ATI Fundamentals for Nursing Review Module

23.3) A nurse is reviewing CDC immunization recommendations with a young adult client. Which of the following vaccines should the nurse recommend as routine, rather than catch-up, during young adulthood? (Select all that apply.) A. Influenza B. Measles, mumps, rubella C. Pertussis D. Tetanus E. Polio

A, C, D: The nurse should identify that the CDC recommends an annual influenza immunization, a booster dose of pertussis vaccine, and a booster dose of diphtheria and ongoing booster doses of tetanus during adulthood.

19.1) A nurse is instructing a class about the physical development of toddlers. Match the age of a toddler with the expected motor skill. 1. Walks up and down stairs 2. Stands on one foot 3. Builds a tower with two blocks A. 15 months B. 2 years C. 2.5 years

A-3; B-1; C-2 When taking actions, the nurse should instruct that a 15-month-old toddler should be able to build a tower with two blocks. A 2-year-old toddler should be able to walk up and down stairs and by age 2.5, a toddler should be able to stand on one foot.

27.3) The image below shows information regarding nursing interventions for hypothermia. Match the object to the correct description. 1. Provide a warm environmental temperature, heated humidified oxygen, warming blanket, and/ or warmed oral or IV fluids. 2. Keep the head covered. 3. Provide continuous cardiac monitoring. 4. Have emergency resuscitation equipment on standby. A. Monitor B. Blanket C. Defibrillator D. Baby with hat

A-3; C-1; E-4; G-2

28.2) A nurse is examining a client's head and neck lymph nodes. Match the name of the lymph node with the location of the lymph node. 1. Base of the skull 2. Over the mastoid 3. Angle of the mandible 4. Under the chin 5. Along the sternocleidomastoid muscle A. Submental B. Postauricular nodes C. Anterior cervical nodes D. Tonsillar nodes E. Occipital nodes

A-4; B-2; C-5; D-3; E-1 When examining a client's head and neck lymph nodes, the nurse should palpate each node for enlargement in the proper sequence and recognize that the occipital nodes are at the back of the skull, the postauricular nodes are over the mastoid, the tonsillar nodes are at the angle of the mandible, the submental nodes are under the chin, and the anterior cervical nodes are along the sternocleidomastoid muscle.

34.5) A nurse is caring for a client who has left-sided hemiplegia resulting from a cerebrovascular accident. The client works as a carpenter and is now experiencing a situational role change based on physical limitations. The client is the primary wage earner in the family. Which of the following describes the client's role problem? A. Role conflict B. Role overload C. Role ambiguity D. Role strain

A. CORRECT: The nurse should identify that the client is experiencing role conflict because their career is extremely physical and they can no longer perform the job duties. However, the client is the primary wage earner in the family.

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

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

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

A: When recognizing cues, the nurse should identity that the AP is threatening the client; therefore, the AP is committing assault. The AP's threats could make the client become fearful and apprehensive.

1.2) A nurse is explaining the various types of health care coverage clients might have to a group of nurses. Which of the following health care financing mechanisms should the nurse include as federally funded? (Select all that apply.) A. Preferred provider organization (PPO) B. Medicare C. Long-term care insurance D. Exclusive provider organization (EPO) E. Medicaid

B & E: Medicare and Medicaid are federally funded health insurance programs

20.3) A nurse is reviewing the Centers for Disease Control and Prevention's (CDC) immunization recommendations with the guardians of preschoolers. Which of the following vaccines should the nurse include in this discussion? (Select all that apply.) A. Haemophilus influenzae type B B. Varicella C. Polio D. Hepatitis A E. Seasonal influenza

B, C, E: When taking action while reviewing the Centers for Disease Control and Prevention's (CDC) immunization recommendations with the parents of preschoolers, the nurse should include the following vaccinations in the discussion: varicella, polio, and seasonal influenza.

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

B: The nurse should identity that because palpation and percussion can alter the frequency and intensity of bowel sounds, auscultation of the abdomen should occur next.

36.2) A nurse is caring for a client who is expected to die within 24 hr. The client's family asks the nurse what physical changes to expect. Which manifestations should the nurse include? (Select all that apply.) A. Increased urine output B. Warm extremities C. Decreased muscle tone D. Periods of apnea E. Bowel incontinence

C, D, E: When taking actions, the nurse should inform the client's family that physical changes that occur within 24 hr of death can include decreased muscle tone, irregular breathing with periods of apnea, and incontinence of the bowels and bladder.

37.3) A nurse is providing instructions about foot care to a client who has diabetes mellitus. Which of the following instructions should the nurse include? (Select all that apply.) A. Wear wool socks. B. Apply lotion between the toes. C. Wash the feet daily, using warm water. D. Warm the feet using a heating pad. E. Smooth the edges of the toenails with an emery board.

C: Clients who have diabetes mellitus often experience neuropathy, which can lead to loss of sensation; therefore, the client should wash the feet daily using warm, not hot, water because they cannot determine when the water is too hot. E: The client should trim the toenails every week and use an emery board or nail file to smooth the edges.

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

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

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

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

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

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

13.2) A nurse educator is providing education on infant safety to a group of guardians. Which of the following statements by a guardian indicates an understanding of the teaching? A. "I should line the crib with bumper pads." B. "I will make sure the crib slats are no more than 3 inches apart." C. "I should place the baby on their back when sleeping." D. "I should place the baby in a vehicle safety seat facing forward in the back seat of the car."

C: When taking action, the nurse should instruct the guardian of an infant to place the infant on their backs to sleep to safeguard against sudden unexpected infant death syndrome (SUIDs). Crib slats should be no more than 6 cm (2.4in) apart to prevent the infant from slipping through the slats, and bumper pads should not be used to line the crib to reduce the risk of SUIDs. When placing the infant in a motor vehicle, the infant should be placed in a federally approved car seat that is rear facing in the back seat of the vehicle.

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

C: With flatus, the protrusion is mainly midline, and there is no change in the flanks.

33.4) A nurse is caring for a family who is experiencing a crisis. Which of the following approaches should the nurse use when working with a family using an open structure for coping with crisis? A. Prescribing tasks unilaterally B. Delegating care to one member C. Speaking to the primary client privately D. Convening a family meeting

D: The nurse should identify that an open structure is loose and convening a family meeting would give all family members input and an opportunity to express their feelings.

34.3) A nurse is caring for a client who is 3 days postoperative following a below-the-knee amputation as a result of a motor-vehicle crash. Which of the following statements indicates that the client has a distorted body image? A. "I'll be able to function exactly as I did before the accident." B. "I just can't stop crying." C. "I am so mad at that guy who hit us. I wish he lost a leg." D. "I don't even want to look at my leg You can check the dressing."

D: This would imply a distorted body image. The nurse should identity that refusing to look at the leg or the dressing indicates that the client is having difficulty acknowledging the fact that the leg has been amputated.

11.2) A nurse is caring for a client who has an infection. Sort the manifestations the nurse would expect to find if the infection is Localized or Systemic. A. Fever B. Malaise C. Edema D. Pain or tenderness E. Increase in pulse and respiratory rate

LOCALIZED: C, D SYSTEMIC: A, B, E When recognizing cues, the nurse identifies edema and pain or tenderness as manifestations of a localized infection, because they are limited to a specific area of the body. The nurse identifies fever, malaise, and increased heart and respiratory rates as manifestations of a systemic infection that is affecting multiple parts of the body.

27.4) A nurse determines a client's radial pulse rate is 68/min and the simultaneous apical pulse rate is 84/min. What is the client's pulse deficit?

When analyzing cues, the nurse should determine that the pulse deficit is the difference between the apical and radial pulse rates. It reflects the number of ineffective or non-perfusing heartbeats that do not transmit pulsations to peripheral pulse points. Therefore, 84 - 68 = 16.

36.3) A nurse is caring for a client who has terminal lung cancer. The nurse observes the client's family assisting the client with all ADLs. What rationale for self-care should the nurse communicate to the family?

When taking actions, the nurse should communicate to the client's family that they should allow the client to perform their own ADLs as much as possible to maintain dignity, control, and self-esteem.

35.5) A nurse enters the room of a client who is reading from a religious book. The client begins to cry and asks to be left alone. What actions should the nurse take?

When taking actions, the nurse should demonstrate culturally responsive care and show respect to the client by providing time for the client to be alone. The nurse should close the door to the client's room and give the client time without interruption to pray and reflect. After giving the client quiet, uninterrupted time, the nurse can establish presence with the client by sitting, listening, showing acceptance, and supporting the client. The nurse can offer to contact a spiritual care provider to provide the client with spiritual support if needed.

38.2) A nurse in an acute care facility is caring for a client who is having difficulty sleeping at night. What actions should the nurse take to promote sleep?

When taking actions, the nurse should try to provide a quiet hospital environment and limit waking the client during the night to reduce interruptions in the client's sleep. A soothing back rub and assisting the client in following their regular bedtime routine, such as taking a bath in the evening, might promote relaxation and sleep in the acute care facility.

22.5) A nurse is preparing a wellness presentation for families about health screening for adolescents. Which of the following information should the nurse include? (Select all that apply.) A. Obtain a periodic mental status evaluation. B. Discuss prevention of sexually transmitted infections. C. Regularly screen for tuberculosis. D. Provide education about drug and alcohol use. E. Teach monthly breast examinations.

A, B, C, D: When generating solutions for a wellness presentation for families about health screening for adolescents, the nurse should include that adolescent should have occasional mental status evaluations. The nurse should also include interventions to prevent sexually transmitted infections, periodic screening for tuberculosis, and education about drug and alcohol use.

2.5) A nurse is acquainting a group of newly licensed nurses with the roles of the various members of the health care team they will encounter on a medical-surgical unit. When providing examples of the types of tasks certified nursing assistants (CNAs) can perform, which of the following client activities should the nurse include? (Select all that apply.) A. Bathing B. Ambulating C. Toileting D. Determining pain level E. Measuring vital signs

A, B, C, E: the nurse should identify that it is within the range of function for a CNA to provide basic care to clients, such as bathing, assisting with ambulation, assisting with toileting, and measuring and recording vital signs.

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

A, B, C: The nurse should identify that posture and skin lesions are part of the body structure or general appearance portion of the general survey. Speech is part of the behavior portion of the general survey. Allergies and immunization status are part of the health history, not the general survey.

45.2) A nurse is caring for a client who had a stroke and has aphasia. Which of the following actions should the nurse take to promote communication? (Select all that apply.) A. Make sure one person speaks to the client at a time. B. Let the client know if they are not understood C. Allow time for the client to respond D. Use long sentences when talking to the client. E. Speak loudly to the client.

A, B, C: When taking actions, the nurse should allow one person to speak to the client at a time, let the client know when they do not understand them, and allow plenty of time for the client to respond. These actions will facilitate communication in the client who has aphasia.

22.2) A nurse on a pediatric unit is caring for an adolescent who has multiple fractures. Which of the following interventions should the nurse take? (Select all that apply.) A. Suggest that the guardians bring in video games to play. B. Provide a television and movies for the adolescent to watch. C. Limit visitors to the adolescent's immediate family. D. Involve the adolescent in treatment decisions when possible. E. Allow the adolescent to perform morning self-care.

A, B, D, E: When taking action while caring for an adolescent who has multiple fractures the nurse should suggest the adolescent play nonviolent video games and watch nonviolent movies. These are suitable diversional activities for an adolescent. The nurse should also allow the adolescent to be involved in making decisions about their treatment. The adolescent is capable of thinking through problems. Involving the adolescent in decisions helps promote independence and control. Allowing the adolescent to perform morning self-care also promotes independence as well as shows respect for their privacy.

21.3) A nurse is reviewing the recommended immunization schedule for the parents of a 6-year-old child. Which immunizations does the nurse inform the parents are generally indicated for a school-age child? A. Varicella B. Influenza C. Shingles D. Hepatitis B E. Measles, mumps, rubella F. Rotavirus

A, B, D, E: When taking actions to review the recommended immunization schedule for school-age children, the nurse should inform the parents that immunizations for varicella, influenza, hepatitis B, and measles, mumps and rubella are appropriate for a school-age child.

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

A, B, D: The nurse should initiate a referral for a social worker to provide information and assistance in coordinating care for community resources available for clients.

38.3) A nurse is assessing a client who reports insomnia. Which of the following findings can contribute to the client's insomnia? (Select all that apply.) A. Irregular schedule B. Stress C. Warm bath D. Alcohol intake E. Morning walk

A, B, D: When analyzing cues, the nurse should identify that an irregular schedule, stress and anxiety, and alcohol intake can contribute to impaired sleep. The nurse should instruct the client to try to maintain a regular bedtime routine, find ways to reduce stress, such as yoga or meditation, and limit alcohol and beverages to 4 hr before bedtime.

5.3) A nurse is discussing occurrences that require completion of an incident report with a newly licensed nurse. Which of the following should the nurse include in the teaching? (Select all that apply). A. Medication error B. Needlesticks C. Conflict with provider and nursing staff D. Omission of prescription E. Missed specimen collection of a prescribed laboratory test

A, B, D: When taking actions, the nurse should include the necessity to complete an incident report regarding a medication error, complete an incident report regarding a needlestick, and complete an incident report following an omission of a prescription.

38.4) The nurse is educating the client about ways to improve sleep. Which of the following recommendations should the nurse include? (Select all that apply.) A. Practice muscle relaxation techniques. B. Exercise each morning C. Take two 30 min naps each day. D. Avoid heavy meals before bedtime. E. Limit fluid intake at least 1 hr before bedtime.

A, B, D: When taking actions, the nurse should instruct the client to practice muscle relaxation techniques to promote relaxation, reduce stress, and induce sleep. The nurse should instruct the client to exercise daily, at least 3 hr before bedtime, to promote sleep. A heavy meal before bedtime can cause indigestion which can disturb sleep.

1.5) A nurse is discussing restorative health care with a newly licensed nurse. Which of the following examples should the nurse include in the teaching? (Select all that apply.) A. Home health care B. Rehabilitation facilities C. Diagnostic centers D. Skilled nursing facilities E. Oncology Centers

A, B, D: restorative nursing care, involves immediate, follow up, care for restoring health and promoting self-care. Home, healthcare, rehabilitation facilities, and skilled nursing facilities are types of restorative healthcare.

35.2) A nurse is using an interpreter to communicate with a client. Which of the following actions should the nurse take? (Select all that apply.) A. Using a facility approved medical interpreter B. Determining the client's understanding several times during the conversation C. Looking at the interpreter when asking the client questions D. Using medical terms during the conversation E. Asking one question at a time

A, B, E: When taking actions, the nurse should use a facility approved medical interpreter to ensure accuracy of the medical information and maintain client confidentiality. Determining client understanding throughout the conversation ensures the client comprehends the information and the nurse will know how to direct the conversation. Asking one question at a time and allowing the client time to respond will promote effective communication between the client and the nurse or interpreter.

25.5) A nurse is talking with an older adult client about improving nutritional status. Which of the following interventions should the nurse recommend? (Select all that apply.) A. Increase protein intake to increase muscle mass. B. Decrease fluid intake to prevent urinary incontinence. C. Increase calcium intake to prevent osteoporosis. D. Limit sodium intake to prevent edema. E. Increase fiber intake to prevent constipation.

A, C, D, E: The nurse should identify that older adults should increase protein intake to increase muscle mass and improve wound healing, increase calcium intake to reduce the risk for osteoporosis, limit sodium intake to reduce the risk for edema and hypertension, and increase fiber intake to prevent constipation.

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

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

44.1) A nurse is teaching a client who has recurrent UTIs. Which of the following instructions should the nurse include? (Select all that apply.) A. Urinate after sexual intercourse. B. Drink at least 1L of fluid each day. C. Clean perineum from the front to back. D. Wear nylon undergarments. E. Avoid bubble baths.

A, C, E: When taking actions, the nurse should instruct the client to urinate after sexual intercourse to flush bacteria from the urinary system. The client should clean the perineum from the front to back to reduce the risk of introducing bacteria in the urinary system and avoid bubble baths that might irritate the urethra.

30.4) A nurse in a provider's office is preparing to assess a client's skin as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply.) A. Capillary refill less than 3 seconds B. 1+ pitting edema in both feet C. Pale nail beds in one hand D. Thick skin on the soles of the feet E. 2+ pulses on the client's lower extremities

A, D, E: When analyzing cues, the nurse should identify that a capillary refill less than 3 seconds and 2+ pulses in the client's lower extremities are expected findings and indicate adequate peripheral circulation. Thick skin on the soles of the client's feet is an expected finding.

1.4) A nurse is explaining the various levels of health care services to a group of newly licensed nurses. Which of the following examples of care or care settings should the nurse classify as tertiary care? (Select all that apply.) A. Intensive care unit B. Oncology treatment center C. Burn center D. Cardiac rehabilitation E. Home health care

A,B,C: tertiary healthcare, involves the provision of specialized and highly technical care, such as the care nurses deliver in intensive care units, come and oncology treatment center, and a burn center.

8.1) A charge nurse is discussing the levels of critical thinking with a newly licensed nurse. Match the following interventions with the appropriate critical thinking level. 1. Basic 2. Complex 3. Commitment A. A nurse follows a facility's procedure manual to change an IV dressing. B. A nurse repositions a client's arm to improve the infusion of an IV. C. A nurse increases an IV rate on a client who has hypotension.

A-1; B-2; C-3 When analyzing cues, the nurse should identify that nursing interventions that involve concrete thinking, based on rules, such as following a facility's procedure manual to change an IV dressing, is an example of basic critical thinking. Complex critical thinking involves analyzing data and using creativity to problem-solve, such as repositioning a client's arm to promote IV infusion. Commitment critical thinking involves using expert knowledge and experience to problem-solve while assuming responsibility, such as increasing an IV rate on a client who has hypotension.

8.2) A charge nurse is discussing the components of critical thinking with a newly licensed nurse. Match the following situations to the appropriate component of critical thinking. 1. Knowledge 2. Experience 3. Competence A. A nurse uses an electronic database to gather information about a medication before administering it to a client. B. A nurse has been working with clients who have diabetes mellitus for over 5 years. C. A nurse uses the nursing process when caring for a client who has hypoglycemia.

A-1; B-2; C-3 When recognizing cues, the charge nurse should identity that using the electronic database to gather intormation about a medication demonstrates the knowledge component of critical thinking. The nurse is taking initiative to increase their knowledge base. The nurse who has been working with clients who have diabetes mellitus for over 5 years demonstrates the experience component of critical thinking. A nurse who has experience has clinical expertise and can apply intuition to critical thinking in clinical situations. A nurse who uses the nursing process when caring for a client who has hypoglycemia is demonstrating the competence component of critical thinking. Competence involves identifying client problems and making clinical judgments using a systematic, individualized process.

17.3) The ostomy nurse is educating the client about the new colostomy. Match the nursing actions to the appropriate domain of learning. 1. Cognitive 2. Affective 3. Psychomotor A. The ostomy nurse encourages the client to share their feelings about their colostomy. B. The client performs a return demonstration of emptying the colostomy pouch. C. The ostomy nurse provides the client with a list of foods they can eat and foods they should avoid in their diet.

A-1; B-3; C-2 When taking actions, the ostomy nurse is using the cognitive domain of learning when providing the client with a list of foods they can eat and foods they should avoid in their diet. The ostomy nurse is encouraging the client to ask questions to promote understanding about the teaching. The ostomy nurse is using the affective domain of learning when encouraging the client to share their feelings about their colostomy. The affective domain promotes the expression of feelings and encourages support from others. The ostomy nurse is using the psychomotor domain of learning when demonstrating how to empty the ostomy pouch and asking the client to perform a return demonstration of the procedure. The psychomotor domain of learning involves performing a physical task.

7.4) A postoperative client reports pain. Match the actions of the newly licensed nurse with the nursing process. 1. Assessment/Data Collection 2. Analysis/Diagnosis/Data Collection 3. Planning 4. Implementation 5. Evaluation A. The newly licensed nurse documents that the client's pain is causing the client to take shallow breaths and could lead to complications such as atelectasis. В. The newly licensed nurse administered the pain medication to the client. C. The newly licensed nurse asks the client to rate the severity of the pain on a scale of 0 to 10. D. The newly licensed nurse checks the client 40 min after administering the pain medication to determine the effectiveness of the medication in relieving the client's pain. E. The newly licensed nurse determines the client is due to receive the pain medication and prepares to administer a dose to the client.

A-2, B-4, C-1, D-5, E-3 The charge nurse is recognizing cues when identifying that the newly licensed nurse is using the steps of the nursing process when caring for the client who is postoperative and reports pain. The newly licensed nurse uses the assessment/data collection step of the nursing process when asking the client to rate the severity of pain on a scale of 0 to 10 scale. Documenting that the client's pain is causing the client to take shallow breaths and could lead to complications such as atelectasis is part of the analysis/diagnosis/data collection step of the nursing process. The newly licensed nurse clusters and interprets data to determine a conclusion. The newly licensed nurse is using the planning step of the nursing process when determining the client is due to receive the pain medication and prepares to administer a dose to the client. Administering the pain medication to the client is part of the implementation step of the nursing process. The newly licensed nurse is using the evaluation step of the nursing process when checking the client 40 min after administering the pain medication to determine the effectiveness of the medication in relieving the client's pain.

21.5) The nurse is contributing to the plan of care for injury prevention for a school-age child. Match each safety issue to the instruction the nurse should suggest for the family to prevent injury related to that issue. 1. Provide approved flotation devices 2. Teach child to use low heat when cooking 3. Educate the child about illegal drugs and alcohol 4. Encourage correct use of seat belts or child safety seats 5. Store firearms in locked cabinets A. Burns B. Poisoning C. Bodily harm D. Drowning E. Motor vehicle injury

A-2; B-3; C-5; D-1; E-4 When generating solutions for injury prevention for a school-age child, the nurse should suggest teaching the child to cook using low heat on the stove to prevent injury from burns. The nurse should suggest educating the child about the dangers of illegal drugs and alcohol to prevent poisoning from ingestion. The nurse should suggest storing firearms in locked cabinets to protect the child from bodily harm caused by the discharge of a firearm. The nurse should suggest providing the child with approved flotation devices when swimming or boating to prevent drowning. The nurse should suggest that the child should be taught correct use of seat belts and child safety seats to protect against injury from a motor vehicle collision.

28.6) A nurse is examining a client's tonsils for size using a grading tool. Match the grade with the findings. 1. The tonsils touch the uvula. 2. The tonsils are behind the soft structures supporting the palate. 3. The tonsils touch each other. 4. The tonsils are between the soft structures and the uvula. A. Grade 1 B. Grade 2 C. Grade 3 D. Grade 4

A-2; B-4; C-1, D-3 The nurse should recognize that expected finding are that the tonsils are pink and smooth and without discharge and behind the soft structures. With each grade the tonsils are progressively larger. Grades 2, 3, and 4 are unexpected finding and should be reported to the provider.

44.2) A nurse is teaching a newly licensed nurse about urine specimen collection. Match the following tests to the procedure. 1. Collect urine for a 24 hr period. 2. Obtain a non-sterile urine specimen. 3. Obtain a sterile urine specimen from an indwelling urinary catheter. 4. Clean the urethral meatus prior to obtaining the urine specimen. A. Random urinalysis B. Clean-catch midstream for culture and sensitivity (C&S) C. Timed urine specimen D. Catheter urine specimen for C&S

A-2; B-4; C-1; D-3 When taking actions, the nurse should instruct the newly licensed nurse that a random urinalysis is a non-sterile urine specimen. A clean-catch midstream for C&S is a sterile specimen collected from a midstream void, after cleaning the urinary neatus. A timed urine specimen is collected over a prescribed period of time. A catheter urine specimen for C&S is a sterile specimen obtained from a straight or indwelling catheter.

36.1) A nurse is caring for a client who has terminal lung cancer. Match the client statements to the Kübler-Ross model stage of grief the client is experiencing. 1. Bargaining 2. Denial 3. Acceptance 4. Anger 5. Depression A. "I am looking forward to our family reunion next year." B. "This is so unfair. Why is this happening to me?" C. "I promise to go to church every day, if I live through this." D. "I have nothing to live for anyway." E. "I have lived a good life."

A-2; B-4; C-1; D-5; E-3 When analyzing cues, the nurse should identify that looking forward to an event the next year indicates the client is experiencing the Kübler-Ross model stage of denial. The client statement that the situation is unfair indicates the client is experiencing the Kübler-Ross model stage of anger. Making a promise in exchange for a longer life is an indication the client is experiencing the Kübler-Ross model stage of bargaining. The client is experiencing the Kübler-Ross model stage of depression by showing overwhelming sadness. The client is experiencing the Kübler-Ross model stage of acceptance by stating they have lived a good life.

8.4) A charge nurse is discussing critical thinking attitudes with a newly licensed nurse. Match the following nursing actions with the critical thinking attitude. 1. Confidence 2. Integrity 3. Humility 4. Discipline 5. Curiosity A. Showing honesty when caring for clients B. Using a head-to-toe approach to conduct a physical examination on a client C. Speaking with certainty to a client when instructing them about a new diet D. Asking questions to obtain more information about a client's problem E. Identifying limitations of oneself when dealing with a clinical situation

A-2; B-4; C-1; D-5; E-3 When recognizing cues, the charge nurse should identify that showing honesty when caring for clients demonstrates the critical thinking attitude of integrity. Integrity is caring for clients truthfully and ethically. Using a head-to-toe approach to conduct a physical examination on a client demonstrates the critical thinking attitude of discipline. Discipline involves using a systematic approach to collecting data and making decisions. Speaking with certainty to a client when instructing them about a new diet demonstrates the critical thinking attitude of confidence. A confident nurse believes in their own abilities. Asking questions to obtain more information about a client's problem demonstrates the critical thinking attitude of curiosity. A curious nurse asks questions to explore and study a clinical situation. Identifying limitations of oneself when dealing with a clinical situation demonstrates the critical thinking attitude of humility. A nurse who has humility acknowledges their own weakness and limitations in expertise and skill.

42.2) A nurse is discussing complementary or alternative therapies with a newly licensed nurse. Match the therapy with the method. 1. Acupuncture 2. Massage therapy 3. Naturopathic medicine 4. Chiropractic medicine 5. Biofeedback A. Muscles are stretched to promote relaxation. B. The spine is manipulated to promote healing. C. Needles are placed along meridians to produce analgesia. D. Instruments are used to visualize a body function to control a physiologic response. E. Herbal remedies are used to promote healing.

A-2; B-4; C-1; D-5; E-3 When taking actions, the nurse should identify that acupuncture regulates vital energy by inserting needles along meridian pathways to produce analgesia or improve body function. Muscles are stretched and loosened to promote circulation and relaxation during massage therapy. Naturopathic medicine involves using herbal remedies to promote healing. Spine manipulation occurs during chiropractic medicine. Biofeedback involves using instruments to see or hear physiological data to gain voluntary control of a physiological response.

42.1) A nurse is discussing complementary and alternative medicine (CAM) with a newly licensed nurse. Match the CAM category with the therapy. 1. Meditation 2. Homeopathy 3. Magnet therapy 4. Probiotics 5. Massage A. Whole medical systems B. Botanical therapy C. Manipulative methods D. Mind-body therapy E. Energy therapy

A-2; B-4; C-5; D-1; E-3 When taking actions, the nurse should instruct that homeopathy is an example of whole medical systems. Other whole medical systems include traditional Chinese medicine and Ayurveda. Probiotics are an example of botanical therapy. Other botanical therapies include herbal preparations and vitamins. Massage is an example of manipulative therapy. Other manipulative therapies are acupuncture and chiropractic medicine. Meditation is an example of mind-body therapy. Other mind-body therapies are biofeedback and yoga. Magnet therapy is an example of energy therapy. Other energy therapies are Reiki and therapeutic touch.

30.1) A nurse is teaching a class about skin lesions. Match the following lesions with the associated skin condition. 1. Acne 2. Warts 3. Psoriasis 4. Herpes Simplex 5. Freckle A. Scale B. Pustule C. Macule D. Nodule E. Vesicle

A-3; B-1, C-5; D-2; E-4 When recognizing cues, the nurse should instruct that acne is an example of a pustule, or a raised lesion filled with pus. Warts are an example of a nodule, or an elevated solid, firm lesion. Psoriasis is an example of scales, or areas of skin that flakes. Herpes simplex lesions are examples of vesicles, which are circumscribed fluid-filled skin elevations. Freckles are examples of macules, or flat areas of skin color change.

28.5) A nurse is performing auditory screening for a client. Match the name of the test with the technique the nurse should use. 1. Rinne test (air conduction) 2. Weber test (bone conductivity) 3. Whisper tests A. The nurse has the client occlude one ear and then tests the other ear to see if the client can hear sounds without seeing the nurse's mouth. B. The nurse places a vibrating tuning fork against the mastoid bone and asks the client to state when the sound can no longer be heard. C. The nurse places a vibrating tuning fork on the top of the head and asks the client if the sound is best in the left or right ear.

A-3; B-1; C-2 The nurse uses the whisper test to assess high-frequency hearing in both ears. Abnormal findings include the client asking the nurse to repeat the words and/or the client is unable to repeat the words. If the client has difficulty with the Whisper test, the nurse proceeds to the Rinne test and Weber's test. During the Rinne test, the nurse places a vibrating tuning fork against the client's mastoid bone and measures the length of time the client can hear the sound. An expected finding is that the client can hear air-conducted sounds twice as long as bone conducted sounds. During the Weber's test, the nurse places a vibrating tuning fork on the top of the client's head and asks the client if the sound is best heard in the left or the right ear. An expected finding of the Weber's test is that the client hears the sound equally in both ears. If the client has conduction deafness, the sound is heard best in the impaired ear. If the client has sensorineural, the sound is heard best in the unaffected ear.

31.3) A nurse is assessing a client's sensory function. The nurse asks the client to close their eyes. Match the nursing action to associated sensory function. 1. Ask the client to report when they feel a cotton ball on their skin. 2. Ask the client to report when they feel the movement of a tuning fork on their skin. 3. Reposition the client's arm and ask the client to report whether it is positioned up or down. 4. Trace a number on the client's palm with the blunt end of a pencil and ask them to identify it. A. Position B. Light touch C. Discrimination D. Vibration

A-3; B-1; C-4; D-2 When taking actions, the nurse should ask the client to close their eyes before assessing sensory function. The nurse should assess the client's sensation of light touch by lightly touching their skin with a cotton ball and then asking them to report when they feel the cotton ball on their skin. The nurse should assess the client's sensation of vibration by touching their skin with the handle of a vibrating tuning fork and then asking them to report when they feel the vibration. The nurse should assess the client's sensation of position by repositioning the client's arm and then asking them to report whether it is positioned up or down. The nurse should assess the client's sensation of discrimination by tracing a number on the client's palm with the blunt end of a pencil and then asking them to identify it.

7.5) A charge nurse is discussing the nursing process with a newly licensed nurse who is caring for a client. Match the following statements by the newly licensed nurse with each step of the nursing process. 1. Assessment/Data Collection 2. Analysis/Diagnosis/Data Collection 3. Planning 4. Implementation 5. Evaluation A. "I will determine the most important client problems that we should address." B. "I will review the past medical history in the client's medical record to obtain more information about the client." C. "I will ask the client if their nausea has resolved." D. "I will review objective and subjective client data to identify a potential client problem." E. "I will administer prescriptions from the provider."

A-3; B-1; C-5; D-2; E-4 The charge nurse is recognizing cues when identifying that the newly licensed nurse is using the steps of the nursing process when caring for the client. The newly licensed nurse uses the assessment/data collection step of the nursing process when reviewing the past medical history on the client's medical record to obtain more information about the client. Reviewing objective and subjective client data to identify a potential client problem is part of the analysis/diagnosis/data collection step of the nursing process. The newly licensed nurse clusters and interprets data to determine a conclusion. The newly licensed nurse is using the planning step of the nursing process when prioritizing client problems. Administering prescribed medications to the client is part of the implementation step of the nursing process. The newly licensed nurse is using the evaluation step of the nursing process when asking the client if their nausea has resolved.

42.3) A nurse is discussing herbal remedies with a newly licensed nurse. Match the herbal remedy with the possible therapeutic effect. 1. Ginkgo biloba 2. Echinacea 3. Ginger 4. Ginseng 5. Valerian A. Antiemetic B. Increases physical endurance C. Enhances immunity D. Produces sleep E. Improves memory

A-3; B-4; C-2; D-5; E-1 When taking actions, the nurse should instruct that ginger is used to reduce nausea, ginseng is used to increase physical endurance, echinacea is used to improve immunity, valerian is used to induce sleep, and ginkgo biloba is used to improve memory.

8.3) A charge nurse is discussing critical thinking attitudes with a newly licensed nurse. Match the following nursing actions with the critical thinking attitude. 1. Creativity 2. Risk-taking 3. Fairness 4. Perseverance 5. Responsibility A. Caring for a client in a nonjudgmental manner B. Checking a client's medical record for allergies before administering a medication C. Taking a calculated chance to find a solution to a client's problem D. Using imagination to find a unique solution to solve a client's problem E. Continuing to work to a solve a problem for a client until there is a solution

A-3; B-5; C-2; D-1; E-4 When recognizing cues, the charge nurse should identify that caring for a client in a nonjudgmental manner demonstrates the critical thinking attitude of fairness. Fairness is using a nonjudgmental, objective approach in looking at clients and situations. Checking a client's medical record for allergies before administering a medication demonstrates the critical thinking attitude of responsibility. The nurse is responsible for administering medications in a safe manner and according to standards of practice. Checking the medical record for allergies helps ensure safety. Taking a calculated chance to find a solution to a client's problem demonstrates the critical thinking attitude of risk-taking. Risk-taking is a calculated approach to solving a problem that is not responding to traditional methods. Using imagination to find a unique solution to solve a client's problem demonstrates the critical thinking attitude of creativity. Continuing to work to solve a problem for a client until there is a solution demonstrates the critical thinking attitude of perseverance.

29.4) A nurse is preparing to auscultate a client's heart. At which location should the nurse place their stethoscope to auscultate Erb's point? 1. Mitral valve 2. Erb's point 3. Aortic valve 4. Tricuspid valve 5. Pulmonic valve

A-3; B-5; C-2; D-4; E-1 When taking actions to auscultate the client's heart, the nurse should systematically auscultate the heart using both the diaphragm and the bell of the stethoscope. The aortic valve is auscultated to the right of the sternum at the second intercostal space. The pulmonic value is auscultated to the left of the sternum at the at the second intercostal space. Erb's point, also referred to as the second pulmonic area, is located to the left of the sternum at the third intercostal space. The tricuspid valve is auscultated to the left of the sternum at the fourth intercostal space. The mitral valve is auscultated to the left of the midclavicular line at the fifth intercostal space.

29.2) A nurse is examining a client's chest. Matching the name of the vertical chest landmarks with their location. 1. Over the center of the sternum. 2. Extends down from the anterior axillary fold. 3. Runs down from the apex of the axillary. 4. Is along the center of the spine. A. Midaxillary line B. Anterior axillary line C. Midsternal line D. The vertebal line

A-3; C-2; E-1; G-4 The midsternal line is through the center of the sternum. The anterior axillary line extends down from the anterior axillary fold. The midaxillary line runs down from the apex of the axilla and is between the anterior and posterior axillary line. The vertebral line is along the center of the spine.

26.6) Match the therapeutic communication technique to the correct definition. 1. Show clients that they have your undivided attention. 2. Use initially to encourage clients to tell their story in their own way. Use terminology clients can understand. 3. Question clients about specific details in greater depth or direct them toward relevant parts of their history. 4. Use active listening phrase ("Go on" and "Tell me more") to convey interest and to prompt disclosure of the entire story. 5. Ask more open-ended questions ("What else would you like to add to that?") to help obtain comprehensive information. 6. Ask questions that require yes or no answers to clarify information ("Do you have any pain when you cannot sleep?"). 7. Validate the accuracy of the story. A. Back channeling B. Clarifying C. Open-ended questions D. Active listening E. Summarizing F. Probing G. Close-end Questions

A-4; B-3; C-2; D-1; E-7; F-5; G-6

18.5) The nurse is contributing to the plan of care for injury prevention for an infant. Match each safety issue on the left to the instruction on the right the nurse should suggest for the family to prevent injury related to that issue. 1. Cover electrical outlets 2. Keep medications in ocked cabinets 3. Remove pillows from the crib injury 4. Stay with the infant at all times while bathing them 5. Use clothes and toys without buttons 6. Place infant in rear-facing car seat A. Aspiration B. Suffocation C. Burns D. Motor vehicle E. Drowning F. Poisoning

A-5; B-3; C-1; D-6; E-4; F-2 When generating solutions for injury prevention for an infant, the nurse should suggest covering electrical outlets to prevent injury from shocks or burns. The nurse should suggest storing medications in locked cabinets to prevent poisoning from ingestion. The nurse should suggest removing pillows and other soft, loose objects trom the crib to prevent suffocation or strangulation. The nurse should suggest never leaving an infant unattended in a water source to prevent drowning. The nurse should suggest using clothes and toys without buttons to avoid a choking hazard if they are accidentally removed. The nurse should suggest that the infant is buckled into a rear-facing car seat to protect against injury from a motor vehicle collision.

5.2) A nurse is receiving a provider's prescription by telephone for morphine for a client who is reporting moderate to severe pain. Which of the following nursing actions are appropriate? (Select all that apply.) A. Repeat the details of the prescription back to the provider. В. Have another nurse listen to the telephone prescription. C. Obtain the provider's signature on the prescription within 24 hr. D. Decline the verbal prescription because it is not an emergency situation. E. Tell the charge nurse that the provider has prescribed morphine by telephone.

A. CORRECT: When taking actions, the nurse should repeat the medications name, dosage, time or interval, route, and any other pertinent information back to the provider and receive document confirmation. B. CORRECT: The nurse should have another nurse listen to the telephone prescription as a safety precaution to help prevent medication errors due to miscommunication. C. CORRECT: The provider must sign the prescription within the time frame the facility specifies in its policies (generally 24 hr).

1.3) A nurse manager is developing strategies to care for the increasing number of clients who have obesity. Which of the following actions should the nurse include as a primary health care strategy? A. Collaborating with providers to perform obesity screenings during routine office visits B. Ensuring the availability of specialized beds in rehabilitation centers for clients who have obesity C. Providing specialized intraoperative training in surgical treatments for obesity D. Educating acute care nurses about postoperative complications related to obesity

A. Obesity screenings at office visits is an example of primary healthcare. Primary healthcare emphasizes health promotion and disease control, is often delivered during office visits, and includes screenings.

7.3) A nurse is caring for a client who is two days postoperative and has not achieved satisfactory pain relief. According to the nursing process, which of the following actions should the nurse take first? A. Check the client to determine the reason for inadequate pain relief. B. Determine whether the change in plan reduces the client's pain. C. Change the plan of care to provide a different method of pain relief. D. Educate the client about the plan of care for managing the pain.

A. When prioritizing hypotheses, and using the nursing process, the first action the nurse should take is to check the client to determine the reason for inadequate pain relief. The nurse should collect objective and subjective data to determine a new plan of care to promote comfort and reduce the client's pain.

15.1) A nurse is caring for multiple clients during a mass casualty event. Which of the following clients is the nurse's priority? A. A client who has partial-thickness and full-thickness burns to the face, neck and chest. B. A client who received crush injuries to the chest and abdomen and is expected to die C. A client who has a 4-inch laceration to the head D. A client who has a fractured fibula and tibia

A: A client who has burns to the face, neck, and chest is at risk for airway obstruction and requires immediate intervention for survival. Using the survival approach to client care, the nurse should give priority to this client (Emergent Category: Class l).

32.2) Which of the following actions should the nurse take when demonstrating an empathic presence to a client? (Select all that apply.) A. Use an open posture. B. Write down what the client says to avoid forgetting details. C. Establish and maintain eye contact. D. Nod in agreement with the client throughout the conversation. E. Sit facing the client.

A: Having an open posture, facing the client, and leaning forward are ways that can demonstrate an empathic presence. C: Establishing and maintaining eye contact are ways that can demonstrate an empathic presence. E: Sitting while facing the client directly can demonstrate an empathic presence. It also helps clients who have a hearing loss understand verbal communication.

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

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

4.4) A nurse is assigned to care for a client who has tuberculosis. The nurse understands that the intent of this tracking is which of the following? A. To track information that poses a threat to the public B. To provide appropriate antibiotics at no cost the client C. To assist the Joint Commission with its goals for client safety D. To aid in obtaining personal protective equipment for the facility

A: The Centers for Disease Control and Prevention monitors certain illnesses and diseases that can pose a threat to the public. The purpose of this activity is to limit the spread of the diseases.

24.1) A nurse is collecting history and physical examination data from a middle adult. The nurse should expect to find decreases in which of the following physiologic functions? (Select all that apply.) A. Metabolism B. Ability to hear low-pitched sounds C. Gastric secretions D. Far vision E. Glomerular filtration

A: The nurse should expect metabolism to decline, causing weight gain during middle adulthood. C: In middle adulthood, decreases in secretions of bicarbonate and gastric mucus begin and persist into older age. This increases the risk of peptic ulcer disease. E: Middle adults begin to lose nephron units, which results in a decline in glomerular filtration rates.

9.3) A nurse is caring for a client who had a stroke and is scheduled for transfer to a rehabilitation center. Which of the following tasks are the responsibility of the nurse at the transferring facility? (Select all that apply.) A. Ensure that the client has possession of their valuables. B. Confirm that the rehabilitation center has a room available at the time of transfer. C. Assess how the client tolerates the transfer. D. Give a verbal transfer report via telephone. E. Complete a transfer form for the receiving facility.

A: The nurse should identify that it is important that both the transferring and receiving nurse account for all of the client's valuables at the time of transfer. B: On the day of the transfer, the transferring nurse should confirm that the receiving facility is expecting the client and that the room is available. It is the responsibility of the nurse at the receiving facility to assess the client upon arrival to determine how they tolerated the transfer. D: The transferring nurse should provide the nurse at the receiving facility with a verbal transfer report in person or via telephone. E: The transferring nurse should complete any documentation for the transfer, including a transfer form and the client's medical records.

16.1) A nurse in a health clinic is caring for a 21-year-old client who tells the nurse that their last physical exam was in high school. Which of the following health screenings should the nurse expect the provider to perform for this client? A. Testicular examination B. Blood glucose C. Fecal occult blood D. Prostate-specific antigen

A: The nurse should identify that starting at puberty, the client should have examinations for testicular cancer, along with blood pressure and body mass index and cholesterol measurements. Testicular cancer is most common in males 15 to 34 years of age.

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

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

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

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

16.5) A nurse in a clinic is planning health promotion and disease prevention strategies for a client who has multiple risk factors for cardiovascular disease. Which of the following interventions should the nurse include? (Select all that apply.) A. Help the client see the benefits of their actions. B. Identify the client's support systems. C. Suggest and recommend community resources. D. Devise and set goals for the client. E. Teach stress management strategies.

A: The nurse should plan to assist the client to recognize the benefits of their health-promoting actions while also overcoming barriers to implementing actions. B: The nurse should plan to collect information about who can help the client change unhealthy behaviors and then suggest steps to have friends and family to become involved and supportive. C: The nurse should plan to promote the client's use of any available community or online resources that can help the client progress toward meeting set goals. E: The nurse should plan to teach that stress is a contributing factor to cardiovascular disease, as well as many other specific and systemic disorders.

24.5) A nurse is preparing a health promotion course for a group of middle adults. Which of the following strategies should the nurse recommend? (Select all that apply.) A. Eye examination every 1 to 3 years B. Decrease intake of calcium supplements C. DA screening for osteoporosis D. Increase intake of carbohydrate in the diet E. Screening for depressive disorders

A: The nurse should recommend middle adult clients have an eye examination every 1 to 3 years to screen for glaucoma and other disorders. C: Middle adults should have a DXA scan to screen for osteoporosis, obtain adequate protein, and consume more fresh fruits, vegetables and whole grains. D: Middle adults should have a DXA scan to screen for osteoporosis, obtain adequate protein, and consume more fresh fruits, vegetables and whole grains. E: The nurse should also recommend screening for anxiety and depression during middle adulthood

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

A: The nurse should turn the clients head toward the mattress so that the mouth is in a dependent position. This promotes drainage of secretions away from the throat and reduces the risk of aspiration.

37.5) A nurse is providing denture care for a client. Which of the following actions should the nurse take? A. Using a gauze pad to grasp and pull forward and downward to remove the upper denture B. Storing the dentures overnight in a labeled denture cup filled with a solution of water and mouth wash C. After brushing the dentures, rinsing them in hot water D. Donning sterile gloves prior to performing denture care

A: The nurse should use gauze to remove the client's dentures because dentures can be slippery and the gauze helps to ensure a firm grip.

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

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

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

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

13.5) A home health nurse is assessing a client who experienced extreme exposure to heat and has a body temperature of 40°C (104°F). The nurse should anticipate that the client will display which of the following manifestations? A. Hypotension B. Bradycardia C. Clammy skin D. Bradypnea

A: When analyzing clues, the home health nurse should recognize that manifestations of heat stroke include hypotension, tachycardia, hot, dry skin and dyspnea.

41.4) A nurse at a clinic is collecting data about pain from of a client who reports severe abdominal pain. The nurse asks the client if there has been any accompanying nausea and vomiting. Which of the following pain characteristics is the nurse attempting to determine? A. Presence of associated manifestations B. Location of the pain C. Pain quality D.Aggravating and relieving factors

A: When asking the client if they are also experiencing nausea and vomiting with their pain, the nurse is assessing the presence of associated manifestations.

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

A: When generating solutions, the nurse should encourage the client to perform antiembolic exercises every 1 to 2 hr to promote venous return and reduce the risk of thrombus formation.

19.2) A parent tells a nurse that their 2-year-old toddler has temper tantrums and says "no" every time the parent tries to help them get dressed. The nurse should identify the toddler is manifesting which of the following stages of development? A. Trying to increase independence B. Developing a sense of trust C. Establishing a new identity D. Attempting to master a skill

A: When recognizing cues, the nurse should identify that the toddler is expressing a desire for independence by challenging those in authority. Toddlers become easily frustrated and express this frustration by a temper tantrum.

8.5) A newly licensed nurse is considering strategies to improve critical thinking. Which of the following actions should the nurse take? (Select all that apply.) A. Find a mentor. B. Use a journal to write about the outcomes of clinical judgments. C. Review articles about evidence-based practice. D. Limit consultations with other professionals involved in a client's care. E. Make quick decisions when unsure about a client's needs. F. Organize client data using a concept map.

A: When taking actions to improve critical thinking, the newly licensed nurse should find a mentor to discuss client care and gain knowledge from the mentor's experience. B: Journaling about decision-making can assist the nurse with self-reflections and improve critical thinking skills. C: Learning new information about evidence-based practice improves the nurse's ability to think critically. F: Creating a concept map improves critical thinking skills by organizing and connecting client data to identify possible clinical patterns and relationships.

31.2) A nurse is performing a neurologic examination for a client. Which of the following assessments should the nurse perform to test the client's balance? A. Romberg test B. Weber's test C. Rosenbaum test D. Snellen test

A: When taking actions, the nurse should identify that the Romberg test is used to assess balance. The client stands with their eyes closed, arms at both side, and feet together. The nurse verifies balance if the client can stand with minimal swaying for at least 5 seconds.

9.1) A nurse is performing an admission assessment for an older adult client. After gathering the assessment data and performing the review of systems, which of the following actions is a priority for the nurse? A. Orient the client to their room. B. Conduct a client care conference. C. Review medical prescriptions. D. Develop a plan of care.

A: When taking actions, the nurse should identify that the greatest risk to this client is injury from unfamiliar surroundings. Therefore, the priority action is to orient she client to the room. Before the nurse leaves the room, the client should know how to use the call light and other equipment at the bedside. It is important to conduct a client care conference. However, another action is the priority. It is important to review prescriptions in the medical record. However, another action is the priority. It is important to develop a plan of care. However, another action is the priority.

39.2) A nurse in a senior center is counseling a group of older adults about their nutritional needs and considerations. Which of the following information should the nurse include? (Select all that apply.) A. Older adults are more prone to dehydration than younger adults. B. The recommended intake of daily fiber decreases in older adults. C. Many older adults need calcium supplementation. D. Older adults need more calories than they did when they were younger. E. Older adults should consume a diet low in carbohydrates.

A: When taking actions, the nurse should include that sensations of thirst diminish with age, leaving older adults more prone to dehydration. B: The recommended amount of daily fiber intake decreases in the older adult due to their lower caloric intake. C: Many older adults need an increased intake of calcium, whether through their diet or through calcium supplements to help prevent bone demineralization (osteoporosis).

27.5) A nurse is instructing an assistive personnel (AP) how to measure a client's respiratory rate. Which of the following statements should the nurse include? (Select all that apply.) A. "Place the client in semi-Fowler's position." B. "Have the client rest an arm across the abdomen." C. "Observe one full respiratory cycle before counting the rate." D. "Count the rate for 30 sec if it is irregular." E. "Inform the client you are counting their respiratory rate."

A: When taking actions, the nurse should instruct the AP to place the client in semi-Fowler's position before counting their respiratory rate to promote ventilation. This position also allows the AP to visualize the client's chest and abdominal movements. B: The nurse should instruct the AP to have the client rest an arm across their abdomen to promote visualization of the client's chest and abdominal movements. C: The nurse should instruct the AP to observe the client for one full respiratory cycle before counting the rate to obtain an accurate measurement.

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

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

19.3) A nurse is teaching the parent of a toddler about discipline. Which of the following statements should the nurse make? A. "Establish consistent boundaries for the toddler." B. "Place the toddler in a room by themselves when they misbehave." C. "Inform the toddler how you feel when they misbehave." D. "Use the toddler's favorite snack as a reward"

A: When taking actions, the nurse should instruct the parent to establish consistent, boundaries to promote a sense of security in the toddler and an understanding of what is right and what is wrong.

27.2) A nurse is caring for a client who has an oral temperature of 38.6° C (101.5° F), heart rate 114/min, and respiratory rate 22/min. Which of the following interventions should the nurse take? (Select all that apply.) A. Obtain culture specimens before initiating antimicrobials. B. Restrict the client's oral fluid intake. C. Encourage the client to rest and limit activity. D. Allow the client to shiver to dispel excess heat. E. Assist the client with oral hygiene frequently.

A: When taking actions, the nurse should obtain culture specimens before initiating antimicrobials to accurately detect the causative microorganism.. C: The nurse should encourage the client to rest and limit activity to conserve energy and decrease their metabolic rate.. E: The nurse should assist the client with oral hygiene frequently to promote comfort and reduce the risk of dry mucous membranes of the mouth and lips..

35.3) A nurse is using the FICA screening tool to gather more data about a client's interfaith needs. Which of the following questions should the nurse ask when using the tool? A. "What gives you a sense of purpose?" B. "Who inspires you?" C. "How has this condition affected you?" D. "Do you have a communication barrier?"

A: When using the FICA screening tool, the nurse should ask open-ended questions to gather more information about the client's interfaith needs. The nurse should ask questions to check the client's faith, implications/influence, community, and address. "What gives you a sense of purpose?" is an appropriate question to ask because this is addressing the client's faith. "Who inspires you?", "How has this condition affected you?", and "Do you have a communication barrier?" are not appropriate questions to ask because they will not address the client's interfaith needs.

5.1) A charge nurse is reviewing documentation with a group of newly licensed nurses. Which of the following legal guidelines should be followed when documenting in a client's record? (Select all that apply.) A. Cover errors with correction fluid, and write in the correct information. B. Put the date and time on all entries. C. Document objective data, leaving out opinions. D. Use as many abbreviations as possible. E. Wait until the end of the shift to document.

B & C: When taking actions, the nurse should ensure that the day and time confirm the recording of the correct sequence of events. The nurse should ensure that the documentation is factual, descriptive, and objective, without opinions or criticism.

17.2) The ostomy nurse is preparing to educate the client about caring for the new colostomy. Place the following actions the ostomy nurse should take in the correct order. A. Ask the client to explain how to care for their colostomy. B. Determine what the client knows about colostomies. C. Select instructional materials about colostomy care to give to the client. D. Demonstrate how to care for the colostomy.

B, C, D, A When taking actions, the ostomy nurse uses the nursing Pre rs action the turse should ake is to dotetine whanthe client knows about colostomies. The ostomy nurse can base the education for the client on preexisting knowledge. The second action the ostomy nurse should take using the nursing process is to plan to use instructional materials to educate the client about colostomy care. The third action the ostomy nurse should take using the nursing process is implementation. The ostomy nurse demonstrates how to care for the colostomy. The fourth action the ostomy nurse should take using the nursing process is evaluation. The ostomy nurse evaluates the client's understanding of how to care for their colostomy.

25.3) A nurse is planning a presentation for a group of older adults about health promotion and disease prevention. Which of the following interventions should the nurse plan to include in the presentation? (Select all that apply.) A. Human papilloma virus (HPV) immunization B. Pneumococcal immunization C. Yearly eye examination D. Periodic mental health screening E. Annual fecal occult blood test

B, C, D, E: The nurse should plan to include information about pneumococcal vaccines, specifically, PCV15, PCV20, and PPSV23. The nurse should also include information about a yearly eye examination to screen for glaucoma and vision changes, periodic mental health assessments, and an annual fecal occult blood test for the group of older adult clients.

44.5) A nurse is preparing to initiate a bladder-retraining program for a client who has urge incontinence. Which of the following actions should the nurse take? (Select all that apply.) A. Restrict the client's intake of fluids during the daytime. B. Have the client record urination times. C. Gradually increase the time of the client's urination intervals. D. Remind the client to try to hold urine until the next scheduled urination time. E. Restrict the client's coffee intake to 2 servings each day.

B, C, D. CORRECT: When taking actions, the nurse should instruct the client to keep track of urination times as a record of progress toward the goal of 4-hr intervals between urination. The nurse should instruct the client to gradually increase the urination intervals and try to hold urine until the next scheduled urination time, to meet the goal of 4-hr intervals between urination.

15.3) A nurse educator is teaching staff members about facility protocol in the event of a tornado. Which of the following should the nurse include? (Select all that apply.) A. Open doors to client rooms. B. Place blankets over clients who are confined to beds. C. Move beds away from windows. D. Draw shades and close drapes. E. Instruct ambulatory clients in the hallways to return to their rooms.

B, C, D: When taking action, the nurse should close all client doors to minimize the threat of flying glass and debris, place blankets over clients to protect them from shattering glass or flying debris, move all beds away from windows to protect clients from shattering glass or flying debris, draw shades and close drapes to protect clients against shattering glass, and instruct ambulatory clients to go to the hallways, away from windows, or other secure locations designated by the facility.

6.3) A nurse is delegating the ambulation of a client who had a knee arthroplasty 2 days ago to an AP. Which of the following information should the nurse share with the AP? (Select all that apply.) A. The client's roommate ambulates independently. B. The client ambulates wearing slippers over antiembolic stockings. C. The client uses a front-wheeled walker when ambulating. D. The client had pain medication 30 min ago. E. The client is allergic to codeine. F. The client ate 50% of breakfast this morning.

B, C, D: When taking actions, the nurse should orovide right direction and communication to ensure the AP can complete this assignment safely. The nurse should share information with the AP to make sure the client wears stockings and slippers and uses a front-wheeled walker while ambulating. The AP should know that the client might be feeling the effects of the pain medication.

11.3) A nurse is contributing to the plan of care for a client who is being admitted to the facility with a suspected diagnosis of pertussis. Which of the following interventions should the nurse suggest?? (Select all that apply.) A. Place the client in a room that has negative air pressure of at least six exchanges per hour. B. Wear a mask when providing care within 3 ft of the client. C. Place a surgical mask on the client if transportation to another department is unavoidable. D. Use sterile gloves when handling soiled linens. E. Wear a gown when performing care that might result in contamination from secretions.

B, C, E: When generating solutions for a client who has pertussis, the nurse should suggest using droplet precautions when caring for this client, including wearing a mask when within 3 feet when caring for the client to protect against inhalation of small droplets and placing a surgical mask on the client when transporting them to contain respiratory droplets. The nurse should also suggest wearing a gown when care may involve contamination from respiratory secretions.

6.1) A nurse is preparing an in-service program about delegation. Which of the following are components of the five rights of delegation? (Select all that apply.) A. Right place B. Right supervision and evaluation C. Right direction and communication D. Right documentation E. Right circumstances

B, C, E: When taking action, the nurse should instruct that right supervision and evaluation, right direction and communication, and right circumstances are included in the five rights of delegation. Right task and right person are also included in the five rights of delegation. The five rights of delegation are used to ensure client care is delegated in a safe and effective manner.

44.3) A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take? (Select all that apply.) A. Empty the client's urinary drainage bag when it is ¾ full. B. Keep the urinary drainage bag below the level of the client's bladder. C. Assess the client's need for the indwelling urinary catheter daily. D. Rest the urinary collection bag on the floor when the client is sitting in a chair. E. Maintain a closed system of the client's urinary catheter.

B, C, E: When taking actions, the nurse should keep the urinary drainage bag below the level of the client's bladder to reduce the risk of urine draining back into the client's bladder. The nurse should assess the need for the indwelling urinary catheter daily and maintain a closed urinary drainage system, to reduce the risk for a CAUTI.

43.2) A nurse is preparing to administer a cleansing enema to a client. Place the steps the nurse should plan to take in the correct order. A. Slowly insert the rectal tube into the client's rectum. B. Warm the enema solution. C. Ask the client to retain the solution. D. Lubricate the end of the rectal tube. E. Hang the enema container 30 to 45 cm (12 to 18 in) above the client's anus.

B, D, A, E, C When taking actions, the nurse should first warm the enema solution to promote comfort. The next action the nurse should take is to lubricate the end of the rectal tube to promote comfort. The nurse should slowly insert the rectal tube about 7.5 to 10 cm (3 to 4 in) into the client's rectum to reduce the risk of injury of the rectal mucosa. The nurse should hang the enema container 30 to 45 cm (12 to 18 in) above the client's anus to allow for slow instillation of the solution. Finally, the nurse should ask the client to retain the solution for the prescribed amount of time, or until the client is no longer able to retain it to promote peristalsis and defecation.

13.4) A nurse is performing a primary survey for a client who has a life-threating condition. In which order should the nurse perform the assessment? A. Check the client's level of consciousness B. Check the client's airway C. Check the client's exposure to adverse elements. D. Check the client's ventilation E. Check the client's circulation

B, D, E, A, C When taking action, the nurse should use the ABCDE principle. This stepwise approach is meant to ensure that life-threatening conditions are identified and treated early. A stands for airway, B stands for breathing (ventilation), C stands for circulation, D stands for disability (level of consciousness) and E stands for exposure (whether the client was exposed to extreme heat or cold).

25.1) A nurse is collecting data from an older adult client as part of a comprehensive physical examination. Which of the following findings should the nurse expect as associated with aging? (Select all that apply.) A. Skin thickening B. Decreased height C. Increased saliva production D. Nail thickening E. Decreased bladder capacity

B, D, E: The nurse should identify that physiological changes that occur with aging can include loss in height due to the thinning of intervertebral disks, thickening of the nails of the fingers and toes, and a reduced bladder capacity. While young adults have a bladder capacity of about 500 to 600 mL, older adults have a capacity of about 250 mL.

22.3) A nurse is reviewing the CDC's immunization recommendations with the guardians of an adolescent. Which of the following recommendations should the nurse include in this discussion? (Select all that apply.) A. Rotavirus B. Varicella C. Herpes zoster D. Human papilloma virus E. Seasonal influenza

B, D, E: When taking action and reviewing the CDC's immunization recommendations with the caregivers of an adolescent, the nurse should include the varicella, human papilloma, and seasonal influenza immunizations as immunizations that are recommended during adolescence.

17.4) The ostomy nurse is educating the client about how to empty their ostomy pouch. Which of the following actions by the client indicates that psychomotor learning has taken place? A. The client states how often the ostomy pouch should be emptied. B. The client demonstrates emptying the ostomy pouch. C. The client writes the steps of how to empty the ostomy pouch on a piece of paper. D. The client states they understand how to empty their ostomy pouch.

B. CORRECT: When evaluating outcomes, the ostomy nurse should identify that the client demonstrating that they can empty the ostomy pouch indicates psychomotor learning has taken place. The psychomotor domain of learning involves performing a physical task.

24.4) A nurse is counseling a middle adult client who describes having difficulty dealing with several issues. Which of the following client statements should the nurse identify as the priority to assess further? A. "I am struggling to accept that my parents are aging and need so much help." B. "It's been so stressful for me to think about having intimate relationships." C. "I know I should volunteer my time for a good cause, but maybe I'm just selfish." D. "I love my grandchildren, but my child expects me to relive my parenting days."

B. CORRECT: When using the urgent vs. nonurgent approach to client care, the counseling priority is the problem that reflects a lack of completion of the previous stage and progression to the current stage of development. According to Erikson, developing intimacy vs. isolation is a task of young adulthood. This middle adult is still struggling with this task and needs assistance in working through searching for and developing intimate relationships with others.

1.1) A nurse is discussing the purpose of regulatory agencies during a staff meeting. Which of the following tasks should the nurse identify as the responsibility of state licensing boards? A. Monitoring evidence-based practice for clients who have a specific diagnosis B. Ensuring that health care providers comply with regulations C. Setting quality standards for accreditation of health care facilities D. Determining whether medications are safe for administration to clients

B. State licensing boards are responsible for ensuring that healthcare providers and agencies comply with state regulations.

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

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

32.3) A nurse is caring for a school-age child who is sitting in a chair. To facilitate effective communication, which of the following actions should the nurse take? A. Touch the child's arm. B. Sit at eye level with the child. C. Stand facing the child. D. Stand with a relaxed posture.

B: Being at the same eye level as the child facilitates communication.

28.1) A nurse in a provider's office is testing the cranial nerves during a head and neck examination. Which of the following cranial nerves are both sensory and motor? (Select all that apply) A. Cranial Nerve Il (Optic) B. Cranial Nerve V (Trigeminal) C. Cranial Nerve VII (Facial) D. Cranial Nerve VIII (Auditory) E. Cranial Nerve XI (Spinal accessory)

B: Cranial nerve V, the trigeminal nerve provides sensory input for the face as well as movement of the jaw; therefore, it is both sensory and motor. C: Cranial nerve VII, the facial nerve allows for facial expression and taste, therefore, it is both sensory and motor.

29.3) A nurse is auscultating a client's lungs. Which of the following findings are expected? (Select all that apply). A. High pitched musical sounds B. Expiration is longer than inspiration over the trachea upon auscultation. C. Soft, breezy, low-pitched sounds D. Medium pitched blowing sounds

B: Expiration that is longer than inspiration over the trachea upon auscultation is an expected bronchial sound. C: Soft, breezy, low- pitched sounds are vesicular sounds which are best heard over the periphery of the lungs and are expected. D: Medium-pitched blowing sounds upon auscultation are bronchovesicular and are expected.

10.4) A nurse has prepared a sterile field for assisting a provider with a chest tube insertion. Which of the following events should the nurse recognize as contaminating the sterile field? (Select all that apply.) A. The provider drops a sterile instrument onto the near side of the sterile field. B. The nurse moistens a cotton ball with sterile normal saline and places it on the sterile field. C. The procedure is delayed 1 hr because the provider receives an emergency call. D. The nurse turns to speak to someone who enters through the door behind the nurse. E. The client's hand brushes against the outer edge of the sterile field.

B: Fluid permeation of the sterile drape or barrier contaminates the field. C: Prolonged exposure to air contaminates a sterile field. D: Turning away from a sterile field contaminates the field because the nurse cannot see if a piece of clothing or hair made contact with the field.

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

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

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

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

37.1) A nurse is providing information about age-related physical changes to the family member of an older adult. Which of the following information should the nurse include? A. Older adults have oilier skin than younger persons. B. Dry mouth is common for older adults. C. It is common for older adults to have increased perspiration. D. Hair in the eyebrows decreases.

B: It is common for older adults to experience dry mouth due to decreased saliva production, and many older adults take medications that lead to dry mouth.

10.1) A nurse is reviewing hand hygiene techniques with a group of assistive personnel (AP). Which of the following instructions should the nurse include when discussing handwashing? (Select all that apply.) A. Apply 3 to 5 mL of liquid soap to dry hands. B. Wash the hands with soap and water for at least 15 seconds. C. Rinse the hands with hot water. D. Use a clean paper towel to turn off hand faucets. E. Allow the hands to air-dry after washing

B: It takes 15 seconds to remove transient flora from the hands. For soiled hands, the recommendation is 2 minutes. D: If the sink does not have foot or knee pedals, the APs should turn off the water with a clean paper towel and not with their hands.

16.4) A nurse at a health department is planning strategies related to heart disease. Which of the following activities should the nurse include as part of primary prevention? A. Providing cholesterol screening B. Teaching about a healthy diet C. Providing information about antihypertensive medications D. Developing a list of cardiac rehabilitation programs

B: Primary prevention encompasses strategies that help prevent illness or injury. This level of prevention includes health information about nutrition, exercise, stress management, and protection from injuries and illness.

24.3) A nurse is collecting data to evaluate a middle adult's psychosocial development. The nurse should expect middle adults to demonstrate which of the following developmental tasks? (Select all that apply.) A. Develop an acceptance of diminished strength and increased dependence on others. B. Spend time focusing on improving job performance. C. Welcome opportunities to be creative and productive. D. Commit to finding friendship and companionship. E. Become involved with community issues and activities.

B: Psychosocially healthy middle adults strive to do well in their environment as part of achieving Erikson's stage of generativity vs. stagnation. C: Psychosocially healthy middle adults accept life's opportunities for creativity and productivity and use these opportunities for achieving Erikson's stage of generativity vs. stagnation. E: Psychosocially healthy middle adults work to contribute to future generations through community involvement and parenting as part of achieving Erikson's stage of generativity vs. stagnation.

16.2) A nurse at a provider's office is talking about routine screenings with a 45-year-old female client who has no specific family history of cancer or diabetes mellitus. Which of the following client statements indicates that the client understands how to proceed? A. "I'll need a colonoscopy in 5 years." B. "For now, I should continue to have a clinical breast exam each year." C. "Because the doctor just did a Pap smear, I'l come back next year for another one." D. "I had my blood glucose test last year, so I won't need it again for 4 years."

B: The female client who is between the ages of 40 and 49 should have a clinical breast exam annually, and they should consult with their provider about the frequency of mammograms.

14.1) A nurse educator is reviewing proper body mechanics during employee orientation. Which of the following statements should the nurse identify as an indication that an attendee understands the teaching? (Select all that apply.) A. "My line of gravity should fall outside my base of support." B. "The low stayiel thr of gravity. C. "To broaden my base of support, I should spread my feet apart." D. "When I lift an object, I should hold it as close to my body as possible." E. "When pulling an object, I should move my front foot forward."

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

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

B: The nurse identifies that in this situation, the client is exercising their right to make their own personal decision about surgery, regardless of others' opinions of what is "best" for them. This is an example of autonomy.

34.4) A nurse is caring for a client who is recovering from a myocardial infarction and a cardiac catheterization. The client states, "I am concerned that things might be a little, you know, 'different' with my partner when I get home." Which of the following statements should the nurse make? A. "It sounds like something you should discuss with them when you get home.". В. "It sounds like you are concerned about sexual functioning. Let's discuss your concerns." C. "Oh, I wouldn't be too concerned. Things will be fine as soon as we get you home." D. "Just make sure you take your medication as directed, and you should be fine."

B: The nurse should acknowledge and allow the client to discuss their concerns regarding sexual functioning. The nurse should not give the client false reassurance.

23.5) A nurse is reviewing safety precautions with a group of young adults at a community health fair. Which of the following recommendations should the nurse include to address common health risks for this age group? (Select all that apply.) A. Install bath rails and grab bars in bathrooms. B. Wear a helmet while skiing. C. Install a carbon monoxide detector. D. Secure firearms in a safe location. E. Remove throw rugs from the home.

B: The nurse should encourage the client to wear a helmet while skiing to reduce the risk of head injury. Although it applies to other age groups, many young adults engage in winter sports. Therefore, this is an age-appropriate recommendation for this developmental group. C: The nurse should remind the client to install a carbon monoxide detector in the home. This is an essential safety precaution for young adults as well as for all other developmental stages. D: The nurse should warn the client to secure firearms in a safe location to reduce the risk of accidental gunshot injuries. Although it applies to all age groups, many young adults own firearms, so this is an age-appropriate recommendation for this developmental group.

33.3) A nurse is caring for a client who has a new diagnosis of type 2 diabetes mellitus. Which of the following nursing interventions for stress, coping, and adherence to the treatment plan should the nurse initiate at this time? (Select all that apply.) A. Suggest coping skills for the client to use in this situation. B. Allow the client to provide input in the treatment plan. C. Assist the client with time management, and address the client's priorities. D. Provide extensive instructions on the client's treatment regimen. E. Encourage the client in the expression of feelings and concerns.

B: The nurse should identify that allowing the client to contribute to the treatment plan allows for greater adherence to the plan. C: Helping the client to prioritize is an intervention that can reduce levels of stress for the client because, many times, time management is extremely difficult in times of stress. E: By using effective communication techniques, encouraging the client to verbalize feelings is an intervention for stress, coping, and adherence that allows the client to reduce stress, validate emotions, and start planning for valid concerns.

33.2) A nurse is caring for a client whose partner passed away 4 months ago. The client has a recent diagnosis of diabetes mellitus. The client is tearful and states, "How could you possibly understand what I am going through?" Which of the following responses should the nurse make? A. "It takes time to get over the loss of a loved one." B. "You are right. I cannot really understand. Perhaps you'd like to tell me more about what you're feeling." C. "Why don't you try something to take your mind off your troubles, like watching a funny movie." D. "I might not share your exact situation, but I do know what people go through when they deal with a loss."

B: The nurse should identify that by stating there is a lack of understanding, the nurse is using the therapeutic communication technique of validation, whereby a person shows sensitivity to the meaning behind a behavior. The nurse is also creating a supportive and nonjudgmental environment and inviting the client to express frustrations.

23.4) A nurse is instructing a young adult client about health promotion and illness prevention. Which of the following statements indicates understanding? A. "I already had my immunizations as a child, so I'm protected in that area." B. "It is important to schedule routine health care visits even if I am feeling well." C. "I will just go to an urgent care center for my routine medical care." D. "There's no reason to seek help if I am feeling stressed because it's just part of life."

B: The nurse should identify that despite being in relatively good health, young adult clients should plan to participate in routine screenings and health care visits.

12.3) A nurse manager is reviewing with nurses on the unit in the care of a client who has had a seizure. Which of the following statements by a nurse requires further instruction? A. "I will place the client on their side." B. "I will go to the nurses' station for assistance." C. "I will note the time that the seizure begins." D. "I will prepare to insert an airway."

B: The nurse should identify that during a seizure, the client should not be left alone, and the call light system should be activated to summon assistance.

34.2) A nurse is caring for a group of clients on a medical-surgical unit. Which of the following clients are at increased risk for body-image disturbances? (Select all that apply.) A. A client who had a laparoscopic appendectomy B. A client who had a mastectomy C. A client who had a left above-the-knee amputation D. A client who had a cardiac catheterization E. A client who had a stroke with right-sided hemiplegia

B: The nurse should identify that having a mastectomy involves a change in physical appearance and can lead to body-image disturbances related to sexuality. C: Having an above-the-knee amputation involves a change in physical appearance and can lead to body-image disturbances related to function, health, and strength. E: Having right-sided hemiplegia involves a change in physical appearance and can lead to body-image disturbances related to function, health, and strength.

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

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

34.1) A nurse is teaching a group of clients how to care for their colostomies. Which of the following statements indicates an issue with self-concept? A. "I was having difficulty with attaching the appliance at first, but my partner was able to help." B. "I'll never be able to care for this at home. Can't you just send a nurse to the house?" C. "I met a neighbor who also has a colostomy, and they taught me a few things." D. "It can take me a while to get the hang of this. I have to admit, I am pretty nervous."

B: The nurse should identify that the client is displaying a lack of interest in learning how to care for the colostomy and preferring dependence on others to perform the care. Issues with self-concept should be suspected.

32.1) A nurse is caring for a client wid if nurs admitted to the unit. Which action should the nurse take to establish a helping relationship with the client? A. Make sure the communication is equally distributed between the nurse's and client's desires. B. Encourage the client to communicate their thoughts and feelings. C. Give the nurse-client communication no time limits. D. Allow communication to occur spontaneously throughout the nurse-client relationship.

B: Therapeutic communication facilitates a helping relationship that maximizes the client's ability to express their thoughts and feelings openly.

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

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

38.5) A nurse is instructing a client who has narcolepsy. Which of the following client statements indicates an understanding of the instructions? A. "I will add plenty of carbohydrates to my meals." B. "I will take a short nap when I feel sleepy." C. "I will increase the heat in my office, so I stay warm." D. "I will limit alcohol intake to one drink per day."

B: When evaluating outcomes, the nurse should identify that the client statement to take short naps when they are feeling drowsy indicates an understanding of the teaching. Taking a planned daytime nap might reduce the risk of falling asleep at an inopportune time, such as when driving or at work. The nurse should also instruct the client to eat high protein meals, perform regular exercise, and avoid activities that might cause drowsiness, such as being in a warm environment and drinking alcohol.

17.5) The ostomy nurse is educating the client about diet. Which of the following actions should the nurse take to evaluate the client's learning? A. Encourage the client to ask questions about their diet. B. Ask the client to list foods to include in their diet. C. Encourage the client to fill out an evaluation form about how the nurse presented the information about diet. D. Ask the client if they have additional resources for further instruction about their new diet,

B: When evaluating outcomes, the ostomy nurse should identify that having the client explain the information in their own words allows the nurse to evaluate what the client remembers, whether the client comprehends the information, and if further instruction is required.

28.4) A nurse is preparing to inspect the ears, nose, mouth, and throat of a client. Which of the following equipment does the nurse need? A. Ophthalmoscope B. Tongue blade C. Penlight D. Gauze square E. Stethoscope

B: When examining the ears, mouth a nose of a client, the nurse needs a tongue blade to examine the client's tongue on all sides and the floor of the mouth, C: A penlight to examine the color, size, position, and texture of the tongue. D: A gauze square to grasp the tongue during the examination.

9.4) A nurse is preparing the discharge summary for a client who has had knee arthroplasty and is going home. Which of the following information about the client should the nurse include in the discharge summary? (Select all that apply.) A. Advance directives status B. Follow-up care Instructions for diet and medications D. Most recent vital sign data E. Contact information for the home health care agency

B: When generating solutions, the nurse should identify that it is essential to include the names and contact information of providers and community resources the client will need after they return home. C: The client will need written information detailing home medication and dietary therapy. A client who has had knee arthroscopy typically requires analgesics, possibly anticoagulants, and dietary instructions for avoiding postoperative complications (constipation). E: It is essential to include the names and contact information of providers and community resources the client will need after returning home. For example, a client who had a knee arthroplasty might require physical therapy at home until able to travel to a physical therapy department or facility.

27.6) A nurse is caring for a client who has a fractured femur and a blood pressure of 140/94 mm Hg. Which of the following actions should the nurse take first? A. Request a prescription for an antihypertensive medication. B. Ask the client if they are having pain. C. Instruct the client about a low-sodium diet. D. Return in 30 min to recheck the client's blood pressure.

B: When taking actions using the nursing process, the first action that the nurse should take is ask the client it they are experiencing pain. Pain can cause an elevated blood pressure. Therefore, the priority action is to evaluate the client for pain.

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

B: When taking actions, the nurse manager should identify that a client who is postoperative following thoracic surgery requires the professional nursing knowledge, skills, and judgment of an RN to provide safe and effective client care.

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

B: When taking actions, the nurse should identify that elastic stockings promote venous return and prevent thrombus formation.

39.4) A nurse is caring for a client who is at high risk for aspiration. Which of the following actions should the nurse take? A. Giving the client thin liquids B. Instructing the client to tuck their chin when swallowing C. Having the client use a straw D. Encouraging the client to lie down and rest after meals

B: When taking actions, the nurse should identify that tucking the chin when swallowing allows food to pass down the esophagus more easily.

5.4) A nurse manager is discussing the HIPAA Privacy Rule with a group of newly hired nurses during orientation. Which of the following information should the nurse manager include? (Select all that apply.) A. A single electronic records password is provided for nurses on the same unit. B. Family members should provide a code prior to receiving client health information. C. Communication of client information can occur at the nurses' station. D. A client can request a copy of their medical record. E. A nurse can photocopy a client's medical record for transfer to another facility.

B: When taking actions, the nurse should identity that the HIPAA Privacy Rule states that information should only be disclosed to authorized individuals to whom the client has provided consent. Many hospitals use a code system to identify those individuals and should only provide information if the individual can give the code. C: The HIPAA Privacy Rule states that communication about a client should only take place in a private setting where unauthorized individuals cannot overhear it. A unit nurses' station is considered a private and secure location D: The HIPAA Privacy Rule states that clients have a right to read and obtain a copy of their medical recora. E: The HIPAA Privacy Rule states that nurses can only photocopy a clients medical record if it is to be used for transfer to another facility or provider.

39.3) A nurse is caring for a client who weighs 80 kg (176 lb) and is 1.6 m (5 ft 3 in) tall. Calculate the body mass index (BMI) and determine whether this client's BMI indicates a healthy weight, underweight, overweight, or obese.

BMI = weight (kg) ÷ height (m2). Step 1: Client's weight (kg) and height (m) = 80 kg and 1.6 m. Step 2: 1.6 × 1.6 = 2.56 m?. Step 3: 80 ÷ 2.56 = 31.25. A BMI greater than 30 identifies obesity.

2.4) A client who had a cerebrovascular accident has persistent problems with dysphagia. The nurse caring for the client should initiate a referral with which of the following members of the interprofessional care team? (Select all that apply.) A. Social worker B. Certified nursing assistant C. Occupational therapist D. Speech-language pathologist E. Physical therapist

C & D: The nurse should identify that a speech-language pathologist and an occupational therapist can initiate specific therapy for clients who have difficulty with feeding due to swallowing difficulties.

15.2) A nurse notes a fire in a trash can in a client's room. In what order should the nurse take action? A. Pull the fire alarm. B. Use the fire extinguisher. C. Help the client and others leave the area. D. Close doors.

C, A, D, B Using the RACE mnemonic, the nurse should: Rescue the client and other individuals from the area. Sound the fire alarm, which activates the EMS response system. Systems that could increase fire spread are automatically shut down with activation of the alarm. After clearing the room or area, close the door leading to the area in which the fire is located as well as the fire doors and any open windows. Fire doors are kept closed as much as possible when moving from area to area within the facility to avoid the spread of smoke and fire. Make an attempt to extinguish small fires using a single fire extinguisher, smothering them with a blanket, or dousing with water (except with an electrical or grease fire). Complete evacuation of the area occurs if the nurse cannot put the fire out with these methods. Attempts at extinguishing the fire are only made when the employee is properly trained in the safe use of a fire extinguisher and when only one extinguisher is needed.

37.2) A nurse is providing a client with a complete bed bath. When providing the care, the nurse must recognize the order in which areas of the body will be bathed. Place the options in the correct order. A. Trunk B. Feet C. Face D. Legs

C, A, D, B When providing the client with a complete bed bath, the nurse should begin with the cleanest area and work down toward the feet. The nurse cleanses the face first. Next, the nurse should wash the client's trunk and upper extremities followed by the legs and then the feet.

11.1) A nurse is reviewing the stages of infection with new nurses. Place the stages in the order in which they occur. A. Prodromal B. Convalescence C. Incubation D. Illness

C, A, D, B When taking actions to revie thbation stage erton in order the nurse will first review the incubation stage, the interval the were the pathogen entering the review the presentation of manifestations. The nurse will then review the prodromal stage, the interval from onset of general manifestations to more distinct findings. The nurse will then review the illness stage, in which manifestations specific to the infection occur. The nurse will discuss last the convalescence stage, in which acute findings disappear and total recovery occurs.

25.4) A nurse is providing teaching for an older adult client who has lost 4.5 kg (9.9 lb) since the last admission 6 months ago. Which of the following instructions should the nurse include in the teaching? (Select all that apply.) A. "Eat three large meals a day." B. "Eat your meals in front of the television." C. "Eat foods that are easy to eat, such as finger foods." D. "Invite family members to eat meals with you." E. "Exercise every day to increase appetite."

C, D, E: The nurse should instruct the client to involve family members with meals and to eat finger foods because finger foods are easier for the older adult client to eat. Socialization during meals promotes nutritional intake, and daily exercise increases appetite.

41.2) A nurse is monitoring a client for adverse effects following the administration of an opioid. Which of the following effects should the nurse identify as an adverse effect of opioids? (Select all that apply.) A. Urinary incontinence B. Diarrhea C. Bradypnea D. Orthostatic hypotension E. Nausea

C, D, E: When evaluating outcomes, the nurse should identify that the manifestations of adverse reaction to opioid medication include bradypnea, orthostatic hypotension, and nausea.

15.5) A nurse on a medical-surgical unit is informed that a mass casualty event occurred in the community and that it is necessary to discharge stable clients to make beds available for injury victims. Which of the following clients should the nurse recommend for discharge? (Select all that apply.) A. A client who is dehydrated and receiving IV fluid and electrolytes B. A client who has a nasogastric tube to treat a small bowel obstruction C. A client who is scheduled for elective surgery D. A client who has chronic hypertension and blood pressure 135/85 mm Hg E. A client who has acute appendicitis and is scheduled for an appendectomy

C, D: When generating solutions, the nurse should recognize that a client who is scheduled elective surgery and a client who has blood pressure of 135/85 mm Hg, which is within the reference range for prehypertension, are stable and should recommend for discharge. A client who is receiving IV fluid and electrolytes, a client who has a nasogastric tube, and a client who has an acute illness and is scheduled for surgery requires ongoing nursing care and are therefore unstable for discharge.

19.6) A nurse is giving a presentation to a group of parents of toddlers about home safety. Which of the following strategies should the nurse include? (Select all that apply.) A. Ensure crib slats are no further apart than 10 cm (3.9 in). B. Keep toilet lids up. C. Turn pot handles toward the back of a stove. D. Make sure balloons are fully inflated. E. Cover electrical outlets with safety covers. F. Place safety gates across stairways.

C, E, F: When taking actions, the nurse should include in the presentation to turn pot handles toward the back of a stove when cooking to reduce the risk of a toddler pulling on the pot and spilling its contents on themselves; to cover electrical outlets with safety covers or safety plugs to prevent the risk of electrocution; and place safety gates across stairways to reduce the risk of the toddler falling down the stairs.

31.1) A nurse is assessing a client's musculoskeletal system as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply.) A. Concave thoracic spine posteriorly B. Exaggerated lumbar curvature C. Concave lumbar spine posteriorly D. Exaggerated thoracic curvature E. Muscles slightly larger on the dominant side

C, E: When analyzing cues, the nurse should expect the client to have a concave lumbar spine posteriorly, and muscle size that is equal on both sides or slightly larger on the client's dominant side.

18.4) A nurse is providing information to parents about nutrition for an infant. Which statements by the parents indicate their understanding of the information? A. "If we stop breastfeeding at 6 months, we can switch to whole milk." B. "If we use formula to feed our newborn, we will include extra water after feedings." C. "Our infant will be ready for solid foods at about 6 months." D. "Our infant will need an iron supplement while breastfeeding."

C. CORRECT: When evaluating outcomes about the parents' understanding of nutrition information for infants, the nurse recognizes that the statement, "Our infant will be ready for solid foods at about 6 months" indicates understanding that the infant is physiologically and developmentally ready for the introduction of solid foods at about 6 months of age.

45.5) A nurse is reviewing instructions with a client who has a new prescription for hearing aids. Which of the following client statements indicates an understanding of the instructions? A. "I will clean the ear molds of my hearing aids with rubbing alcohol each day." B. "I will use hairspray to keep my hair away from my hearing aids." C. "I will take the batteries out of my hearing aids when I take them off at night." D. "I will soak my hearing aids in warm water once each week."

C. CORRECT: When evaluating outcomes, the nurse should identify that the client statement to take the batteries out of the hearing aids at night indicates an understanding of the teaching. To conserve battery power, the client should turn off the hearing aids and remove the batteries when not in use.

35.1) A nurse is providing teaching with a newly licensed nurse about incorporating culturally responsive nursing care. Which of the following statements by the newly licensed nurse indicates understanding? A. "It is a form of client ethnocentrism." B. "It involves being knowledgeable about various cultures." C. "It involves the delivery of care that includes the client's beliefs." D. "It is the examination of the nurse's personal attitude."

C: Culturally responsive nursing care involves the delivery of care that considers a client's cultural beliefs that could affect their well-being

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

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

29.1) A nurse is examining the breast of a female young adult client. The nurse should determine that which of the following are expected findings? (Select all that apply) A. The client's nipples are inverted. B. The client has a dimple on the left breast. C. The client's left breast is smaller than the right breast. D. The client's areolae are oval shaped. E. The underlying veins in the breast are visible.

C: One breast being larger than the other is a common, expected finding. D: The client's areolae can be either round or oval shaped. E: The veins can be visualized for client who is thin.

10.2) When entering a client's room to change a surgical dressing, a nurse notes that the client is coughing and sneezing. Which of the following actions should the nurse take when preparing the sterile field? A. Keep the sterile field at least 6 ft away from the client's bedside. B. Instruct the client to refrain from coughing and sneezing during the dressing change. C. Place a mask on the client to limit the spread of micro-organisms into the surgical wound. D. Keep a box of facial tissues nearby for the client to use during the dressing change.

C: Placing a mask on the client prevents contamination of the surgical wound during the dressing change.

32.5) A nurse is caring for a client who is concerned about being discharged to home with a new colostomy because of being an avid swimmer. Which of the following statements should the nurse make? (Select all that apply.) A. "You will do great! You just have to get used it." B. "Why are you worried about going home?" C. "Your daily routines will be different when you get home." D. "Tell me about the support system you'll have after you leave the hospital." E. "It sounds like you are not sure how having a colostomy will affect swimming."

C: Presenting reality is an effective communication technique that can help the client focus on what will really happen after the changes the surgery has made. D: Asking open-ended questions and offering general leads and broad opening statements are effective communication techniques that encourage the client to express feelings through dialogue and offer additional information. E: Focusing is an effective communication technique that clearly directs the interaction to the relevant point.

20.2) A nurse is planning diversionary activities for preschoolers on an inpatient pediatric unit. Which of the following activities should the nurse include? (Select all that apply.) A. Hide and seek B. Pulling wheeled toys C. Putting puzzles together D. Using musical toys E. Playing with puppets F. Coloring with crayons

C: Putting puzzles together helps a preschooler develop fine motor and cognitive skills. D: Playing with musical toys helps a preschooler develop fine motor skills and coordination. E: Playing with puppets helps a preschooler develop oral language and actively use their imagination. F: Using crayons to color on paper or in coloring books helps a preschooler develop fine motor skills and coordination.

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

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

16.3) A nurse is caring for a young adult at a college health clinic. Which of the following actions should the nurse take first? A. Give the client information about immunization against meningitis. B. Tell the client to have a TB skin test every 2 years. C. Determine the client's health risks. D. Teach the client about exercise recommendations.

C: The first action that should be taken using the nursing process is assessment. Talk with the client first to determine what risk factors the client might have before initiating the health promotion and disease prevention measures.

4.3) A nurse is providing preoperative teaching for a client who is scheduled for surgery the next week. The client tells the nurse, "I plan to prepare my advance directives before I come to the hospital." Which of the following statements made by the client indicates an understanding of advance directives? A. "I'd rather have my brother make my decisions for me, but I know it must be my spouse." B. "I know they won't go ahead with the surgery unless I fill out the form." C. "I plan to tell them I don't want to be kept on a breathing machine." D. "I will get my regular doctor to approve my plan before I hand it to the hospital."

C: The hospital staff cannot refuse care based on the lack of advance directives. The client has the right to decide and specify which medical procedures they want when a life-threatening situation arises.

10.5) A nurse is wearing sterile gloves in preparation for performing a sterile procedure. Which of the following objects can the nurse touch without breaching sterile technique? (Select all that apply.) A. A bottle containing a sterile solution B. The edge of the sterile drape at the base of the field C. The inner wrapping of an item on the sterile field D. An irrigation syringe appropriately placed on the sterile field E. One gloved hand with the other gloved hand

C: The inner wrappings of any objects dropped onto the sterile field are sterile. Touch them with sterile gloves. D: Any sterile objects dropped onto the sterile field during the setup are sterile. Touch the syringe with sterile gloves. E: One sterile gloved hand may touch the other sterile gloved hand because both are sterile.

39.5) A nurse is caring for a client who requires a low-residue diet. The nurse should expect to see which of the following foods on the client's meal tray? A. Cooked barley B. Pureed broccoli C. Vanilla custard D. Lentil soup

C: The nurse should identify that a low-residue diet consists of foods that are low in fiber and easy to digest. Dairy products and eggs (custard and yogurt are appropriate for a low-residue diet.

23.1) A charge nurse is explaining the various stages of the lifespan to a group of newly licensed nurses. Which of the following examples should the charge nurse include as a developmental task for a young adult? A. Becoming actively involved in providing guidance to the next generation B. Adjusting to major changes in roles and relationships due to losses C. Devoting time to establishing an occupation D. Finding oneself "sandwiched" between and being responsible for two generations

C: The nurse should identify that exploring career options and then establishing oneself in a specific occupation is a major developmental task for a young adult.

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

C: The nurse should identify that justice is fairness in care delivery and in the use of resources. By applying the same qualifications to all potential kidney transplant patients, organ procurement organizations demonstrate this ethical principle, and determining the allocation of these scarce resources.

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

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

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

C: The nurse should identify that the dorsal surface of the hand is the most sensitive to temperature

23.2) A nurse is counseling a young adult who describes having difficulty dealing with several issues. Which of the following statements should the nurse identify as the priority to assess further? A. "I have my own apartment now, but it's not easy living away from my guardians." B. "It's been so stressful for me to even think about having my own family." C. "I don't even know who I am yet, and now I'm supposed to know what to do." D. "My partner is pregnant, and I don't think l have what it takes to be a good parent."

C: The nurse should identify that when using the urgent vs. nonurgent approach to client care, the counseling priority is the problem that reflects a lack of completion of the previous stage of development and progression to the current stage. According to Erikson, it is a task of adolescence to develop identity vs. role confusion. The nurse should recognize this young adult is still struggling with this task and needs assistance in working through that dilemma.

33.1) A nurse is caring for a client awaiting transport to the surgical suite for a coronary artery bypass graft. Just as the transport team arrives, the nurse takes the client's vital signs and notes an elevation in blood pressure and heart rate. The nurse should recognize this response as which part of the general adaptation syndrome (GAS)?? A. Exhaustion stage B. Resistance stage C. Alarm stage D. Recovery stage

C: The nurse should identify that, in the alarm stage of GAS, body functions (blood pressure and heart rate) are heightened in order to respond to stressors.

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

C: The nurse should instruct the client to have a table beside the bed so they can sit on the bedside and rest their arms on the table. This is an accurate description for the orthopneic position. This position allows for chest expansion and is especially beneficial for clients who have COPD.

4.2) A nurse notes that an oncoming nurse smells of alcohol and seems unsteady. Which of the following actions should the nurse take? A. Report the oncoming nurse to the board of nursing. B. Confront the oncoming nurse. C. Notify the oncoming supervisor. D. Ask an assistive personnel (AP) if they smelled alcohol on the oncoming nurse's breath.

C: The nurse's duty is to protect client safety. The nurse should report the observation to the oncoming supervisor whose duty is to ensure that a thorough investigation occurs, and if the facts indicate the nurse reported to work after drinking alcohol, report the nurse to the state board of nursing.

22.4) A nurse is talking with an adolescent who is having difficulty dealing with several issues. Which of the following issues should the nurse identify as the priority? A. "I kind of like this boy in my class, but he doesn't like me back." B. "I want to hang out with the kids in the science club, but the jocks pick on them," C. "I am so fat, I skip meals to try to lose weight." D. "My dad wants me to be a lawyer like him, but I just want to dance."

C: When analyzing cues while talking with an adolescent who is having difficulty dealing with several issues the nurse should identify that the greatest risk to the adolescent is injury due to an eating disorder. The priority issue is to provide counseling to promote body image and ensure proper nutrition.

41.5) A nurse is assessing a client who is reporting pain despite taking analgesia. Which of the following actions should the nurse take to determine the intensity of the client's pain? A. Ask the client what precipitates the pain. B. Question the client about the location of the pain. C. Offer the client a pain scale to measure their pain. D. Use open-ended questions to identify the client's pain sensations.

C: When assessing the intensity of a client's pain, the nurse should use a numeric, verbal, or visual analog scale that is appropriate to the client's individual needs the nurse to help the client report the intensity of their pain.

41.3) A nurse is caring for a client who is receiving morphine via a patient-controlled analgesia (PCA) infusion device after abdominal surgery. Which of the following statements indicates that the client knows how to use the device? A. "I'll wait to use the device until it's absolutely necessary." B. "I'll be careful about pushing the button too much so I don't get an overdose." C. "I should tell the nurse if the pain doesn't stop while I am using this device." D. "I will ask my adult child to push the dose button when I am sleeping."

C: When evaluating outcomes, the nurse should identify that the client understands the purpose of a PCA infusion by their statement, "I should tell the nurse if the pain doesn't stop while I am using this device". This indicates that while the client knows that the device is used for pain control, but if it does not adequately control their pain, the nurse can notify the provider to modify the PCA settings to ensure adequate pain control.

19.5) A nurse is reviewing nutritional guidelines with the parent of a 2-year-old toddler. Which of the following parent statements indicates an understanding of the teaching? A. "I will give my child popcorn because it is more nutritious than sweets." B. "I have to give my child whole milk until age 3 years." C. "I'll give my child 2 tablespoons of food for each serving." D. "It's okay for me to give my child a cup of apple juice with each meal."

C: When evaluating outcomes, the nurse should identify that the parent understands that a serving size for toddlers should be about 1 tbsp of solid food per year of age, so 2-year-olds should have about 2 tbsp of food per serving.

30.2) A nurse is performing an integumentary assessment for a group of clients. Which of the following findings is the nurse's priority? A. Pallor B. Jaundice C. Cyanosis D. Erythema

C: When prioritizing a hypothesis, using the airway, breathing, circulation approach to client care, the nurse should identify that the priority finding is cyanosis. Cyanosis is a manifestation of hypoxia and can indicate impaired oxygenation. Therefore, cyanosis is the priority finding.

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

C: When prioritizing hypotheses, the nurse should identify that the greatest risk to this client is injury from skin breakdown due to unrelieved pressure over a bony prominence from prolonged sitting in a chair. Instruct the client to shift their weight every 15 min, and reposition the client after 1 hr.

17.1) The ostomy nurse is providing preoperative education for the client who is scheduled for a sigmoid colostomy. The nurse should identify that which of the following client statements is an indication that the client is ready to learn? A. "I will not look at my incision after the surgery." B. "Will you give me pain medicine after the surgery?" C. "Can you tell me about how long the surgery will take?" D. "I can't remember what my doctor told me about the surgery."

C: When recognizing cues, the ostomy nurse should identify that asking a concrete question about the procedure indicates that the client is ready to learn about the surgery.

20.1) A nurse is talking with the caregiver of a 4-year-old child who reports that the child is waking up at night with nightmares. Which of the following interventions should the nurse suggest? A. Offer the child a large snack before bedtime. B. Allow the child to watch an extra 30 min of TV in the evening. C. Have the child go to bed at a consistent time every day. D. Increase physical activity before bedtime.

C: When taking action while talking to the caregiver of a 4-year-old child who reports that the child is waking up at night with nightmares, the nurse should encourage the caregiver to have the child go to bed at a consistent time every night to promote a bedtime routine. It is also helpful to bathe the child or read a story every night before bed to promote consistency, which should provide reassurance and ensure the child gets adequate sleep:

15.4) An occupational health nurse is caring for an employee who was exposed to an unknown dry chemical, resulting in a chemical burn. Which of the following interventions should the nurse include in the plan of care? A. Irrigate the affected area with running water. B. Wash the affected area with antibacterial soap. C. Brush the chemical off the skin and clothing. D. Leave the clothing in place until emergency personnel arrive.

C: When taking action, the nurse should not apply water to a dry chemical exposure because it could activate the chemical and cause further harm. The nurse should wash the skin with antibacterial soap in the event of a biological exposure, use a brush to remove the chemical off the skin and clothing, and plan to remove the client's clothing following decontamination.

36.5) A nurse is preparing to perform postmortem care for a client. The family wishes to view the body. Which of the following actions should the nurse take? A. Make sure the body is lying completely flat. B. Remove dentures from the client. C. Place a clean gown on the client's body. D. Remove all equipment from the client's bedside. E. Dim the lights in the client's room.

C: When taking actions, the nurse should demonstrate respect to the client by washing soiled areas of the client's body and covering the client with fresh linens and a clean gown. D: The nurse should remove all equipment and supplies from the client's bedside to provide a calm, uncluttered environment. E: Dimming the lights provides a peaceful atmosphere for the family.

22.1) A nurse is teaching the guardian of a 12-year-old male client about manifestations of puberty. The nurse should explain that which of the following physical changes occurs first? A. Appearance of downy hair on the upper lip B. Hair growth in the axillae C. Enlargement of the testes and scrotum D. Deepening of the voice

C: When using evidence-based practice to take action and teaching to the parent of a 12-year-old male client about the manifestation of puberty, the nurse should explain that the first prepubescent change in boys is an increase in the size of the testicles and scrotum, and growth of pubic hair.

6.4) A nurse on a medical-surgical unit has received change-of-shift reports on five clients. Understanding that a PN can perform each of the following tasks, sort the tasks the nurse should assign to the AP or the PN. 4. Assist with updating the plan of care tor a client who is postoperative B. Reinforce teaching with a client who is learning to walk using a quad cane C. Reapply a condom catheter for a client who has urinary incontinence D. Apply a sterile dressing to a pressure injury E. Perform postmortem care for a client who has died

CNA: C, E LPN: A, B, D When taking actions, the nurse should identify that assisting with updating the plan of care for a client, reinforcing teaching a client, and applying a sterile dressing requires professional nursing knowledge and judgment and should be assigned to the PN. The application of a condom catheter and performing postmortem care are noninvasive, routine procedures that can be delegated to the AP.

45.4) A nurse is teaching a newly licensed nurse about assessing clients who have hearing loss. Sort the following findings into conductive hearing loss or sensorineural hearing loss. A. The client speaks softly. B. The client speaks loudly. C. Weber test that indicates the tuning fork sound is heard better in the affected ear. D. Weber that indicates the tuning fork sound is heard better in the unaffected ear. E. Cerumen obstructs the ear canal. F. The client reports tinnitus.

CONDUCTIVE HEARING LOSS: A, C, E SENSORINEURAL HEARING LOSS: B, D, F When taking actions, the nurse should instruct the newly licensed nurse that findings associated with a conductive hearing loss include the Weber test indicates the tuning fork sound is heard better in the affected ear, cerumen obstructs the ear canal, and the client speaks softly. The nurse should instruct the newly licensed nurse that findings associated with a sensorineural hearing loss include the Weber test indicates the tuning fork sound is heard better in the unaffected ear, the client reports tinnitus, and the client speaks loudly.

11.4) The nurse is reviewing the use of transmission-based isolation precautions with a group of new nurses. Sort the following infectious diseases by the type of precautions required. (Contact, Droplet, Airborne) A. Tuberculosis B. SARS-CoV-2 (COVID-19) C. Influenza D. C. difficile E. MRSA

CONTACT: D, E DROPLET: C AIRBORNE: A, B When taking actions to review transmission-based isolation precautions, the nurse discusses contact precautions for C. difficile and MRSA to prevent transmission of microorganisms from one client to another through direct or indirect contact. The nurse discusses droplet precautions for influenza to prevent transmission of respiratory droplets greater than 5 microns. The nurse discusses airborne precautions for tuberculosis and SARS-CoV-2 to prevent transmission of respiratory droplets smaller than 5 microns.

18.1) A nurse is reviewing motor development with the parents of an infant. Identify the order in which these motor skills are expected to occur. A. Pulls self up into a standing position B. Rolls from stomach to back C. Walks holding someone's hand D. Lifts head off mattress E. Sits without support

D, B, E, A, C When taking actions to explain the expected development of motor skills in order, the nurse will explain that lifting the head off of the mattress is expected to occur at 2 to 4 months; rolling from back to stomach is expected to occur at 4 to 6 months; sitting without support is expected to occur at 6 to 8 months; pulling self into a standing position is expected to occur at 8 to 10 months; and walking holding onto a hand or furniture is expected to occur at 10 to 12 months.

18.3) A nurse is reviewing the recommended immunization schedule for parents of an infant. Which immunizations does the nurse inform the parents are recommended within the first year? (Select all that apply.) A. Varicella B. Human papillomavirus (HPV) C. Meningococcal D. Hepatitis B E. Diphtheria F. Rotavirus

D, E, F: When taking actions to review the recommended immunization schedule for infants, the nurse should inform the parents that hepatitis B, diphtheria, and rotavirus immunizations are recommended within the first year.

21.1) A school nurse is preparing a presentation about physical, cognitive, and psychosocial development for families of school-age children. Which of the following characteristics should the nurse include? (Select all that apply.) A. Onset of separation anxiety B. Peer influence is minimal C. Uncoordinated fine motor control D. Good understanding of time and routines E. Fully developed vision and hearing

D, E: When generating solutions for a presentation for parents about the development of school-age children, the nurse should include that the characteristics of school-age children are a good understanding of time (cognitive development) and developed vision and hearing.

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

D. The nurse should identify that an occupational therapist can assist clients who have physical challenges to use adaptive devices and strategies to help with self-care activities. A certified nursing assistant can help the client with feeding, but does not typically procure adaptive devices for the client.

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

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

24.2) A charge nurse is explaining the various stages of the lifespan to a group of newly licensed nurses. Which of the following examples should the nurse include as a developmental task for middle adulthood? A. The client evaluates their behavior after a social interaction. B. The client states they are learning to trust others. C. The client wishes to find meaningful friendships. D. The client expresses concerns about the next generation.

D: The nurse should identify that Erickson's task for a middle adult is generativity vs. stagnation. The nurse should include showing concern for the next generation as an example for this age group.

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

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

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

D: The nurse should identify that nonmaleficence is a commitment to do no harm. In this situation, administering the medication could harm the client. By questioning it, the nurse is demonstrating this ethical principle.

25.2) A nurse is counseling an older adult who describes having difficulty dealing with several issues. Which of the following problems verbalized by the client should the nurse identify as the priority? A. "I spent my whole life dreaming about retirement, and now I wish I had my job back." B. "It's been so stressful for me to have to depend on my child to help around the house." C. "I just heard my friend Al died. That's the third one in 3 months." D. "I keep forgetting which medications I have taken during the day."

D: The nurse should identify that the greatest risk to this client is injury from overdosing or underdosing medications due to loss of short-term memory. The priority issue is to assist the client to implement safe medication strategies. Assist the client to use a pill organizer to help them remember to take their medications and to keep a list of all current medications.

10.3) A nurse has removed a sterile pack from its outside cover and placed it on a clean work surface in preparation for an invasive procedure. Which of the following flaps should the nurse unfold first? A. The flap closest to the body B. The right side flap C. The left side flap D. The flap farthest from the body

D: The priority goal in setting up a sterile field is to maintain sterility and thus reduce the risk to the client's safety. Unless the nurse pulls the top flap (the one farthest from their body) away from the body first, there is a risk of touching part of the inner surface of the wrap and thus contaminating it.

41.1) A nurse is discussing the care of a group of clients with a newly licensed nurse. Which of the following clients should the newly licensed nurse identify as experiencing chronic pain? A. A client who has a broken femur and reports hip pain. B. A client who has incisional pain 72 hr following pacemaker insertion. C. A client who has food poisoning and reports abdominal cramping. D. A client who has episodic back pain following a fall 2 years ago.

D: When analyzing cues, the nurse should identify that a client who reports pain that lasts more than 6 months and continues beyond the time of tissue healing is experiencing chronic pain. The nurse should assist with planning interventions to relieve manifestations associated with the pain.

15.6) A nurse educator is reviewing actions to take in the event of a bomb threat by phone to a group of new nurses. Which of the following statements by a nurse indicates understanding? A. "I will get the caller off the phone as soon as possible so I can alert the staff." B. "I will begin evacuating clients using the elevators." C. "I will not ask any questions and just let the caller talk." D. "I will listen for background noises."

D: When evaluating outcomes, the nurse educator should identify that the teaching was effective by the new nurse's statement, "I will listen for background noises." In the event of a bomb threat, individuals should listen for background noises (church bells, train whistles, or other distinguishing noises) to try to identify the location of the caller; keep the caller on the line in order to trace the call and to collect as much information as possible; ask the caller about the location of the bomb and the time it is set to explode in order to gather as much information as possible; and avoid using the elevators so that they are free for the authorities to use. Clients should not be evacuated unless directed to by facility protocol.

9.2) As part of the admission process, a nurse at a long-term care facility is gathering a nutrition history for a client who has dementia. Which of the following components of the nutrition evaluation is the priority for the nurse to determine from the client's family? A. Body mass index B. Usual times for meals and snacks C. Favorite foods D. Difficulty swallowing

D: When recognizing cues, the greatest risk to this client related to a nutrition-related evaluation is from difficulty swallowing, or dysphagia. It puts the client at risk for aspiration, which can be life-threatening. It is important to calculate body mass index to determine the client's weight status and related risks. However, there is a higher priority. It is important to know and try to follow the meal schedule the client follows at home. However, there is a higher priority. It is important to know which foods are the client's favorites in case it becomes difficult to get the client to consume adequate nutrients. However, there is a higher priority.

43.1) A nurse is teaching a client about performing a fecal occult blood test at home. Which of the following information should the nurse include? A. Do not eat red meat within one day of the test. B. One stool specimen is sufficient for testing. C. A red color change indicates a positive test. D. Ensure the specimen does not include urine.

D: When taking actions, the nurse should instruct the client to avoid contaminating the stool specimen with urine or water to ensure accurate test results.

39.1) A nurse is preparing a presentation about basic nutrients for a group of high school athletes. The nurse should include that which of the following provides the body with the most energy? A. Fat B. Protein C. Glycogen D. Carbohydrates

D: When taking actions, the nurse should state that carbohydrates are the body's greatest energy source; providing energy for cells is their primary function. They provide glucose, which burns completely and efficiently without end products to excrete. They are also a ready source of energy, and they spare proteins from depletion.

32.4) Please sort the listed skills and techniques into the Effective category or the Ineffective category. A. Stereotyping B. Challenging C. Clarifying D. Approving E. Active Listening F. Asking for an explanation

EFFECTIVE: C, E; INEFFECTIVE: A, B, D, F Effective therapeutic communication skills and techniques are silence, presenting reality, active listening, asking questions, open-ended questioning, clarifying techniques, offering general leads, broad opening statements, showing acceptance and recognition, focusing, giving information, summarizing, offering self, touch, and sharing feelings. Ineffective therapeutic communication skills and techniques include asking irrelevant personal questions, offering personal opinions, stereotyping, giving advice, giving false reassurance, minimizing feelings, changing the topic, asking "why" questions or for an explanation, challenging, offering value judgments, asking excessive probing questions, responding approvingly or disapprovingly, being defensive, testing, judging, offering sympathy, arguing, making automatic responses, and reacting with passive or aggressive responses.

30.5) A nurse is performing a skin assessment on an older adult client. Sort the following findings as Expected or Unexpected in older adult clients. A. Thin, parchment-like skin B. Hematoma C. Diminished skin elasticity D. Wrinkles E. Petechiae

EXPECTED: A, C, D UNEXPECTED: B, E When analyzing cues, the nurse should identify that thin, parchment-like skin, diminished skin elasticity, and wrinkles are expected changes in the older adult client due to loss of moisture and subcutaneous fat. A hematoma and petechiae are not expected findings and might be a manifestation of an illness or disease process.

21.4) A nurse is evaluating education provided to the guardians of a 10-year-old child about nutrition. Sort the statements made by the guardians into Indicates Understanding or Indicates Additional Teaching Is Needed. A. "Our child eats at a different time than we do so we can eat whatever we want." B. "Our child skips lunch sometimes, but we think it's okay as long as we eat a healthy breakfast and dinner. C. "We reward school achievements with a point system instead of pizza or ice cream." D. "We can't control the amount of fat they eat from fast foods." E. "We are teaching our child to read food labels, but we are not teaching them to count calories"

INDICATES UNDERSTANDING: C, E; INDICATES MORE TEACHING IS NEEDED: A, B, D; When evaluating outcomes related to nutrition education with the family of a school-age child, the nurse should recognize that the guardians understand the education provided by expressing that they use a point system instead of food for rewards and calorie counting for a school-age child is not appropriate. The nurse recognizes that additional teaching is needed about modeling healthy eating behaviors, preventing the child from skipping meals, and selecting healthier options from fast food restaurants.

7.1) A nurse is assessing/collecting data from a client to sort the findings into objective or subjective data. A. Respiratory rate is even and unlabored at 22/min B. The clients partner states, " They had burning leg pain after walking 10 minutes." C. The clients pain rating is 3 on a scale of 0 to 10. D. The clients skin is consistent with genetic background, warm, and dry E. An assistive personnel reports to the client walked with a limp

OBJECTIVE DATA: A, D, E SUBJECTIVE DATA: B, C The nurse should analyze cues to identify objective and subjective data. Objective data includes information the nurse can feel, see, hear, or smell, through observation or physical measurement such as respiratory rate, skin color, temperature, and characteristics, and observation that the client is walking with a limp. Subjective data includes a client's feelings, perceptions, and descriptions of health status, such as pain level, description of pain, and contributing factors to pain.

27.1) A nurse is instructing a newly licensed nurse about choosing a site to measure a client's temperature. Sort the following clients with the correct temperature site: Oral or Rectal. A. A clients who breathes through the mouth B. A client who has a low platelet count C. A client who has facial trauma D. A client who has hemorrhoids

ORAL: B, D RECTAL: A, C When taking actions, the nurse should take an oral temperature on a client who has a low platelet count to decrease the risk of bleeding. The nurse should take a rectal temperature on a client who breathes through the mouth to obtain an accurate reading. The nurse should take an oral temperature on a client who has hemorrhoids to decrease the risk of bleeding. The nurse should take a rectal temperature on a client who® has facial trauma to reduce the risk of injury to the client.

7.2) A charge nurse is talking with a newly licensed nurse about nursing interventions that require a provider's prescription and nursing interventions that are nurse-initiated. Sort the following interventions into Nurse-Initiated or Provider-Initiated A. Inserting a nasogastric tube to relieve gastric distention B. Showing a client how to use progressive muscle relaxation C. Performing a daily bath after the evening meal D. Repositioning a client every 2 hr to reduce pressure injury risk E. Writing a prescription for morphine as needed for pain

PROVIDER-INITIATED: A, E NURSE-INITIATED: B, C, D When analyzing cues, the nurse should identify that nursing interventions that require a provider's prescription include prescription for medications and insertion of a nasogastric tube. Nurse-initiated interventions include showing a client how to use progressive muscle relaxation, performing an evening bed bath, and repositioning a client to reduce pressure injury risk.

38.1) A nurse is preparing a presentation at a local community center about sleep hygiene. Sort the following characteristics into either rapid eye movement (REM) sleep or non-rapid eye movement (NREM) sleep. A. Cognitive restoration occurs B. Light sleep C. 75% of time sleeping D. Loss of muscle tone occurs E. Vivid dreaming occurs

REM: A, D, E NREM: B, C When taking actions, the nurse should identify that cognitive and brain tissue restoration, loss of muscle tone, and vivid, colorful dreams are characteristics of REM sleep. NREM sleep occurs during 75% of the sleep time and includes light sleep.

42.5) A nurse is discussing complementary and alternative therapies they can incorporate into their practice without the need for specialized licensing or certification with a group of newly licensed nurses. Sort the following therapies into either those that require a specialized licensed or those that do not require a specialized license. A. Acupuncture B. Chiropractic medicine C. Guided imagery D. Humor E. Therapeutic communication

REQUIRES SPECIALIZED LICENSED: A, B DOES NOT REQUIRE SPECIALIZED LICENSE: C, D, E When taking actions, the nurse should inclüde that acupuncture and chiropractic medicine are alternative therapies that require a specialized licensing or certification. Guided imagery, humor, and therapeutic communication are alternative therapies nurses can incorporate into their practice without the need for specialized licensing or certification.

6.5) A charge nurse is assigning client care to an RN and a PN. Understanding that an RN can perform each of the following tasks, match the tasks the nurse should assign to the RN or the PN. A. Creating a plan of care for a client who is recovering following a stroke B. Assessing a pressure injury on a client who is on bed rest C. Providing nasopharyngeal suctioning for a client who has pneumonia D. Teaching a client who has asthma to use a metered-dose inhaler E. Administer enteral feeding to a client who has a nasogastric tube F. Inserting a urinary catheter for a client who has urinary retention

RN: A, B, D LPN: C, E, F When taking actions, the nurse should identify that creating a plan of care, assessing a pressure injury, and teaching a client requires professional nursing knowledge, skills, and judgment that is outside the scope of care of a PN and should be assigned to the RN. Providing nasopharyngeal suctioning, administering enteral feeding through a nasogastric tube, and inserting a urinary catheter is within the scope of practice of the PN.

19.4) A nurse is planning activities for toddlers on an inpatient unit. Sort the following activities into those that are considered Safe for toddlers and those that are considered Unsafe for toddlers. A. Playing with toys that contain small parts B. Looking at books C. Playing with blocks D. Playing with balloons E. Tossing a ball

SAFE: B, C, E UNSAFE: A, D When taking actions, the nurse should identify that playing with balloons and playing with toys that contain small parts are considered unsafe activities for toddlers. Toddlers might place balloon fragments or small objects in their mouth, which can lead to choking or aspiration. Looking at books, playing with blocks, and tossing a ball, are considered safe activities for toddlers. These activities promote fine motor skills, imagination, and provide sensory stimulation.

45.3) A nurse is teaching a newly licensed nurse about interventions for clients who have sensory deprivation or overload. Sort the following interventions into those that should be implemented for clients who have sensory deprivation and those that should be implemented for clients who have sensory overload A. Encourage the client's family to visit with the client. B. Provide a private room for the client. C. Limit visitors for the client. D. Dim lighting in the client's room. E. Increase the ringer volume on the client's phone. F. Communicate frequently with the client.

SENSORY DEPRIVATION: A, E, F SENSORY OVERLOAD: B, C, D When taking actions, the nurse should encourage visitors, increase the ringer volume on the client's phone, and communicate frequently with the client who has sensory deprivation to provide meaningful stimulation for the client. The nurse should provide a private room, limit visitors, and dim lights for clients who have sensory overload to minimize stimulation.

21.2) A nurse caring for clients in an inpatient pediatric unit is planning age-appropriate activities. Sort the activities by whether they are more appropriate for Toddlers or for School-age children. A. Building simple models B. Painting C. Stacking blocks D. Reading chapter books E. Using toy carpentry tools

TODDLER: C, E SCHOOL-AGE CHILDREN: A, B, D When generating solutions for age-appropriate activities, the nurse should plan activities for toddlers that are appropriate for their fine motor skill and cognitive development, including stacking blocks and using toy carpentry tools. The nurse should plan activities for school-age children that are appropriate for their fine motor skill and cognitive development, including building models, painting, and reading chapter books.

18.2) A nurse is conducting screening assessments for infants. Sort the findings by whether the nurse expects to observe them in infants under 6 months of age or infants 6 to 12 months of age. A. Development of object permanence B. Closure of posterior fontanel C. Presence of grasping reflex D. Sits without support E. Birth weight doubles

WITHIN FIRST 6 MONTHS: B, C, E 6 TO 12 MONTHS: A, D When recognizing cues, the nurse should expect the grasping reflex to be present until 3 to 6 months of age. The nurse should expect the posterior fontanel to be closed by age 2 to 3 months. The nurse should expect the birth weight to double within the first 6 months. The nurse should expect the infant to realize that objects that can no longer be seen still exist by 7 to 9 months. The nurse should expect the infant to sit without support at 6 to 8 months.

13.3) A home health nurse is educating a new home health aide about home safety for the older adult. What information should the nurse include?

When generating solutions, the home health nurse should remind the new home health aide that items such as throw rugs and loose carpets should be removed and electric cords and extension cords should be against the wall and behind furniture because they could cause the client to trip; steps and sidewalks should be in good repair; grab bars should be installed near the toilet, shower and tub; a stool riser should be used; a nonskid mat should be in the shower or tub; a shower chair and a beside commode might be necessary; there should be adequate lighting both inside and outside the home; and all clutter should be removed.

31.4) A nurse is teaching a class about expected changes associated with aging. What information should the nurse include?

When recognizing cues, the nurse should instruct that expected changes that can occur with aging can include reduced muscle mass, decline in speed, strength, resistance to fatigue, reaction time, and coordination, decalcification of bones can lead to loss of bone mass and height, and an increasing risk for osteoporosis. Other changes that can occur include minimal decline in short-term memory, decreased vision, hearing, taste, smell, and touch.

36.4) A nurse is consoling the partner of a client who just died after a long battle with cancer. The grieving partner states, "I hate them for leaving me." What actions should the nurse take to facilitate mourning for the client's partner?

When taking actions, the nurse should assist the client's partner through the mourning process by using therapeutic communication to encourage the partner to express their feelings. The nurse should ask the client's partner whether they would like to talk to a spiritual leader to provide spiritual support and guidance. The nurse should provide education to the grieving individual about the grieving process and about emotions they can expect at this time to assist the client's partner through the mourning process.

30.3) A nurse is performing a peripheral vascular assessment of the lower extremities on a client who is postoperative following knee surgery. What information should the nurse include in the assessment?

When taking actions, the nurse should check and compare the skin color and temperature of the client's lower extremities. Pallor, cyanosis, and coolness are manifestations of inadequate circulation. The nurse should check and compare the pulses of the client's lower extremities. A decreased pulse strength indicates impaired circulation to the client's legs. The nurse should assess the client for the presence of edema. Edema is a manifestation of inadequate venous circulation and should be reported.

35.4) A nurse is caring for a client who tells the nurse that, based on religious values and mandates, a blood transfusion is not an acceptable treatment option. What actions should the nurse take?

When taking actions, the nurse should demonstrate culturally responsive care and show respect for the client's religious beliefs. The nurse should have the provider discuss the necessity for a blood transfusion, alternatives to the use of blood products, and allow the client to make an informed decision.

42.4) A nurse is caring for a client who is scheduled for abdominal surgery. The client reports being worried. What interventions can the nurse implement to reduce the client's anxiety?

When taking actions, the nurse should implement complementary and alternative therapies to promote relaxation and reduce the client's anxiety. The nurse should use therapeutic communication to allow the client to verbalize their fears and anxieties. The nurse can assist the client in relaxation therapies, such as guided imagery, healing intention, breath work, humor, meditation, simple touch, music or art therapies, and passive or progressive relaxation.

45.1) A nurse is teaching a newly licensed nurse about contributing factors for sensory alterations. What contributing factors should the nurse include in the teaching?

When taking actions, the nurse should instruct that presbyopia, cataracts, glaucoma, diabetic retinopathy, macular degeneration, infection, inflammation, injury, or brain tumor are risk factors for vision loss. Obstruction, wax accumulation, tympanic membrane perforation, ear infections, or otosclerosis are risk factors for conductive hearing loss. Exposure to loud noises, ototoxic medications, aging, and acoustic neuroma are risk factors for sensorineural hearing loss. Xerostomia or reduced salivation are risk factors for taste deficit. Neurological deficits can result in peripheral numbness, and a stroke can result in loss of sensation and aphasia.

44.4) A nurse is teaching a client who reports stress urinary incontinence. What instructions should the nurse include?

When taking actions, the nurse should instruct the client to maintain adequate fluid intake, empty the bladder completely with each void, avoid bladder irritants, such as caffeine and alcohol, and pertorm pelvic muscle exercises (Kegel) 3 to 4 times each day.

13.1) A nurse is providing information about how to reduce the risk of poisoning in infants and toddlers to a group of guardians. What information should the nurse include?

When taking actions, the nurse should recommend that the guardians keep house plants and cleaning agents out of reach; look for paint chips which can expose the infant to lead; have the poison control hotline readily available; place poisons, paint, and gasoline in a locked cabinet; keep medications, including vitamins, in child-proof containers and locked up; and dispose of unused medications.

43.3) A nurse is administering a cleansing enema to a client who reports abdominal cramping. What actions should the nurse take?

When taking actions, the nurse should slow the flow of the solution by lowering the container. Slowing the flow of the enema should decrease abdominal cramping. If the client is experiencing severe abdominal cramping, stop the enema, assess the client's vital signs, and notify the provider.