Dyanamic Quizzes (Moderate)

A nurse is preparing to insert an indwelling urinary catheter. Which of the following instructions should the nurse give the client to ease the passage of the catheter through the urinary meatus?

"Bear down" The nurse should ask the client to "bear down" gently as if to void. This can enable the nurse to better visualize the urinary meatus and promote relaxation of the external urinary sphincter. Additionally, this will ease the passage of the catheter through the urinary meatus.

A charge nurse is providing teaching to a newly licensed nurse about removing sutures from a client's laceration. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

"I will clip each suture close to the skin and pull it through from the other side." Clipping close to the skin and pulling the suture from the other side does not disrupt the wound-healing process.

A nurse is preparing a client for discharge and providing instructions about performing dressing changes at home. Which of the following statements should the nurse identify as an indication that the client understands medical asepsis?

"I'll wash my hands before I remove the old dressing and again before putting on the new one." It is essential that the client understands the importance of hand hygiene before, during, and after any handling of the wound or its dressings.

A nurse is teaching a client about how to remove a soiled dressing. Which of the following statements by the client indicates an understanding of the teaching?

"I'll wear nonsterile gloves." Wearing gloves prevents the spread of microorganisms outside of the dressings and onto the client's hands. The gloves the client uses can be clean and do not need to be sterile unless the provider specifically prescribes sterile gloves for dressing changes.

A nurse is reviewing the use of side rails with an assistive personnel (AP). Which of the following statements by the AP indicates that further teaching is required?

"If the client seems confused, I'll raise all 4 side rails so that he doesn't hurt himself." Raising all 4 side rails can put the client at greater risk for injury. For example, the client might try to climb over the side rails, which could result in a fall.

A nurse is caring for a client who is scheduled to receive transcutaneous electrical nerve stimulation (TENS) for pain management. The client asks the nurse how a TENS unit helps relieve pain. Which of the following responses should the nurse make?

"It modulates the transmission of the pain impulse." The nurse should inform the client that a TENS unit applies low-voltage electrical stimulation directly over a location of pain at an acupressure point. It modulates the transmission of the pain impulse and can also cause a release of endorphins to assist with pain relief.

A nurse is caring for a client who is scheduled to receive transcutaneous electrical nerve stimulation (TENS) for pain management. The client asks the nurse how a TENS unit helps to relieve pain. Which of the following responses should the nurse make?

"It modulates the transmission of the pain impulse." The nurse should inform the client that a TENS unit applies low-voltage electrical stimulation directly over a location of pain at an acupressure point. It modulates the transmission of the pain impulse and can also cause a release of endorphins to assist with pain relief.

A nurse is admitting a client who will undergo a craniotomy. During the planning phase of the nursing process, which of the following actions should the nurse take?

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

A nurse is admitting a client who has decreased circulation in his left leg. Which of the following actions should the nurse take first?

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

A nurse is performing a physical assessment of a client. The nurse should recognize that which of the following findings places the client at risk of impaired skin integrity?

Faint pedal pulses Faint pedal pulses can indicate poor circulation and tissue perfusion, which puts the client at risk of impaired skin integrity.

A nurse is caring for a client who has a temperature of 38.7°C(101.7°F). Which of the following actions should the nurse take?

Keep the client's bed linens dry The nurse should maximize the client's heat loss by keeping the client's clothes and bed linens dry. The nurse should also reduce external coverings on the client's bed without causing shivering.

A nurse is reviewing a client's laboratory results and notes a WBC count of 3,600/mm^3. The nurse should identify this result as which of the following conditions?

Leukopenia Leukopenia occurs when there is a decrease in the production of WBCs. This alteration places the client at an increased risk of infection.

A nurse is measuring a client's vital signs. The client's resting radial pulse rate is 55/min. Which of the following actions should the nurse take next?

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

A nurse is planning to document care provided for a client. Which of the following abbreviations should the nurse use?

PC for after meals The nurse can use this abbreviation because it is approved and not error-prone.

A nurse is employing a thorough, systematic method while obtaining objective data about a client. Through which of the following methods should the nurse collect this information?

Physical examination Physical findings are objective, and the nurse should collect this information in a systematic way.

A nurse is reviewing a client's laboratory report. The client's ABG levels are pH 7.5, PaCO2 32 mmHg, and HCO3- 24 mEq/L. The nurse should determine that the client has which of the following acid-base imbalances?

Respiratory alkalosis This client's pH is elevated above the expected reference range of 7.35 to 7.45, indicating alkalosis. Additionally, the client's PaCO2 is below the expected reference range of 35 to 45 mmHg, which indicates a respiratory origin. Hence, the nurse should conclude that the client's elevated pH and decreased PaCO2 indicate respiratory alkalosis.

A nurse is caring for an adult client in the terminal stages of lung cancer who refuses any further treatment. The nurse should provide care that facilitates which of the following outcomes?

Supports self-determination The nurse must honor the client's autonomy and ability to make health care decisions. The client has the right to refuse treatment; as the client's advocate, the nurse must support that right.

A nurse is evaluating a client's use of crutches. The nurse should identify that which of the following actions by the client indicates safe usage of this equipment?

The client has slightly flexed elbows when ambulating with the crutches. The client should have slightly flexed elbows when ambulating with crutches. This allows the client to bear weight on the hands and not on the axillae.

A nurse is demonstrating postoperative deep breathing and coughing exercises to a client who is scheduled for emergency surgery for appendicitis. Which of the following statements indicates a lack of readiness to learn by the client?

The client reports severe pain. A client who is experiencing severe pain is not able to concentrate and is not ready to learn a new activity.

A nurse is applying antiembolitic stockings for a client who has a history of deep vein thrombosis. Which of the following actions should the nurse take when applying the stockings?

Turn the stocking inside out up to the heel before applying The nurse should turn the stocking inside out up to the client's heel to make the application of the stocking easier and cause fewer constrictive wrinkles.

A nurse is evaluating the development of a group of clients. According to Erikson, the developmental task of intimacy vs. isolation occurs during which of the following stages of development?

Young adulthood The developmental task of young adulthood is intimacy vs. isolation.

A nurse is caring for a client who is receiving mechanical ventilation via a tracheostomy tube and has a gastrostomy tube for enteral feedings. Which pieces of information are critical to communicate to the next nurse who will be caring for this client? (Select all that apply.)

• New prescriptions • Arterial blood gas results • Tracheal secretion characteristics The nurse should report any changes in the client's treatment in the nursing handoff report. For a client who is receiving mechanical ventilation, the latest arterial blood gas results reflect the client's current respiratory and ventilatory status and are an essential part of the nursing handoff report. Additionally, tracheal secretion characteristics provide important information about the client's current respiratory and ventilatory status and are an essential part of the nursing handoff report.

A nurse is providing preoperative teaching to a client who is scheduled for arthroplasty in the next month and may require a blood transfusion. The client expresses concern about the risk of acquiring an infection from the blood transfusion. Which of the following statements should the nurse share with the client?

"Donate autologous blood before the surgery." Autologous blood transfusion is the collection and reinfusion of the client's blood. With preoperative autologous blood donation, the blood is drawn from the client 3 to 5 weeks before an elective surgical procedure and stored for transfusion at the time of the surgery. Autologous blood is the safest form of blood transfusion because exclusive use of a client's own blood eliminates exposure to a transfusion-transmitted infection.

A nurse is planning an in-service training session about nutrition. Which of the following statements should the nurse include in the teaching?

"Fats provide energy." Fat serves as a stored energy source for the body, providing 9 cal/g of energy.

A nurse is planning to insert a nasogastric tube for a client after explaining the procedure. The client states, "You are not putting that hose down my throat." Which of the following statements should the nurse make?

"I can see that this is upsetting you." This response uses the therapeutic communication techniques of reflecting and restating, which encourages further communication by the client.

A nurse is teaching a client who has asthma about the proper use of an albuterol inhaler. Which of the following client statements indicates an understanding of the teaching?

"I will shake the inhaler well right before I use it." The nurse should instruct the client to shake the inhaler vigorously for 3 to 5 seconds, which will mix the medication within the inhaler evenly.

A nurse in a long-term care facility is admitting a client who is incontinent and smells strongly of urine. His partner, who has been caring for him at home, is embarrassed and apologizes for the smell. Which of the following responses should the nurse make?

"It must be difficult to care for someone who is confined to bed." This response addresses the feelings of the partner by reflecting her feelings, which facilitates therapeutic communication because it is nonjudgmental and encourages the partner to express her feelings.

A nurse is performing an admission assessment for a client. Which of the following responses by the nurse reflects the communication technique of clarifying?

"It sounds like your pain is intermittent." This response by the nurse reflects the communication technique of clarifying. The nurse should use this technique to ensure an understanding of the client's message.

A nurse is talking with the parent of a preschool-aged child who tells the nurse, "My child has suddenly become disinterested in certain foods." Which of the following statements should the nurse make?

"Keep a diary of the foods your child eats each day." The nurse should encourage the parent to keep a diary of the foods the child eats throughout the day for 1 week. This can help the parent realize that the child may be eating better than expected. Evidence suggests that children can self-regulate their caloric intake. When they eat less at a meal, they can compensate by eating more at another meal or by having a snack.

A nurse is providing teaching about crutches to a client who has a fracture of the right foot. Which of the following instructions should the nurse include?

"Keep the rubber crutch tips securely in place." The client should never use crutches without the rubber crutch tips. The client should inspect the tips regularly, replace them when they show signs of wear, and remove and dry them thoroughly with paper towels if they become wet.

A nurse is caring for a client who has a terminal illness. The family wants to care for the client at home. Which of the following statements indicates that the nurse understands family-centered care?

"Let's set up a meeting time with the doctor to discuss your options for home care." In family-centered care, the nurse considers the health of the family as a unit; therefore, the client and family members help determine their outcomes and goals. Setting up a meeting to discuss this with the provider will give them a sense of autonomy and foster the family-centered nursing environment.

A nurse is preparing to insert an NG tube for a client who requires enteral feedings. Which of the following instructions should the nurse give the client before beginning the procedure?

"Raise your index finger if you need to pause during the insertion." The nurse should instruct the client that the insertion of an NG tube is uncomfortable and the gag reflex will be activated during the procedure. The nurse should establish a communication technique such as having the client raise a finger or hand to indicate distress and the need to pause the insertion process.

A middle-aged adult client is discussing future plans with the nurse. Which of the following statements should the nurse identify as an indication that the client is having difficulty achieving Erikson's developmental task for this age group?

"We miss our daughter so much that we are going to move closer to her." According to Erikson, the stage of psychosocial development for middle adults is generativity vs. stagnation. Accepting the independence of adult children is part of the developmental task of middle age.

A nurse is assessing a client who has a sudden onset of severe back pain of unknown origin. Which of the following questions should the nurse ask to encourage discussion with the client?

"What do you think caused the onset of your pain?" The nurse is using an open-ended question that allows the client to respond with a wide range of information by using more than a few words.

A nurse is performing a spiritual assessment of a client. Which of the following questions should the nurse ask?

"What is your source of strength and hope?" This is a broad, open-ended question that encourages the client to express feelings without any assumptions on the nurse's part. It correctly focuses on a global view of spirituality as a complex concept that encompasses the client's life experiences and beliefs about strength, love, and hope.

A nurse is caring for an older adult client who becomes agitated when the nurse requests that the client's dentures be removed prior to surgery. Which of the following responses should the nurse provide?

"What worries you about being without your teeth?" This response by the nurse is therapeutic because it validates the client's feelings of agitation and seeks a reason.

A nurse is teaching the parent of a child who is to take 30 mL of a liquid medication. The parent has a hollow medication spoon that has marks to indicate teaspoons and tablespoons. How many tablespoons of medication should the nurse instruct the parent to give to the child? (Fill in the blank with the numeric value only, round the answer to the nearest whole number, and use a leading zero if applicable. Do not use a trailing zero.)

2 15 mL = 1 tbsp

A nurse is assessing the pH of a client's gastric fluid to confirm the placement of an NG tube in the stomach. Which of the following pH values should the nurse expect?

2 A pH of 2 is within the expected reference range of 0 to 4 for gastric secretions.

A nurse is preparing to administer sotalol to a client with a prescription for 320 mg/day divided equally every 12 hr. The medication is available in 80 mg tablets. How many tablets should the nurse administer per dose? (Fill in the blank with the numeric value only, round the answer to the nearest tenth, and use a leading zero if applicable. Do not use a trailing zero.)

2 Have/Quantity = Desired/X 80 mg/1 tablet = 320 mg/X tablet X = 4 If there are 80 mg/tablet and the prescription reads 320 mg/day divided into 2 doses, the nurse should administer 2 tablets with each dose.

A nurse is preparing to administer 700 mL of 0.9% sodium chloride IV to a child to infuse over 24 hr. The drop factor of the manual IV tubing is 60 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? (Fill in the blank with the numeric value only, round the answer to the nearest whole number, and use a leading zero if applicable. Do not use a trailing zero.)

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A nurse is preparing to administer 40 mL of 0.9% sodium chloride IV to infuse over 20 min. The drop factor of the manual IV tubing is 15 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? (Fill in the blank with the numeric value only, round the answer to the nearest whole number, and use a leading zero if applicable. Do not use a trailing zero.)

30 Volume (mL)/Time (min) x drop factor (gtt/mL) = X 40 mL/ 20 min x 15 gtt/mL = X gtt/min 30 = X

A nurse is caring for a client who requires fluid restriction and may drink only 1 oz of water with each oral medication. How many milliliters of water should the nurse document as intake for the 3 separate medications the client receives during a 12-hr night shift? (Round the answer to the nearest whole number and fill in the blank with the numeric value only.)

90 1 oz = 30 mL

A nurse is responding to a parent's question about his infant's expected physical development during the first year of life. Which of the following pieces of information should the nurse include?

A 10-month-old infant can pull up to a standing position. An 8- to 10-month-old infant can pull up to a standing position.

A nurse is planning care for a group of clients receiving oxygen therapy. Which of the following clients should the nurse plan to see first?

A client who has heart failure and is receiving 100% oxygen via partial rebreather mask The nurse should apply the safety and risk-reduction priority-setting framework, which assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's hierarchy of needs, the ABC priority-setting framework, and/or nursing knowledge to identify which risk poses the greatest threat to the client. The nurse should frequently check the bag on a rebreather mask to ensure it inflates properly. If the bag is deflated, the client will rebreathe exhaled carbon dioxide instead of receiving the prescribed oxygen dose. Therefore, the nurse should first see the client who has heart failure and is receiving 100% oxygen via partial rebreather mask. Oxygen is a gas that can cause toxicity and is highly combustible, and higher concentrations of oxygen increase the risk of client injury.

A nurse on an oncology unit receives report at the beginning of her shift about 4 clients who are postoperative. Which of the following clients should the nurse see first?

A client who is 2 days postoperative following a colectomy due to colorectal cancer and has an ostomy bag full of bright red, bloody drainage The nurse should apply the unstable vs stable priority-setting framework when caring for clients. Using this framework, unstable clients are prioritized due to needs that threaten survival. The nurse should first address problems involving the airway, breathing, or circulatory status that are life-threatening. Clients whose vital signs or laboratory values indicate a risk of becoming unstable are also a higher priority than clients who are stable. The nurse may need to use nursing knowledge to determine which option describes the most unstable client. An ostomy bag full of blood indicates that the client's bowel is hemorrhaging, and the nurse must report this finding to the surgeon immediately. The client may require fluid replacement, transfusion, and additional surgery to repair the bleeding vessel. This finding poses an immediate threat to the client's circulation.

A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the following actions should the nurse take?

Administer analgesics to the child on a routine schedule throughout the day and night. To soothe the client's throat following a tonsillectomy, the nurse should administer pain medication routinely. The nurse can provide the medication rectally or intravenously to avoid the oral route.

A nurse is supervising a newly licensed nurse who is suctioning a client's tracheostomy. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure?

Administering high-flow oxygen prior to the procedure The nurse should instruct the newly licensed nurse to administer 3 to 4 breaths of 100% oxygen via a resuscitation bag before suctioning to the client to reduce the risk of hypoxia.

A nurse is assisting a client who has dysphagia at mealtimes. Which of the following actions should the nurse take?

Advise the client to tuck his chin downward To help the client swallow safely, the nurse should have the client sit upright, lean slightly forward, tilt his head forward, and tuck his chin. This position helps move the food downward without lodging in the throat, where the client could aspirate it.

A nurse is performing an admission assessment for a client who has asthma and reports several food allergies. Which of the following actions should the nurse take first?

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

A nurse is supervising a newly licensed nurse who is administering a controlled substance. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure?

Asking another nurse to observe the disposal of an unused portion of the medication The nurse should ask another nurse to witness the disposal of a controlled substance to maintain safe control of the narcotic.

A nurse is beginning a therapeutic relationship with a client. Which of the following actions should the nurse take to convey empathy when using the therapeutic communication technique of active listening?

Assume an open position The nurse should sit with arms and legs uncrossed. Crossing them suggests a defensive posture.

A nurse is planning weight-loss strategies for a group of clients who are obese. Which of the following actions by the nurse will improve the clients' commitment to a long-term goal of weight loss?

Attempt to increase the clients' self-motivation Motivation to learn is a key part of improving a client's commitment to achieving a health goal, as well as increasing the amount and speed of learning.

A nurse is assessing a client's vascular system. Which of the following techniques should the nurse use when evaluating the carotid arteries?

Auscultation of the arteries for bruits with the bell of the stethoscope The bell of the stethoscope is more effective than the diaphragm in transmitting blowing or swishing sounds, such as those from turbulence in blood vessels.

A nurse rates a client's biceps reflex as 2+. Which of the following characteristics should the nurse document about the client's reflexes?

Average Reflexes range on a scale of 0 to 4+. Active or expected reflexes are 2+.

A nurse in a provider's office is assessing a client who has heart failure. The client has gained weight since her last visit, and her ankles are edematous. Which of the following findings is another clinical manifestation of fluid volume excess?

Bounding pulse A bounding pulse is an expected finding of fluid volume excess.

A nurse is caring for a client who is having difficulty with muscle coordination following a head injury. The nurse should suspect injury to which of the following areas of the brain?

Cerebellum The nurse should suspect an injury to the cerebellum if the client is experiencing difficulty controlling balance and coordination. A client's movements can become uncoordinated, unsure, and clumsy following an injury to this area of the brain.

A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following actions should the nurse take?

Check the client's capillary blood glucose level every 4 hr The nurse should check the client's capillary blood glucose level every 4 hours or according to facility policy due to the client's risk of hyperglycemia while receiving TPN. The dextrose concentration in TPN increases the risk of this complication.

A nurse is caring for a client who has a stage III pressure ulcer on the heel. When preparing to irrigate the wound, which of the following actions should the nurse take first?

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

A nurse is caring for a client who has major fecal incontinence and reports irritation in the perianal area. Which of the following actions should the nurse take first?

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

A nurse is caring for a client who requires a dressing change. Which of the following actions should the nurse take?

Clean the drain site from the center outward The nurse should clean the drain site from the center outward to avoid introducing microorganisms from the periphery of the wound into the center of the wound.

A nurse is conducting an admission interview with a client. Which of the following pieces of assessment information should the nurse collect during the introductory phase of the interview?

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

A nurse is caring for a client who had a mastectomy and has a self-suction drainage evacuator in place. Which of the following actions should the nurse take to ensure proper operation of the device?

Collapse the device to remove air after emptying The nurse should collapse the device to remove air after emptying the contents periodically. This will create enough suction to pull fluid exudate into the collection area of the device.

A nurse is planning care for a client who has a prescription for collection of a sputum specimen for culture and sensitivity. Which of the following actions should the nurse take when obtaining the specimen?

Collect the specimen when the client rises in the morning The nurse should plan to collect the sputum specimen when the client arises in the morning because the client will be able to cough up the secretions that have accumulated during the night. Generally, the deepest specimens are obtained in the early morning, and it is preferable to collect the specimen before breakfast. The nurse should instruct the client to rinse the mouth, take a deep breath, and cough prior to expectorating into the sterile container.

A newly licensed nurse is preparing to administer medications to a client. The nurse notes that the provider has prescribed a medication that is unfamiliar to him. Which of the following actions should the nurse take?

Consult the medication reference book available on the unit A nurse must have knowledge about medications to administer them safely. The nurse should become familiar with the medication by looking it up in the medication reference on the unit.

A nurse is preparing to assess the function of the client's trigeminal nerve (cranial nerve V). Which of the following items should the nurse gather for the test?

Cotton wisps The trigeminal nerve has both sensory and motor capabilities. To assess its sensory function, the nurse uses a safety pin to assess for recognition of pain and a cotton wisp to evaluate recognition of touch sensations. To test motor abilities of cranial nerve (CN) V, the nurse should ask the client to clench the teeth.

A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following actions should the nurse perform first after discovering that the client's wound has eviscerated?

Cover the incision with a moist sterile dressing The nurse should apply the safety and risk-reduction priority-setting framework, which assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting framework, and/or nursing knowledge to identify which risk poses the greatest threat to the client. An open wound increases the risk of peritonitis, and any exposed organ tissue could dry out. Therefore, covering the wound with a moist sterile dressing is the first action the nurse should take to protect the client.

A nurse is reviewing the laboratory values of a client who has a positive Chvostek's sign. Which of the following laboratory findings should the nurse expect?

Decreased calcium Calcium is necessary for nerve conduction and muscle contractions. When the client's total calcium level is <8.4 mg/dL, tetany and muscle spasms may occur. The nurse should tap the facial nerve in front of the client's ear. If facial muscle twitching follows this stimulus, it is a positive Chvostek's sign and an indication of hypocalcemia.

A nurse is caring for a client who is immobile. The nurse should recognize that immobility places the client at risk of which of the following health alterations?

Decreased cardiac output During immobility, the client's heart rate increases to compensate for increased venous pooling. The reduction in circulating volume increases the workload of the heart, resulting in orthostatic hypotension and decreased cardiac output.

A nurse is caring for a client who has a BMI of 29 and expresses a desire to lose weight. Which of the following actions should the nurse take first?

Determine the client's intention to change current eating habits When using the nursing process, the nurse should first assess the client's readiness to commit to a change in behavior.

A nurse is caring for a client who is producing large amounts of urine. The nurse should document this finding as which of the following?

Diuresis Diuresis or polyuria is the excretion of a high volume of urine. This condition has many causes, including metabolic and hormonal imbalances and diuretic therapy for treating renal, cardiovascular, and pulmonary disorders.

A nurse is performing an otoscopic examination of a client's right ear. The light reflex is visible in the right lower quadrant of the tympanic membrane. Which of the following actions should the nurse take in response to this finding?

Document this as an expected finding The light of the otoscope reflects off the tympanic membrane, which is cone-shaped or triangular. In the right ear, it is visible in the right lower quadrant of the eardrum. In the left ear, it is visible in the left lower quadrant.

A nurse is preparing to administer eye drops to a client following surgery. Which of the following actions should the nurse take when instilling the eye drops?

Drop the eye medication into the lower conjunctival sac The nurse should drop the eye medication in the lower conjunctival sac to avoid placing the drops on the cornea and causing damage.

A nurse is caring for a client who is receiving IV therapy via a peripheral catheter. The nurse should identify that which of the following findings is an indication of infiltration?

Edema at the infusion site Edema due to fluid entering subcutaneous tissue is an indication of infiltration.

A home health nurse is planning to provide health promotion activities for a group of clients in the community. Which of the following activities is an example of primary prevention?

Educating clients about the recommended immunization schedule for adults Primary prevention includes health education about disease prevention.

A nurse is preparing to administer a feeding via a gastrostomy tube to a client who had a stroke. Which of the following actions should the nurse take prior to initiating the feeding?

Elevate the head of the client's bed Clients who have a brain injury are typically unable to swallow effectively and thus cannot protect their airway from aspiration. Even though this route bypasses the nasopharynx, it is still possible for the client to cough or vomit enteral formula into the oral cavity. Consequently, the nurse should strive to prevent aspiration by elevating the head of the bed prior to initiating the feeding.

A nurse is caring for a client who has an NG tube for intermittent enteral feedings. Which of the following actions should the nurse take?

Elevate the head of the client's bed to 45° before the feeding The nurse should elevate the client's head of bed between 30° and 45° to prevent aspiration.

A nurse is teaching an assistive personnel (AP) how to obtain a capillary finger-stick blood sample. Which of the following actions by the AP requires the nurse to intervene?

Elevating the finger above heart level The nurse should intervene if the client elevates the finger above the level of the heart. Holding the finger below the level of the heart in a dependent position will help increase blood flow to the area and ensure an adequate specimen for collection.

A nurse is teaching an assistive personnel (AP) how to obtain a capillary finger- stick blood sample. Which of the following actions by the AP requires the nurse to intervene?

Elevating the finger above heart level The nurse should intervene if the client elevates the finger above the level of the heart. Holding the finger below the level of the heart, in a dependent position; will help increase blood flow to the area and ensure an adequate specimen for collection.

A nurse is applying an ice bag to the ankle of a client following a sports injury. Which of the following actions should the nurse take?

Fill the bag 2/3 full with ice The nurse should fill the bag two-thirds full with ice, which allows the bag to be molded around the client's ankle.

A nurse is performing a comprehensive physical assessment of a client. The nurse should use inspection to assess which of the following?

Gait Inspection is the technique of looking or observing. Gait inspection involves watching the client's walking movements and observing any unusual findings.

A nurse is removing personal protective equipment (PPE) after performing a procedure for a client who requires isolation precautions. Which of the following items of PPE should the nurse remove first?

Gloves According to evidence-based practice, the nurse should first remove the gloves because they are the most contaminated piece of PPE. Next, the nurse should remove the goggles or face shield and then the gown. Finally, the nurse should remove the respirator or mask because it is the least contaminated piece of PPE.

A nurse is reviewing a client's 24 hr dietary recall. The client reports eating a slice of toasted white bread with butter, a banana, a glass of milk, and a cup of coffee for breakfast; grilled chicken, a baked potato, and a glass of milk for lunch; an apple and cheddar cheese for a snack; and 2 servings of chicken, 2 cups of steamed broccoli, and a glass of milk for dinner. This client's diet is deficient in which of the following food groups?

Grains This client only consumed 1 serving of grains on the day of the 24-hour dietary recall. USDA dietary guidelines recommend 3 or more ounce-equivalents of whole-grain products per day. Additionally, the choice of white bread is low in fiber, which can lead to constipation and an increased risk of developing hyperlipidemia. The USDA guidelines recommend that at least half of the grains consumed should be whole grain.

A nurse is providing teaching to a group of unit nurses about wound healing by secondary intention. Which of the following pieces of information should the nurse include in the teaching?

Granulation tissue fills the wound during healing. A beefy, red tissue called granulation tissue fills the wound during healing. The wound is left open to drain and heal by secondary intention, which should occur within 5 to 21 days. Open wounds increase the risk of wound infection.

A nurse is teaching a client about lifestyle changes to manage a chronic illness. Which of the following strategies should the nurse use first to help the client make a commitment to these lifestyle changes?

Help the client identify ways that these changes will result in positive personal outcomes According to evidence-based practice, the motivation to change must precede taking steps to make the change. Therefore, helping clients identify ways that the changes will promote positive outcomes should precede other educational strategies for making the changes. The client should first see how the changes directly affect his/her life, thus enhancing the motivation to make the changes.

A nurse is caring for a client who has a tracheostomy and requires suctioning. Which of the following actions should the nurse take?

Hyperoxygenate the client before suctioning The nurse should use a manual resuscitation bag to hyperoxygenate the client for several minutes prior to suctioning.

A nurse is caring for a client who requires a chest X-ray. Prior to the client being transported for the procedure, which of the following actions should the nurse take first?

Identify the client using 2 identifiers. The nurse should apply the safety and risk-reduction priority-setting framework, which assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting framework, and/or nursing knowledge to identify which risk poses the greatest threat to the client.

A nurse is performing a breast examination for a female client. Which of the following techniques should the nurse use first?

Inspect both breasts simultaneously According to evidence-based practice, the nurse should first inspect both breasts with the client's arms in several different positions to look for asymmetry, masses, retraction, lesions, inflammation, and dimpling.

A nurse in an acute care facility is planning care for a client who is alert but temporarily immobile due to a total hip arthroplasty. Which of the following interventions should the nurse plan to take to prevent a complication of immobility?

Instruct the client to perform foot and leg exercises every 1-2 hr while awake to help prevent thrombophlebitis Antiembolic exercises (e.g. flexion of the knees and rolls and pumps of the feet and ankles) every 1-2 hours help prevent thrombophlebitis, which is a complication of immobility.

A nurse is caring for a client who has a temperature of 38.7°C (101.7°F). Which of the following actions should the nurse take?

Keep the client's bed linens dry The nurse should maximize the client's heat loss by keeping the client's clothes and bed linens dry. The nurse should also reduce external coverings on the client's bed without causing shivering.

A nurse is caring for a client who begins having a tonic-clonic seizure while sitting in a chair at the bedside. Which of the following actions should the nurse take first?

Lower the client to the floor The nurse should apply the safety and risk reduction priority-setting framework, which assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's hierarchy of needs, the ABC priority-setting framework, and/or nursing knowledge to identify which risk poses the greatest threat to the client. Therefore, if a client begins to have a seizure while sitting or standing, the nurse should first lower the client to the floor to protect the client from injury.

A nurse is performing a physical examination of a client. The nurse should use percussion to evaluate which of the following parts of the client's body?

Lungs Percussion creates a vibration that helps the examiner determine the density of the underlying tissue. The lungs are hollow organs that can produce sounds such as resonance (a hollow sound over alveoli) or dullness (a dull sound over consolidated areas of the lungs or diaphragm). The nurse also uses auscultation and palpation when evaluating the lungs.

A nurse is caring for a client who has a dysrhythmia. Which of the following techniques should the nurse to use to assess for a pulse deficit?

Obtain the apical and radial rates simultaneously To assess for a pulse deficit, the nurse and a second person assess the client's radial and apical pulses simultaneously and the compare both rates. To calculate the pulse deficit, the nurse should subtract the difference between the apical and radial pulse rates.

A charge nurse is observing a newly licensed nurse perform tracheostomy care for a client. Which of the following actions by the newly licensed nurse requires intervention?

Obtaining cotton balls for tracheostomy care Cotton ball particles can be aspirated into the tracheostomy opening, possibly causing a tracheal abscess. The charge nurse should intervene for this action.

A nurse is performing a physical examination for a client. To evaluate the client's skin moisture, the nurse should use which of the following techniques?

Palpation

A nurse is leading an education session about disposing of biohazardous materials. Which of the following instructions should the nurse include in the teaching?

Place soiled linen in a single linen bag. Soiled linen should be placed in a single bag that is tightly secured to reduce the risk of transmission of microorganisms.

A nurse is providing oral care for a client who is unconscious. Which of the following actions should the nurse take?

Place the client in a lateral position with the head turned to the side before beginning the procedure The nurse should place the client in a lateral position with the head turned to the side to reduce the risk of aspiration of fluids and secretions.

A nurse is preparing to administer a tap water enema to a client. Which of the following actions should the nurse take?

Place the client in a left Sims' position The nurse should place the client into a left Sims' position for the insertion of an enema. This left lateral position facilitates the flow of the enema solution into the sigmoid and descending colon. The anus is exposed by flexing the right leg.

A nurse is planning to collect a stool specimen for ova and parasites from a client who has diarrhea. Which of the following actions should the nurse take when collecting the specimen?

Place the stool specimen collection container in a biohazard bag The nurse should place the specimen collection container in a biohazard bag with the client label on the container and the bag for easy identification. This will also prevent contamination with microorganisms.

A nurse on a rehabilitation unit is preparing to transfer a client who is unable to walk from a bed to a wheelchair. Which of the following techniques should the nurse use?

Place the wheelchair at a 45-degree angle to the bed. Positioning the wheelchair at a 45-degree angle allows the client to pivot, lessening the amount of rotation required.

A nurse is monitoring a client's laboratory results. Which of the following results should the nurse report to the provider?

Potassium 3.0 mEq/L This potassium level is below the expected reference range, indicating hypokalemia. The nurse should report this finding to the provider for instructions about preventing muscle weakness that could affect respiration.

A nurse is planning an in-service training session about nutrition. Which of the following pieces of information should the nurse include?

Protein serves as an energy source when other sources are inadequate. Protein is used as an energy source for the body when carbohydrates and fat stores are unavailable or depleted.

A nurse is caring for a client who is receiving intermittent enteral feedings through an NG tube. The specific gravity of the client's urine is 1.035. Which of the following actions should the nurse take?

Provide more water with feedings The elevation in the client's specific gravity indicates dehydration. The nurse should provide more fluids either by adding free water to feedings or by instilling water between feedings. Another strategy is to request a formula that contains less protein.

A nurse is inserting an NG tube into a client who begins to cough and gag. Which of the following actions should the nurse take?

Pull the NG tube back slightly The nurse should slightly pull back the NG tube and instruct the client to breathe slowly. Once the client relaxes, the nurse should gently advance the tube as the client swallows.

A nurse is preparing to perform mouth care for an unresponsive client. Which of the following actions should the nurse plan to take?

Raise the level of the bed. The nurse should raise the bed to allow the use of proper body mechanics and reduce the risk of self-injury.

A nurse is preparing to administer a partial dose of a prefilled opioid analgesic parenterally to a client. Which of the following actions should the nurse plan to take?

Record the amount of medication wasted on the controlled substance inventory record 2 nurses should sign the controlled substance inventory record to document the amount of medication wasted.

A nurse is caring for a client who has chronic kidney disease. The kidneys regulate body fluids as well as assisting with which of the following functions?

Regulation of acid-base balance The nurse should identify that the kidneys assist with the regulation of acid-base balance in the body by retaining bicarbonate as they excrete hydrogen ions.

A nurse is caring for a client who requires wrist restraints. Which of the following actions should the nurse take?

Remove the restraints at least every 2 hr The nurse should remove the restraints at least every 2 hours to reposition the client, provide fluids and nutrients, assist with range-of-motion exercises, and evaluate the client's overall wellbeing.

A nurse is caring for an older adult client who is violent and attempting to disconnect her IV lines. The provider prescribes soft wrist restraints. Which of the following actions should the nurse take while the client is in restraints?

Remove the restraints one at a time. The nurse should remove one restraint at a time for a client who is violent or noncompliant.

A nurse is helping a client change his hospital gown. The client has an IV infusion via an infusion pump. Which of the following actions should the nurse take first?

Remove the sleeve of the gown from the arm without the IV line According to evidence-based practice, the nurse should first remove the gown from the client's arm without the IV line. Beginning this process will enable the nurse to move the gown fully off the client before stopping the system to remove the gown from the line, resulting in minimal interruption of the IV flow.

A nurse is planning care for a client who is confused and requires a prescription for wrist restraints. Which of the following interventions should the nurse include in the plan of care?

Renew the prescription for the use of restrains within 24 hr The nurse should plan to renew the prescription for the restraints within 24 hours, only after the provider has evaluated the client.

A nurse is caring for a client who is receiving continuous enteral feedings through an NG tube and develops diarrhea. Which of the following actions should the nurse take?

Request a prescription for an isotonic enteral nutrition formula The nurse should assist a client who develops diarrhea while receiving NG tube feedings by consulting with the provider and the dietitian regarding changing the client's formula to an isotonic formula. This formulation can be easier for the client to digest and can decrease diarrhea.

A nurse is preparing to administer a bolus feeding to a client through an NG tube and observes that the exit mark on the tube has moved since the last feeding. Which of the following actions should the nurse plan to take?

Request an X-ray of the client's abdomen The nurse should request an X-ray to verify the placement of the NG tube both after the initial insertion of the tube and if displacement of the tube is suspected. The nurse should verify NG tube placement prior to administering a bolus feeding.

A nurse is preparing to administer a unit of packed RBCs to a client when she discovers that the IV line is no longer patent. The IV team informs her that someone can come to initiate a new line in 30 min. Which of the following actions should the nurse take?

Return the blood to the laboratory Because the nurse knows that the delay will be more than a few minutes, she should return the unit of packed RBCs immediately to the laboratory where the technician will maintain it at the appropriate temperature until the client is ready to receive it.

A nurse delegates the collection of a client's temperature to an assistive personnel (AP). The nurse notes in the documentation that the AP obtained the client's axillary temperature; however, the nurse wanted an oral temperature. The nurse should identify that which of the following rights of delegation should have prevented this situation from occurring?

Right communication The situation could have been avoided if the right communication was given by the nurse to the AP. The right communication entails providing clear, concise instructions regarding the task, including the objective, limits, and expectations.

A nurse is assessing a client's incision and observes the drainage to be blood-tinged. Which of the following terms should the nurse use to document this finding?

Sanguineous The nurse should document blood-tinged drainage as sanguineous. This type of drainage contains large amounts of red blood cells, indicating that damaged capillaries are allowing the escape of red blood cells from the plasma.

A community health nurse is preparing a campaign about seasonal influenza. Which of the following plans should the nurse include as a form of secondary prevention?

Screening groups of older adults in nursing care facilities for early influenza manifestations Screening older adults who have some manifestations of illness to determine if they have influenza is an example of secondary prevention. Secondary prevention is focused on preventing complications of an illness or providing care to prevent an illness from becoming severe.

A nurse is caring for a client who has bilateral casts on her hands. Which of the following actions should the nurse take when assisting the client with feeding?

Sit at the bedside while feeding the client The nurse should avoid appearing to be in a hurry. Sitting at the bedside provides the client with the nurse's full attention during the feeding.

A nurse is reviewing the laboratory data of a client who has a fever and watery diarrhea. Which of the following results should the nurse report to the provider?

Sodium 150 mEq/L A sodium level of 150 mEq/L is greater than the expected reference range of 135 to 145 mEq/L. This client is at risk for dehydration due to diarrhea. Hypernatremia is a manifestation of dehydration, and the nurse should report this finding to the provider.

A nurse is caring for a client who has xerostomia with a lack of saliva. Which of the following nutrients will be affected by the lack of salivary amylase?

Starch Salivary amylase begins the process of digestion in the mouth with the initial breakdown of starches. The majority of starch breakdown occurs in the small intestine with pancreatic amylase.

A nurse is caring for a client who has a history of dysrhythmias. Upon entering the room, the nurse discovers the client is unresponsive to verbal or painful stimuli, has no respirations, and is pulseless. Which of the following actions should the nurse take first?

Start chest compressions The nurse should apply the safety and risk-reduction priority-setting framework, which assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's hierarchy of needs, the ABC priority-setting framework, and/or nursing knowledge to identify which risk poses the greatest threat to the client. The nurse should perform cardiopulmonary resuscitation, which starts with chest compressions followed by opening the airway and breathing for adults and pediatric clients; evidence indicates a great survival rate when chest compressions are started before a breath is initiated.

A nurse is providing teaching to a client about a surgical procedure that she is scheduled for later in the day. The client states that no one has spoken to her about the procedure before. Which of the following actions should the nurse take?

Stop the teaching and check with the surgeon about informed consent. The client's statement indicates that she has not given informed consent; therefore, the nurse should interrupt the teaching and notify the surgeon.

A nurse is caring for a client who has breast cancer. The client has been receiving radiation therapy for several months and now refuses to undergo further treatment. Which of the following actions should the nurse take?

Support the client's decision The nurse has the responsibility to support the client's decision and respect the client's right of refusal. The nurse should notify the provider of the client's decision and document the refusal in the client's medical record.

A nurse in the emergency department is caring for a client who has abdominal trauma. Which of the following assessment findings should the nurse identify as an indication of hypovolemic shock?

Tachycardia Due to the decreased circulating blood volume that occurs with internal bleeding, the oxygen-carrying capacity of the blood is reduced. The body attempts to relieve the hypoxia by increasing the heart rate and cardiac output while increasing the respiratory rate.

A nurse is caring for a client who is receiving IV fluid replacement. Which of the following findings should the nurse identify as infiltration of the IV infusion site?

Taut skin around the IV catheter site that is cool to the touch A client who has taut skin around the IV catheter site that is cool to the touch might have an infiltrated IV site. The nurse should stop the IV infusion, elevate the extremity, and apply a warm moist compress or a cold compress (according to the type of infiltration).

A nurse is planning care for a client who reports abdominal pain. An assessment by the nurse reveals the client has a temperature of 39.2°C (102.6°F), a heart rate of 105/min, a soft nontender abdomen, and menses overdue by 2 days. Which of the following findings should be the nurse's priority?

Temperature Elevated temperature is an emergent physiological need that requires priority intervention by the nurse. The nurse should consider Maslow's Hierarchy of Needs, which includes five levels of priority. The levels are as follows: physiological needs, safety, and security needs, love and belonging needs, personal achievement and self-esteem needs, and achievement of full potential and the ability to problem-solve and cope with life situations. When applying Maslow's Hierarchy of Needs, the nurse should review physiological needs first before following the remaining four levels. However, it is important for the nurse to consider all contributing client factors, as higher levels of the pyramid can compete with those at the lower levels, depending on the situation.

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

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

A hospice nurse is visiting with the family member of a client. The family member states that the client has insomnia almost nightly. Which of the following practices should the nurse identify as contributing to the client's insomnia?

The client watches television in her bed during the day. To promote sleep, the client should avoid watching television in bed. She should use the bed only for sleep or sexual activities.

A nurse is providing nutrition counseling to a middle-aged adult client who has a sedentary job. Which of the following factors should the nurse consider?

The client's basal metabolic rate could decrease. The basal metabolic rate decreases as adipose tissue replaces skeletal muscle mass. This places the client at risk of weight gain if a healthy diet is not maintained.

A nurse is caring for an adult client who is grieving following the death of a loved one. Which of the following factors increases the client's risk of developing complicated grief?

The death was sudden. Complicated grief can occur when the death of a loved one is sudden and unexpected.

A nurse is caring for a client who has a prescription for a vest restraint. Which of the following actions should the nurse take?

Tie the restraint with a quick-release knot. The nurse should use a quick-release knot that can be untied easily in case the client's well-being requires quickly removing the restraints.

A nurse is administering an IM injection to a 5-month-old infant. Which of the following injection sites should the nurse use?

Vastus lateralis The nurse should use the vastus lateralis site over the anterior thigh for IM injections for infants and children.

A nurse is planning care for a client who has a wound infection following abdominal surgery. To promote healing and fight infection, which of the following vitamins and minerals should the nurse plan to increase in the client's diet?

Vitamin C and zinc The client's body needs both vitamin C and zinc to fight a wound infection. The client should receive a multivitamin and a mineral supplement of both these substances. In addition, vitamin E supplements also are needed to promote skin and wound healing.

A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA). Which of the following precautions should the nurse implement?

Wear a gown when in the client's room The nurse should apply a gown at all times when in the client's room to maintain contact precautions. This client who has MRSA should be placed in contact isolation, which includes the use of gloves and a gown when providing care.

A client is being discharged home with oxygen therapy delivered through a nasal cannula. Which of the following instructions should the nurse provide to the client and family members?

Wear cotton clothing to avoid static electricity. The use of cotton clothing will limit the buildup of static electricity. Oxygen is a highly combustible gas. The use of oxygen in high concentrations has great combustion potential and readily fuels fire. Although it will not spontaneously burn or cause an explosion, it can easily cause a fire in a client's room if it contacts a spark.

A nurse is performing a straight urinary catheterization for a female client who has urinary retention. Which of the following actions indicates the nurse is maintaining sterile technique?

Wiping the labia minora in an anteroposterior direction The nurse should wipe anteroposteriorly both the right and left labia minora with separate cotton swabs to destroy any microorganisms in the area that would contaminate the catheter.