residue in the intestines and should be avoided the day before the test.

The nurse is caring for a 73-year-old client with a history of arthritis who was admitted after suffering a stroke. The stroke has made communication difficult for the client. Which pain assessment tool should the nurse use for this client? 1. number scale from one to ten 2. face rating scale 3. body diagram 4. questionnaire

Correct response: face rating scale Explanation: The face rating scale, which depicts five or more faces with expressions that range from happy to very unhappy, is the best way for this client to communicate level of pain because he/she can simply point to the face that illustrates how he/she is feeling. A number scale, body diagram, or questionnaire may be difficult for this client to use.

When caring for a client with a 3-cm stage II pressure ulcer on the coccyx, which action can the nurse institute independently? 1. cleaning the wound three times per day with a povidone-iodine wash 2. gently irrigating the wound with a normal saline solution and applying a protective dressing as necessary 3. applying an antibiotic cream to the area three times per day 4. cleaning the wound with a wound cleanser and applying a hydrogel wound dressing

Correct response: gently irrigating the wound with a normal saline solution and applying a protective dressing as necessary Explanation: Gently irrigating the area with normal saline solution and applying a protective dressing are within the nurse's realm of interventions and will protect the area. Using a povidone-iodine wash, an antibiotic cream, and a hydrogel wound dressing require a physician's order.

In the delivery of care, the nurse acts in accordance with nursing standards and the code of ethics and reports a medication error that the nurse has made. The nurse is most clearly demonstrating which professional values? 1. integrity 2. altruism 3. social justice 4. human dignity

Correct response: integrity Explanation: The nurse is demonstrating integrity which is defined as acting in accordance with an appropriate code of ethics and accepted standards of practice. Seeking to remedy errors made by self or others is an example of integrity. Altruism is a concern for the welfare and being of others. Social justice is upholding moral, legal, and humanistic principles. Human dignity is respect for the inherent worth and uniqueness of individuals and populations.

The nurse administers sublingual nitroglycerin to a client who reports chest pain. Which client symptom should the nurse report immediately? 1. irregular heart beat 2. throbbing headache 3. dizziness when standing 4. burning under the tongue

Correct response: irregular heart beat Explanation: An irregular heartbeat is a serious adverse side effect of nitroglycerine therapy and should be reported to the primary care provider. Headache, dizziness, and a burning sensation under the tongue commonly occur at the beginning of nitroglycerin therapy; however, clients typically develop a tolerance to the drug as therapy continues.

A nurse is caring for a client who had a transurethral resection of the prostate 1 day prior and is on continuous bladder irrigation. The nurse suspects the catheter is blocked. Which nursing intervention is appropriate? 1. tell the client to try to urinate around the catheter 2. slow the irrigation rate to prevent bladder distention 3. prepare to reinsert a new three-way urinary catheter 4. use sterile technique to irrigate the catheter gently

Correct response: use sterile technique to irrigate the catheter gently Explanation: If a catheter is blocked by blood clots, it should be irrigated gently according to the primary care provider's prescription or institution protocol. The nurse should use sterile technique to reduce the risk of infection. Urinating around the catheter can cause painful bladder spasms. The catheter remains in place for 2 to 4 days after surgery and is removed only with a primary care provider's prescription. The continuous irrigation solution should be stopped while the catheter is irrigated to prevent over distention of the bladder.

A nurse is providing cardiopulmonary resuscitation (CPR) to a 4-year-old. What should the nurse do? 1. compress the sternum with both hands 2. at a depth of 1½ to 2 inches (4 to 5 cm) deliver 12 breaths/minute 3. perform two-person CPR only 4. use the heel of one hand for sternal compressions

Correct response: use the heel of one hand for sternal compressions Explanation: To perform CPR on a child, the nurse should use the heel of one hand and compress at least one-third of the anterior-posterior diameter of the chest. This corresponds to approximately 2 inches (5 cm) in most children. For an adult, the nurse should use the heels of both hands clasped together and compress the sternum at least 2 inches. Either one-person or two-person CPR can be provided to a child. For a child, the nurse should deliver 30 chest compressions followed by two breaths instead of 12 breaths/minute.