Fundamentals ATI Dynamic Quizzes
A nurse is planning a community presentation for young adults. Which of the following behaviors should the nurse suggest incorporating into the presentation as part of Erikson's expected developmental task for this age group?
Adjusting to living with a partner Erikson's developmental task for young adults is intimacy vs isolation. Developmental tasks for this age group include finding a partner, adjusting to daily living with the partner, making plans to start a family, raising and nurturing children, managing a home, establishing an affiliation with a social group, and taking on civic responsibility. Incorrect Answers: A. Learning a socially productive skill relates to Erikson's developmental task for school-aged children, which is industry vs inferiority. C. Establishing a sense of sexual identity relates to Erikson's developmental task for adolescents, which is identity vs role confusion. D. Establishing and maintaining an economic standard of living relates to Erikson's developmental task for middle adults, which is generativity vs stagnation.
A nurse is assisting with the care of a client who is having difficulty with muscle coordination following a head injury. The nurse should suspect an injury to which of the following areas of the brain?
Cerebellum The nurse should suspect an injury to a client's 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. Incorrect Answers: A. The nurse should suspect an injury to the hypothalamus if the client is experiencing difficulty with sleeping. This area of the brain serves as the sleep center in the body by secreting hypocretins, which promote rapid eye movement (REM) sleep. B. The nurse should suspect an injury to the cerebral cortex if the client is experiencing difficulty with expression. This area of the brain contains the neural networks that facilitate complex behaviors like learning, memory, and language. C. The pituitary gland produces several hormones such as adrenocorticotropic hormone, which gives rise to cortisol. These hormones are necessary for stress adaptation.
A nurse rates a client's biceps reflex as 2+. Which of the following characteristics should the nurse document about the client's reflexes? A. Diminished ✔Correct answer B B. Average C. Brisk D. Hyperactive
Correct Answer: B. Average Reflexes range on a scale of 0 to 4+. Active or expected reflexes are 2+. Incorrect Answers: A. Diminished reflexes are 1+ or less. C. Brisk reflexes are 3+ or more. D. Hyperactive reflexes are 4+.
A nurse is performing eye irrigation for a client who was exposed to smoke and ash. Which of the following actions should the nurse take? (Q12)
Exert pressure on the bony prominences R: The nurse should hold the client's upper lid against the eyebows and the lower lid against the cheekbone when irrigating the eye. The nurse should hold the irrigator 2.5cm (1 in.) above the eye to keep the irrigator from touching the eye and to prevent the soln. from damaging the eye tissue. The nurse should direct the irrgation soln. onot the lower conjunctival sac to avoid injuring the cornea and having contaminated fluid flow down the nasolacrimal duct. The nurse should direct the irrigation soln. from the inner canthus to the outer canthus of the eye to avoid injuring the cornea and having contaminated fluid flow down the nasolacrimal duct.
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. According to evidence based practice, nurses should remove the most contaminated piece of PPE first and the least contaminated piece of PPE last. The most contaminated pieces of PPE are the gloves, and the least contaminated piece of PPE is the mask.
A nurse is collecting data from a client who reports nausea and vomiting for 2 days. Which of the following findings should indicate to the nurse that the client is experiencing fluid volume deficit?
Increased heart rate An increased heart rate should indicate to the nurse that the client is experiencing fluid volume deficit. Other findings can include an increased BUN level, dry mucous membranes, and dark yellow urine. Incorrect Answers: A. An increase in urine specific gravity should indicate to the nurse that the client is experiencing fluid volume deficit. C. An increased hematocrit should indicate to the nurse that the client is experiencing fluid volume deficit. D. Poor skin turgor should indicate to the nurse that the client is experiencing fluid volume deficit.
A nurse is assisting with planning care for a client who has anorexia and nausea due to cancer treatment. Which of the following interventions should the nurse suggest? (Q16)
Limit drinking liquids when eating food. Drinking beverages with food leads to early satiety and bloating, which results in the client consuming fewer calories. The nurse should make sure client receives cold or room-temperature foods. To increase the nutritional value of the food and the client's caloric intake, the nurse should make sure the client receives high-protein, high-calorie, nutrient-dense foods. The client should also eat nutrient-dense foods first during meals. To reduce nausea, the client should sit uprignt for 1 hour after meals. The client should also rest before meals to converse energy for eating and digesting the food.
A nurse is caring for a client who is receiving a fluid infusion through a peripheral IV catheter. The nurse notes that the part of the arm immediately surrounding the insertion site is red and feels warm. Which of the following actions should the nurse take?
Remove the IV catheter The client's manifestations suggest phlebitis. The nurse should stop the infusion and remove the IV catheter immediately. The nurse should then apply warm compresses to the site. Incorrect Answers: A. "Change infusion tubing" The client's manifestations do not suggest that the infusion tubing is punctured, contaminated, occluded, or expired. B. "Flush IV catheter" This action could worsen the complication suggested by the client's manifestations. D. "Apply cool compress to site" Warm, moist heat is part of the treatment protocol for the complication suggested by the client's manifestations.
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 can send someone in 30 minutes to initiate a new line. Which of the following actions should the nurse take? (Q18)
Return the blood to the laboratory. R: B/c the nurse knows that the delay will be more than a few minutes, she should retuen 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. The unit of packed RBCs should NOT be at room temp. b/c the lack of temperature control could damage the blood. Blood products require specific temp. regulation, which is not consistenly possible with a standard nursing-unit refrigerator. The nurse should never leave blood products or medications at the bedside due to the potential loss, misuse, or contamination.
A nurse is caring for a client who has peripheral edema. The nurse should identify that which of the following nutrients regulates extracellular fluid volume?
Sodium The nurse should identify that sodium regulates extracellular fluid balance as well as nerve impulse transmission, acid-base balance, and various other cellular activities. Incorrect Answers: B. The nurse should identify that calcium supports bone and tooth formation and facilitates nerve impulse transmission. However, it does not affect extracellular fluid volume. C. The nurse should identify that potassium affects the storage of glycogen, nerve impulse transmission, cardiac conduction, and smooth muscle contraction. However, it does not affect extracellular fluid volume. D. The nurse should identify that magnesium affects enzyme and neurochemical activities and the excitability of cardiac and skeletal muscles. However, it does not affect extracellular fluid volume.
A nurse is caring for a client who is exhibiting confusion. The nurse should identify that which of the following laboratory values can cause confusion?
Sodium 123 mEq/L The nurse should identify that a sodium level of 123 mEq/L is below the expected reference range of 136 to 145 mEq/L. Low sodium levels can cause confusion and lead to seizures, coma, and death. Incorrect Answers: B. A blood glucose of 100 mg/dL is within the expected reference range of 70 to 110 mg/dL for fasting and <200 mg/dL for a casual blood draw. C. A potassium level of 3.5 mEq/L is within the expected reference range of 3.5 to 5 mEq/L. D. A hemoglobin level of 13 g/dL is within the expected reference range of 12 to 18 g/dL.
A nurse is preparing to perform oral care for a client who is unresponsive. Which of the following actions should the nurse plan to take? (Q19)
or Raise the level of the bed. R: Nurse should raise the bed to allow the use of proper body mechanics and reduce the rish of of self-injury. To prevent the risk of aspiration, the nurse should raise the client's head to 30° or place the client in a side-lying posittion (NOT supine). To prevent straining and reduce rish of self-injury, nurse should lower the near side rail (therefore, keep side rails down). To reduce the risk of self-injury, nurse should never insert fingers into the mouth of an unresponsive client.
A nurse is reinforcing teaching with a client who has a new colostomy. Which of the following statements should the nurse identify as an indication that the client understands the instructions?
"I will make sure to replace my pouch around 4 hours after I eat." It is best for the client to replace the pouch at a time when the bowel is least active, either after arising in the morning or at least 2 to 4 hours after a meal. Otherwise, the client risks releasing stool while there is no pouch in place. Incorrect Answers: A. The nurse should remind the client to empty the pouch when it is a third to half full to reduce the risk of the seal breaking, the pouch detaching, and stool coming in contact with the skin near the seal. B. The nurse should remind the client to replace the pouch twice a week to prevent leakage. If the client has skin breakdown around the appliance, the pouch will require replacement every 24 to 48 hours for skin treatment. C. The nurse should remind the client to cut an opening in the barrier than is no more than 1/8 inch larger than the stoma. This is the right amount of space for slight expansion but not enough to allow contact of stool with the skin.
A nurse documents clubbing of the fingernails for a client who has emphysema. The nurse should identify that which of the following is the underlying cause of this finding?
Chronic hypoxemia Clubbing of the nails of the fingers and toes is the result of chronic hypoxemia as seen in COPD. It is a change in the angle between the nail and the nail base, often with enlargement of the fingertips. Trauma does not cause clubbing of the fingernails. Trauma can cause Beau's lines, which are another type of nail alteration involving transverse depressions in the nail. Trauma can also cause paronychia, an inflammation of the skin at the base of the nail. Severe infection does not cause clubbing of the fingernails but can cause Beau's lines. Iron-deficiency anemia does not cause clubbing of the fingernails. Iron-deficiency anemia can cause koilonychia ("spoon nail"), which is another type of nail alteration that involves concave curves.
A nurse is caring for a group of clients who are receiving oxygen therapy. Which of the following clients should the nurse plan to see first? ✔Correct answer A A. A client who has heart failure and is receiving 100% oxygen via a partial rebreather mask B. A client who has emphysema and is receiving humidified oxygen at 3 L/min via a transtracheal oxygen cannula C. A client who has an old tracheostomy and is receiving 40% humidified oxygen via tracheostomy collar D. A client who has COPD and
Correct Answer: A. A client who has heart failure and is receiving 100% oxygen via a 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 risk 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 a partial rebreather mask. Oxygen can cause toxicity and is highly combustible, and higher concentrations o
A nurse is admittng a client who has measles. Which of the following types of transmission precautions should the nurse initiate?
Correct Answer: A. Airborne Airborne precautions are required for clients who have infections that spread via droplet nuclei that are smaller than 5 microns in diameter, including varicella, tuberculosis, and measles. Incorrect Answers: B. Droplet precautions are required for clients who have infections that spread via droplet nuclei that are larger than 5 microns in diameter, including rubella, meningococcal pneumonia, and streptococcal pharyngitis. C. Contact precautions are required for clients who have infections that spread via direct contact or contact with the environment, including vancomycin-resistant Enterococci, methicillin-resistant Staphylococcus aureus, and scabies. D. Clients with compromised immune systems (e.g. after an allogeneic hematopoietic stem cell transplant) require a protective environment.
A nurse is measuring a client's blood pressure. The nurse notes that the systolic reading is typical for the client, but the diastolic reading is considerably higher than the client's usual baseline. Which of the following errors in blood-pressure measurement is a possible cause of a falsely elevated result? ✔Correct answer A A. Deflating the cuff too slowly B. Using a bladder cuff that is too wide C. Inflating the cuff insufficiently D. Holding the stethoscope too tightly against the skin
Correct Answer: A. Deflating the cuff too slowly Deflating the cuff too slowly can falsely elevate the diastolic pressure. Deflating it too quickly can cause a falsely low systolic and falsely high diastolic reading. Incorrect Answers: B. Using a bladder cuff that is too wide can result in falsely low blood-pressure readings. C. Not inflating the cuff to a high enough level can result in a falsely low systolic reading. D. Holding the bell of the stethoscope too tightly against the skin of the client's antecubital fossa can result in falsely low diastolic readings.
A nurse is caring for a client who has a stage II pressure ulcer. Which of the following wound dressings should the nurse apply to the ulcer? ✔Correct answer A A. Hydrocolloid B. Collagen C. Calcium alginate D. Proteolytic enzyme
Correct Answer: A. Hydrocolloid The nurse should apply a hydrocolloid dressing to a stage II pressure ulcer. This type of dressing is applied to absorb exudate and to produce a moist environment that will facilitate healing while preventing maceration of surrounding skin. Incorrect Answers: B. The nurse should apply collagen to a clean, moist wound to stop bleeding, bring cells into the wound, and stimulate their proliferation to facilitate healing. C. The nurse should apply calcium alginate to a stage IV pressure ulcer. This type of dressing is used for wounds with significant exudate and must be covered with a secondary dressing. D. The nurse should apply a proteolytic enzyme to an unstageable pressure ulcer. This type of dressing is applied to facilitate debridement and to soften eschar.
A nurse is collecting data for a client who has had diarrhea and decreased urination for several days. Which of the following actions should the nurse take to determine if the client is dehydrated?
Correct Answer: B. Grasp a skinfold on the chest under the clavicle, release it, and note whether it springs back The nurse should use this technique for collecting data on skin turgor. If the client has good turgor and is properly hydrated, the skin will immediately return to normal; in dehydration, the skin will remain tented. The nurse can also collect data on skin turgor by grasping a skinfold on the back of the forearm. Incorrect Answers: "Push on a fingernail bed until it blanches, release it, and observe how long it takes the skin to become pink" A. This technique is for assessing capillary refill, which is a test to determine arterial blood flow in the extremity. "Press the skin in above the ankle for 5 sec, release it, and note the depth of the impression" C. This technique is for determining how much pitting edema a client has. It is not used to determine dehydration. "Measure the skin fold thickness at the upper arm using a pair of calibrated skinfold calipers" D. This
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? (actually question 6)
Correct Answer: B. 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. Incorrect Answers: A. "Apply an alcohol-water solution to the client's skin." This therapy is no longer recommended as an intervention for a fever because it can lead to shivering, which is counterproductive and can cause an increase in energy expenditure. C. "Apply ice packs to the groin." This therapy is no longer recommended as an intervention for fever because it can lead to shivering, which is counterproductive and can cause an increase in energy expenditure. D. "Limit the client's fluid intake to 1183 ml (40 oz) of fluid per day. The nurse should satisfy the client's increased metabolic needs by providing the client with at least 1893 mL (64 oz) of fluid per day.
A nurse is preparing to administer an intramuscular injection to a client who is overweight. Which of the following sites should the nurse select for the injection? A. The lower medial quadrant of the buttock near the coccyx ✔Correct answer B B. The side hip between the iliac crest and anterior iliac spine C. The tissue of the posterior upper arm D. The lower inner thigh, 2 finger widths above the patella
Correct Answer: B. The side hip between the iliac crest and anterior iliac spine The side hip between the iliac crest and anterior iliac spine forms the boundaries for a ventrogluteal injection; therefore, this is an appropriate site for the nurse to select. This site is the preferred site for intramuscular injections for an adult client. The nurse should prepare the client for injection by placing a hand on the client's greater trochanter (e.g. with the right hand on the client's left hip) with the first 2 fingers touching the iliac crest and anterior superior iliac spine, forming a "V" shape. Incorrect Answers: A. To administer an intramuscular medication using the dorsogluteal site, the nurse should select the upper lateral quadrant of the buttock. However, this site can increase the risk of injury to the client because the medication is more likely to be injected into subcutaneous tissue, and there is an increased risk of piercing the sciatic nerve. C. The nurse should select
A nurse is explaining Piaget's theory of cognitive development to a group of day care providers for employees' children at an acute-care facility. Which of the following activities should the nurse include as an example of concrete operational thinking? A. Playing in the sand B. Playing dress-up with old clothes ✔Correct answer C C. Collecting and trading game cards D. Describing interpersonal relationships
Correct Answer: C. Collecting and trading game cards Collecting and trading game cards require seriation of the cards, involving what to collect, what to trade, and what has value. This is a characteristic of Piaget's concrete operational stage for ages 7 to 11 years. Incorrect Answers: A. Playing in the sand is an example of Piaget's sensorimotor stage, which characterizes children from birth to 2 years of age. B. Playing dress-up is pretending, which reflects Piaget's preoperational thinking stage for ages 2 to 7 years. D. Describing interpersonal relationships requires abstract thought, which is part of Piaget's formal operational reasoning stage for ages 11 years and beyond.
A nurse is using the Braden scale to predict the pressure-ulcer risk for a client in a long-term care facility. Using this scale, which of the following parameters should the nurse evaluate?
Correct Answer: C. Nutrition Nutrition, sensory perception, moisture, activity, mobility, and friction and shear are the parameters of the Braden scale for determining a client's risk for developing pressure ulcers. Incorrect Answers: A. Incontinence is a parameter on the Norton scale, not on the Braden scale. B. Mental state is a parameter on the Norton scale, not on the Braden scale. D. General physical condition is a parameter on the Norton scale, not on the Braden scale.
A nurse is preparing to remove an NG tube for a client who had a partial colectomy. Which of the following actions should the nurse take? A. Maintain suction while removing the NG tube B. Instill 100 mL of air into the NG tube before removal ✔Correct answer C C. Pinch the NG tube while removing the tube D. Instruct the client to breathe in and out during the removal of the NG tube
Correct Answer: C. Pinch the NG tube while removing the tube The nurse should pinch the NG tube while removing it to decrease the risk of aspiration of any gastric contents. Incorrect Answers: A. The nurse should disconnect the NG tube from the suction apparatus before removal to decrease the risk of injury to the gastrointestinal mucosa. B. The nurse should instill 50 mL of air into the tube to clear the contents of gastric drainage and decrease the risk of aspiration on removal of the tube. D. The nurse should instruct the client to take a deep breath and to hold it during the removal of the NG tube to close the glottis and decrease the risk of aspiration of any gastric contents.
A nurse is preparing to administer a tap water enema to a client. Which of the following actions should the nurse take? (question 9)
Correct Answer: C. 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. Incorrect Answers: A. "Raise the enema bag if the client experiences cramping." The nurse should administer the fluids slowly and lower the container for a client who experiences fullness or pain during the administration of the enema. B. "Lubricate 2.54 cm (1 in) of the tip of the rectal tube prior to the insertion."The nurse should lubricate 5.08 cm (2 in) of the tip rectal tube prior to insertion. D. "Don sterile gloves prior to the procedure." The nurse should don clean gloves to perform an enema procedure for a client.
A nurse is preparing to irrigate a client's wound. Which of the following actions should the nurse take? A. Use a 10 mL syringe B. Attach a 22-gauge catheter to the syringe ✔Correct answer C C. Warm the irrigating solution to 37°C (98.6°F) D. Administer an analgesic 10 minutes before the irrigation
Correct Answer: C. Warm the irrigating solution to 37°C (98.6°F) The nurse should prepare about 200 mL of irrigating solution and warm it to body temperature to minimize the client's discomfort and vascular constriction. Incorrect Answers: A. The nurse should use a syringe that has at least a 30-mL capacity. B. The nurse should use an 18- or 19-gauge catheter. A smaller catheter will exert too much pressure on the wound. D. The nurse should administer an analgesic 20 to 30 minutes before the irrigation to give the medication enough time to provide pain management during the procedure.
A nurse is collecting data regarding a client's nutritional status during a community health screening. The nurse determines the client is consuming 500 calories per day more than his energy level requires. When will the client have gained 4.5 kg (10 lb)? A. 10 months B. 5 months C. 5 weeks ✔Correct answer D D. 10 weeks
Correct Answer: D. 10 weeks Because 1 lb of body fat is equivalent to 3,500 calories, 500 calories each day for 7 days would mean 3,500 calories total and a 1 lb gain per week. So, at the rate of 1 lb per week, the client would gain 10 lb in 10 weeks. Incorrect Answers: A. At the rate of 1 lb per week, the client would gain 40 to 50 lb in 10 months. B. At the rate of 1 lb per week, the client would gain 20 to 25 lb in 5 months. C. At the rate of 1 lb per week, the client would gain 5 lb in 5 weeks.
A nurse is preparing to administer a tuberculin skin test to a client. After performing hand hygiene, which of the following actions should the nurse take? A. Select a 23-gauge needle B. Insert the needle into the skin at a 25º angle C. Massage the injection area following removal of the needle ✔Correct answer D D. Circle the area of the injection with a pen
Correct Answer: D. Circle the area of the injection with a pen Circling the area using a pen ensures the nurse will examine the correct site when reading the test 48 to 72 hours later. Incorrect Answers: A. A 25- to 27-gauge needle is used for intradermal injections. B. The needle should be inserted at an angle of 10º to 15º. This ensures the solution will be injected into the intradermal area. C. The area should not be massaged because this can spread the injection into the tissue or out through the insertion site.
A nurse in an acute-care facility is assisting with planning care for a client who is alert but is temporarily immobile due to a total hip arthroplasty. Which of the following interventions should the nurse suggest to prevent a complication of immobility? A. Move the client from supine to a low-Fowler's position every 2 to 3 hours to help prevent orthostatic hypotension B. Limit fluid intake to 1 L (33.8 oz) in 24 hours to help prevent dependent edema C. Encourage the client to turn from side
Correct Answer: D. Instruct the client to perform foot and leg exercises every 1 to 2 hours while awake to help prevent thrombophlebitis Anti-embolic exercises such as flexion of the knees and rolls and pumps of the feet and ankles every 1 to 2 hours help prevent thrombophlebitis, which is a complication of immobility. Incorrect Answers: A. Moving the client from supine to a low-Fowler's position every 2 to 3 hours is not sufficient to help prevent orthostatic hypotension. Changing positions slowly helps prevent or minimize the effects of orthostatic hypotension. B. Clients who are immobile should consume at least 1.1 to 1.4 L (37.2 to 47.3 oz) of fluid in 24 hours to help prevent bladder complications. Limiting fluid intake does not prevent dependent edema. C. The client should cough and breathe deeply every 1 to 2 hours to help prevent respiratory complications. Turning from side to side every 1 to 2 hours also helps to prevent skin breakdown.
A nurse is reviewing the laboratory results of a client and notes a WBC count of 3,600/mm^3. The nurse should identify this result as an indication of which of the following conditions? A. Leukoplakia B. Leukemia C. Leukocytosis ✔Correct answer D D. Leukopenia
Correct Answer: D. Leukopenia The nurse should identify that leukopenia occurs when there is a decrease in the production of WBCs. This alteration places the client at an increased risk of infection. Incorrect Answers: A. Leukoplakia occurs when there are thick white patches found in the mucosa of the mouth. These lesions can be precancerous and are often seen in clients who smoke heavily. B. Leukemia occurs when there is an uncontrolled production of blast cells or immature white blood cells in the bone marrow. C. Leukocytosis is an increase in circulating white blood cells in response to white blood cells exiting from the blood vessels as a result of inflammation.
A nurse has received a prescription for dextran to administer to a client. The nurse should recognize that dextran belongs to which of the following functional classifications? A. Skeletal muscle relaxants B. Beta-adrenergic blockers C. Broad-spectrum anti-infectives ✔Correct answer D D. Plasma volume expanders
Correct Answer: D. Plasma volume expanders Dextran and albumin are plasma volume expanders. They help correct hypovolemia in emergency situations such as after hemorrhage or burns. Incorrect Answers: A. Dextran is not a skeletal muscle relaxant. Examples of skeletal muscle relaxants are cyclobenzaprine and metaxalone. B. Dextran is not a beta-adrenergic blocker. Examples of beta-adrenergic blockers are propranolol and carvedilol. C. Dextran is not a broad-spectrum anti-infective. Examples of broad-spectrum anti-infectives are ampicillin and cefixime.
A nurse is evaluating the development of a group of clients. The nurse should understand that, according to Erikson, the developmental task of intimacy vs. isolation occurs during which of the following stages of development? A. Middle adulthood B. Adolescence C. Childhood ✔Correct answer D D. Young adulthood
Correct Answer: D. Young adulthood The developmental task of young adulthood is intimacy vs. isolation. Incorrect Answers: A. The developmental task of middle adulthood is generativity vs. self-absorption and stagnation. B. The developmental task of adolescence is identity vs. role confusion. C. The developmental task of school-aged children is industry vs. inferiority.
A nurse is reinforcing teaching about body mechanics with assistive personnel. Which of the following instructions should the nurse include? (Select all that apply.)
Correct Answers: A. "Sit with your back supported." B. "Keep your knees at hip level." C. "Use an ergonomically designed computer keyboard." Using lumbar support in a straight-back chair helps maintain good posture and prevent back pain. Keeping the knees at the level of the hip or higher helps reduce the risk of lordosis, which is an exaggeration of the curve of the lumbar spine. Using a keyboard that maintains ergonomic positioning of the wrists can help prevent carpal tunnel syndrome. Incorrect Answers: D. Keeping the upper arms and elbows close to the body limits straining of the shoulders and the upper back muscles. E. Tilting the screen and tilting the head to look at it can strain the cervical spine.
A nurse is collecting data from a client who is experiencing an obstruction of the flow of the vitreous humor in the eye. The nurse should identify that this manifestation is consistent with which of the following eye disorders?
Glaucoma An obstruction of the flow of the vitreous humor of the eye is a manifestation of glaucoma. This obstruction leads to increased intraocular pressure, resulting in damage to the eye. The nurse should identify that manifestations of retinopathy include changes in the blood vessels of the retina, which can lead to blindness. The nurse should identify that manifestations of cataracts include an increase in the opacity of the lens, blocking rays of light from entering the eye. The nurse should identify that manifestations of macular degeneration include changes in the sharp and central vision. These findings are often associated with aging.
A nurse is changing the dressings for a client recovering from an appendectomy following a ruptured appendix. The client's surgical wound is healing by secondary intention. Which of the following observations should the nurse report to the provider?
Halo of erythema on the surrounding skin The nurse should report to the provider when the client has a ring of erythema (redness) on the surrounding skin, which might indicate an underlying infection. This and any other manifestation of infection such as purulent drainage, swelling, warmth, or a strong odor should be reported to the provider. Incorrect Answers: A. Tenderness to touch is an expected finding in a postoperative wound healing by secondary intention. Severe pain might indicate an infection or underlying tissue destruction and should be reported. B. Pink, shiny tissue with a grainy appearance is granulation tissue and indicates the proliferative stage of wound healing when the body begins to build the wound bed with new skin cells. This is an expected finding in a postoperative wound healing by secondary intention. C. Serosanguineous drainage, which is made up of RBCs and plasma, is an expected finding in a postoperative wound healing by secondary intention. Purulent drainage suggests an infection and should be reported.
***A nurse is caring for a client who has a tracheostomy and requires suctioning. Which of the following actions should the nurse take?*** (Q20)
Hyperoxygenate the client before suctioning. R: The nurse should use a manual resuscitation bag to hyperoxygenate the client for several minutes prior to suctioning. The nurse should insert the catheter during INHALATION. Applying suction while inserting the catheter increases the risk of damage to the tracheal mucosa and removes oxygen from the airways (Apply suction during insertion of catheter--NO!) The nurse should apply suction for NO MORE THAN 10 SECONDS.
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? (Q15)
I will shake the inhale well right before I use it. R: Nurse should instrct client to shake inhaler vigorously for 3 to 5 seconds, which will mix the medication within the inhaler evenly. Nurse should instruct client to wait 20 to 30 seceonds between inhalations of bronchodilator medications such as albuterol. Nurse should instruct the client to place the inhaler in the the mouth an tightly close the lips aorund the mouthpiece to create a seal. The client should then depress the canister, take a deep breath, and hold it for at least 10 seconds.
A nurse is collecting data for an adult client. What is the correct sequence of steps for data collection of the abdomen? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
Inspection, Auscultation, Percussion, Palpation The appropriate sequence for abdominal data collection is to inspect, auscultate, percuss, and palpate. This sequence prevents altering the bowel sounds and causing false results. The appropriate sequence for any other data collection for an adult client is: Step 1. Inspection Step 2. Palpation Step 3. Percussion Step 4. Auscultation
A nurse is preparing to change a dressing on a client who is receiving negative-pressure wound therapy (NPWT). In what sequence should the nurse plan to take the following actions? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
Turn off the vacuum on the NPWT device and administer the prescribed analgesic. Remove the soiled dressing and perform hand hygiene. Apply sterile or clean gloves and irrigate the wound. Apply skin protectant or a barrier film to the skin around the wound. Place prepared foam into the wound bed and cover with transparent dressing. Connect the tubing to transparent film and turn on the NPWT unit. Step 1. The nurse should turn off the vacuum on the NPWT device to loosen the dressing and administer the prescribed analgesic. Step 2. The nurse should gently remove the soiled dressing and perform hand hygiene. Step 3. The nurse should apply sterile or clean gloves and irrigate the wound to remove debris. Step 4. The nurse should apply a skin protectant or a barrier film to the surrounding skin to ensure an airtight seal and provide protection. Step 5. The nurse should place foam in the wound bed and cover with a transparent dressing to provide an airtight seal. Step 6. The nurse should
A nurse is reinforcing teaching about nutritious diets to a group of adult women. Which of the following statements should the nurse include in the teaching?
"Include 2.5 cups of vegettables in your daily diet" Nutritious diets contain a variety of foods to ensure the required daily allowance of nutrients is ingested. The nurse should instruct the women to include 2.5 cups of vegetables and 2 cups of fruit into their daily diets. Fruits and vegetables should be a variety of colors to provide an assortment of nutrients. The nurse should instruct these women to consume sodium in moderation. The American Heart Association recommends consuming less than 2.5 g of sodium daily, while the adequate intake (AI) is 1.5 g. Excessive intake of sodium can lead to hypertension. Although certain alcoholic beverages such as red wine contain phytochemicals that can reduce the risk of cardiovascular disease and have anti-inflammatory properties, excessive intake can lead to a deficiency in other nutrients. The recommended amount of alcohol for women is 1 drink per day, which is equivalent to 350 mL (12 oz) of beer, 148 mL (5 oz) of wine, or 44 mL (1.5 oz) of hard alcohol that is greater than 80 proof. Water is an important component of a nutritious diet because it is necessary for the digestion, absorption, and transport of nutrients. The nurse should instruct these women to drink between 2 and 3 L of water daily to maintain homeostasis based on client comorbidities, the climate, and the client's activity level.
**A nurse is collecting a specimen for culture from a client's infected wound. Which of the following actions should th enurse take?** (Q17)
Cleanse the wound with 0.9% sodium chloride irrigation. The nurse should cleanse the wound with sterile water or 0.9% sodium chloride irrigation to remove any surface debris or old exudate. The nurse should wear clean gloves to collect a wound culture specimen (doesn't have to be sterile gloves). The nurse's hands will not touch the wound of the cultre swab. Pooled drainage can collect microorrganisms that are not the pathogens causing the wound infection ("Allow the collection swab to absorb old exudate"-NO). The nurse should rotate the swab back and forth over clean areas in the base of the wound to collect the pathogens causing the wound infection. The edges of the wound can harbor superficial microorganisms from the skin that are not infecting the wound ("Rotate the collection swab over the edges of the wound"--NO).
A nurse is caring for a client who is well-hydrated and has no visible evidence of nutritional deficiencies. A laboratory result within the expected reference range for which of the following substances is an indication that the client has adequate protein uptake and synthesis? ✔Correct answer A A. Albumin B. Calcium C. Sodium D. Potassium
Correct Answer: A. Albumin The nurse should identify that an albumin level within the expected reference range is an indication that the client has adequate protein uptake and synthesis. Albumin levels measure protein status. They are useful for identifying long-term protein depletion rather than short-term or acute changes in nutritional status. Incorrect Answers: B. Calcium levels do not reflect protein status. Calcium levels reflect the adequacy of bone and tooth formation, blood clotting, nerve impulse transmission, muscle contraction and relaxation, and various other essential processes. C. Sodium levels do not reflect protein status. Sodium levels provide an indicator of fluid balance, nerve impulse transmission, acid-base balance, and various other cellular activities. D. Potassium levels do not reflect protein status. Potassium levels reflect the status of many metabolic activities, including nerve impulse transmission, cardiac conduction, and skeletal and smooth muscle con
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? A. Stand toward the client's stronger side B. Instruct the client to lean backward from the hips ✔Correct answer C C. Place the wheelchair at a 45° angle to the bed D. Assume a narrow stance with feet 15 cm (6 in) apart
Correct Answer: C. Place the wheelchair at a 45° angle to the bed Positioning the wheelchair at a 45° angle allows the client to pivot, lessening the amount of rotation required. Incorrect Answers: A. Safely transferring a client from a bed to a wheelchair requires the nurse to stand in front of the client toward the side that requires the most support. This technique will help maintain balance during the transfer. B. Safely transferring a client from a bed to a wheelchair requires the nurse to instruct the client to lean forward from the hips. This technique positions the client in the proper direction of the movement. D. Safely transferring a client from a bed to a wheelchair requires the nurse to assume a wide stance with a foot in front of the other. This technique protects the nurse from losing balance during the transfer.
Various dietary practices
Kosher diets involve restrictions regarding processing, preparation, and eating of food. Ovo-vegetarian diets are primarily vegetable-based and exlude meats and dairy EXCEPT for egg. Therefore, eggs included. Macrobiotic diets are primarily plant-based but DO include fish and seafood. Flexitarian diet are primarily plant-based WITH occasional consumption of meat, fish, and dairy products.
A nurse is auscultating the heart sounds of a client who has developed chest pain that worsens with inspiration. The nurse hears a high-pitched scratching sound with the diaphragm of the stethoscope placed at the third intercostal space of the left sternal border. Which of the following heart sounds should the nurse document?
Pericardial friction rub. A pericardial friction rub has a scratching, grating, or squeaking leathery sound. It tends to be high frequency and best heard with the diaphragm of the stethoscope at the third intercostal space of the left sternal border. A pericardial friction rub is a manifestation of pericardial inflammation and can be heard with infective pericarditis, with myocardial infarction, following cardiac surgery or trauma, and with some autoimmune problems such as rheumatic fever. A client who develops pericarditis typically has chest pain that becomes worse with inspiration or coughing and may be relieved by sitting up and leaning forward. An audible clicking sound occurs in clients who have prosthetic valve replacement surgery. A heart murmur has a swishing or a whistling sound. Heart murmurs are caused by turbulent blood flow through valves or ventricular outflow tracts. Low- and medium-frequency sounds are more easily heard with the bell of the stethoscope applied lightly to the skin; high-frequency sounds are more easily heard with a diaphragm. A murmur can be a manifestation of valvular disease. A third heart sound (S3) is a low-pitched sound after the second heart sound. An S3 is caused by rapid ventricular filling during diastole. It is best heard at the mitral area, with the client lying on the left side. An S3 is commonly heard in children and young adults. In older adults and clients who have heart disease, an S3 often indicates heart failure.
A nurse is preparing to adminster a partial dose of a prefilled opioid analgesic parenterally to a client. Which of the following actions should the nurse plan to take? (question 10)
Record the amount of medication wasted on the controlled substance inventory record R: Two nurses should sign the controlled substance inventory record to document the amount of medication wasted. Incorrect Answers: A. The nurse should not return the unused portion of medication to the pharmacy. The medication should be wasted, and the amount wasted should be recorded on the controlled substance inventory. B. The nurse should dispose of a controlled substance into a sharps container. Both the amount of the medication given and the amount of medication wasted should be signed for. D. A second nurse, not an AP, must serve as the witness to the wasting of the remaining controlled substance.
A nurse is caring for a client in a long-term care facility. Which of the following findings should alert the nurse to the possibility that the client has developed delirium?
Reduced level of consciousness When a client has delirium, the nurse should expect a reduced level of consciousness, sudden memory impairment, illogical thinking, and sleep disturbances. Incorrect Answers: A. Gradual memory loss is a common finding in dementia rather than delirium. C. Difficulty with abstract thought is a common finding in dementia rather than delirium. D. Verbalization of feelings of hopelessness is a common finding in depression rather than delirium.
A nurse is auscultating breath sounds for a client who has fine crackles. At which of the following areas on the lung field should the nurse place the stethoscope? (Make a selection in the artwork below and choose only the hot spot that corresponds to the answer.)
The nurse should place the stethoscope at the lower lobes of the lung field to auscultate for fine crackles that arise from the small airways of the lungs. Crackles are interrupted sounds that are heard at the end of inspiration. Fine crackles are caused by atelectasis, pneumonia, and chronic pulmonary disease. Incorrect Answers: B. The nurse should place the stethoscope over the trachea to auscultate for bronchial breath sounds. Bronchial breath sounds are caused by consolidation and sound high-pitched and loud. C. The nurse should place the stethoscope over the bronchioles lateral to the sternum as the bronchus branches off the main bronchial stem to auscultate for rhonchi. Rhonchi are lower-pitched coarse sounds caused by thick, tenacious mucous; tumors; or obstruction by a foreign body.
