fundemntal

which sound the nurse will hear over the periphery of the major lung fields?

vesicular sounds. These sounds are soft and low-pitched.

A nurse is providing discharge teaching to an older adult client about personal safety. Which of the following statements by the client indicates an understanding of the teaching?

. "I will put a night-light in the hallway." The nurse should instruct the client to use night-lights in and around the home as an important safety measure to reduce the risk of falls in the home. Physiological changes associated with aging can affect an older adult client's ability to see surroundings. Older adults and infants are at an increased risk of serious injury from falls, and most falls occur in the client's home. Incorrect Answers: A. The nurse should instruct the client to paint or mark only the edges of the steps with a light color to make them more prominent. Physiological changes associated with aging can affect an older adult client's ability to see the edges of the steps. C. The nurse should instruct the client to wear well-fitting slippers with non-skid soles as an important safety measure to reduce the risk of falls in the home. Physiological changes associated with aging can affect an older adult client's ability to balance, increasing the risk of falls. D. The nurse should instruct the client that securing wires under a rug can create an electrical hazard and should be avoided. Physiological changes associated with aging can affect an older adult client's ability to see surroundings and to react quickly to hazards when walking.

A nurse is collecting data for the health history of a client who is postoperative and has paralytic ileus. Which of the following findings should the nurse expect?

. Absent bowel sounds with distention Paralytic ileus is an immobile bowel. In this disorder, bowel sounds are absent, and the abdomen is distended.

A nurse is replacing the surgical dressing on a client who had abdominal surgery. Which of the following actions should the nurse take?

. Don clean gloves to remove the old dressing The nurse should use standard precautions by applying clean gloves whenever there is a possibility of coming into contact with secretions. Removing a soiled dressing is a procedure that requires wearing clean, not sterile, gloves. Sterile gloves are not necessary until the nurse applies the new sterile dressing. Incorrect Answers: B. The nurse should remove the tape by loosening and pulling toward the wound or dressing to decrease tension or stress on the healing wound edges. C. The nurse should remove the old dressing a layer at a time to prevent the removal of drains and allow the nurse to assess the drainage. D. The nurse should open the sterile supplies after removing the old dressings, after washing hands, and before applying sterile gloves to apply the sterile dressing to prevent microorganisms from contaminating the sterile field.

A nurse is collecting data from a client who is experiencing stress and anxiety regarding a recent diagnosis. Which of the following findings should the nurse expect?

. Increased blood pressure The nurse should expect a client who is experiencing stress and anxiety to manifest increased blood pressure and heart rate as a result of sympathetic stimulation. Incorrect Answers: B. The nurse should expect a client who is experiencing stress and anxiety to manifest an increase in blood sugar levels due to the release of glucocorticoids and gluconeogenesis. C. The nurse should expect a client who is experiencing stress and anxiety to manifest an increase in oxygen use due to the increased metabolic rate and oxygen demands of the body. D. The nurse should expect a client who is experiencing stress and anxiety to manifest decreased gastrointestinal motility, which can result in constipation and flatus.

A nurse on a medical unit is caring for a client who has been coughing intermittently during meals, attempting to clear her throat repeatedly, and eating only a small portion of her meals. The nurse should recommend a referral to which of the following members of the interprofessional team to evaluate the client for dysphagia?

. Speech-language pathologist A speech-language pathologist can perform a thorough evaluation of the client for dysphagia and help the client learn to eat safely. For example, the client can learn the supraglottic swallow (take a breath, hold the breath while swallowing, cough after swallowing, and swallow again to clear the mouth). Incorrect Answers: B. A social worker can assist the client with finding and accessing community services such as meal delivery and financial services once the client is at home. However, a social worker cannot evaluate the skills the client needs to swallow and eat safely. C. A physical therapist can evaluate the strength and mobility of a client who has musculoskeletal problems but cannot evaluate the skills the client needs to swallow and eat safely. D. An occupational therapist can help clients who have physical limitations or disabilities gain the optimal level of independence in performing ADLs but cannot evaluate the skills the client needs to swallow and eat safely

A nurse is presenting an in-service session about nutrition. Which of the following simple sugars should the nurse identify as the carbohydrate found in milk?

: A. Lactose The nurse should identify that lactose is a form of sugar that is found in milk. Incorrect Answers: B. Sucrose is table sugar. It is also found in fruits and vegetables. C. Maltose is found in germinating cereals such as barley. D. Fructose is found in honey and fruit.

By asking a client to explain the statement, "A bird in the hand is worth 2 in the bush," the nurse is evaluating the client's ability in which of the following intellectual functions?

Abstract reasoning This exercise evaluates higher-level thinking and the ability to understand and interpret abstract thoughts. Incorrect Answers: A. To test judgment, the nurse asks what decisions the client would make in response to a specific real-life challenge. B. To test short-term memory, the nurse might ask the client to recall something like a list of 3 words that the nurse asked the client to remember a few moments earlier. C. To test attention span, the nurse might ask the client to count backward from 100 in intervals of 7.

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.

A nurse is evaluating a client for conductive hearing loss. Using the Rinne test, which of the following results should the nurse identify as an indication that the client has conductive hearing loss of the left ear?

Air conduction is less than bone conduction in the left ear. This finding indicates conductive hearing loss of the left ear. Incorrect Answers: B. This finding does not indicate hearing loss of any type. C. D. This is a result of the Weber test, not the Rinne test.

A nurse is admitting a client who has measles. Which of the following types of transmission precautions should the nurse initiate?

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 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?

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 preparing to administer timolol eye drops for a client who has glaucoma. When instilling the medication, which of the following actions should the nurse take?

Apply pressure to the bridge of the nose after instillation of the medication The nurse should instill timolol into the conjunctival sac and apply pressure to the bridge of the nose for 1 minute afterward to prevent systemic absorption of the medication. Incorrect Answers: A. The nurse should instruct the client to close the eyes gently and to avoid blinking after instillation to prevent loss of the medication out of the eye and to promote absorption. B. The nurse should instruct the client to look at the ceiling during instillation of the medication to allow proper placement of the medication and to suppress the client's blink reflex. D. The nurse should instill the medication into the client's conjunctival sac and should take measures to protect the client's cornea during the administration of the medication.

A nurse is caring for a client who has a terminal illness. The client is restless and reports severe pain but refuses the prescribed opioid pain medication. Which of the following actions should the nurse take first?

Ask why the client is refusing the pain medication Using the nursing process, the nurse should first collect data to determine the reason for the client's refusal of opioid pain medication. Incorrect Answers: B. The nurse should administer a PRN antianxiety medication if it is indicated to complement other pain management interventions; however, there is another action the nurse should take first. C. The nurse should assist the client in changing positions to complement other pain management interventions; however, there is another action the nurse should take first. D. The nurse should offer the client a heat or cold pack to complement other pain management interventions; however, there is another action the nurse should take first.

A nurse is caring for a client who is having difficulty breathing. The client is lying in bed with a nasal cannula delivering oxygen. Which of the following interventions is the nurse's priority?

Assist the client to an upright position The priority action the nurse should take when using the airway, breathing, and circulation (ABC) approach to care is to improve the client's respiratory status by seeking to relieve dyspnea. High Fowler's positioning permits full chest and lung expansion and makes breathing easier. Incorrect Answers: A. The nurse should administer a bronchodilator if the provider prescribes it, depending on the client's disorder. This will help alleviate dyspnea by opening constricted airways; however, there is another action the nurse should take first. C. The nurse should encourage the client to use pursed-lip breathing to help alleviate dyspnea by prolonging exhalation and minimizing air trapping; however, there is another action the nurse should take first. D. The nurse should reposition the client from side to side to ensure maximal expansion of each lung alternately; however, there is another action the nurse should take first.

A nurse is collecting data about 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

A nurse is caring for a client who has a cuffed endotracheal tube in place. The nurse should identify that the purpose of inflating the cuff is which of the following? (Select all that apply.)

B. Stabilizing the position of the tube C. Preventing aspiration of secretions D. Preventing air leaks An inflated cuff helps prevent movement of the endotracheal tube, reduces the risk of aspiration of oropharyngeal secretions, and helps keep air from leaking around the outer portion of the endotracheal tube. Incorrect Answers: A. The client cannot speak when an endotracheal tube is in place. E.

A nurse is reinforcing teaching with a client who has hypertension and is starting medication therapy for treatment. The provider has recommended that, because of these new medications, the client should increase her intake of potassium. Which of the following foods should the nurse remind the client to include in her diet?

Bananas are a good source of potassium, with 422 mg of potassium in a medium-size banana. Incorrect Answers: A. Mozzarella cheese is a poor source of potassium, with only 24 mg of potassium in 28.4 g (1 oz) of mozzarella cheese. B. White rice is a poor source of potassium, with only 55 mg of potassium in a 1-cup serving of cooked white rice. D. Grape juice is a poor source of potassium, with only 139 mg of potassium in a 1-cup serving of grape juice.

A nurse is collecting data about a client's pulses of the lower extremities. The nurse should identify which of the following as the location of the most distal pulse?

C. Dorsalis pedis The dorsalis pedis pulse is located on the top of the foot, following the groove between the tendons of the great toe. It is best felt by putting the fingertip between the first and second toe and slowly moving up the dorsum of the foot. However, this pulse is congenitally absent in some clients.

A nurse is reinforcing teaching with a client who has a new colostomy about proper care. Which of the following information should the nurse include in the teaching?

Cleanse the skin around the stoma with warm water The nurse should instruct the client to cleanse the skin around the stoma with warm water because using soap can leave a residue on the skin and cause poor adherence of the pouch adhesive. Incorrect Answers: A. The nurse should instruct the client to change the colostomy bag before a meal because drainage from the ostomy is least likely to occur. C. The nurse should instruct the client to change the pouch every 3 to 7 days to avoid skin breakdown around the stoma. D. The nurse should instruct the client not to place an aspirin in the ostomy pouch because it can cause stoma bleeding

A nurse is collecting a specimen for culture from a client's infected wound. Which of the following actions should the nurse take?

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. Incorrect Answers: A. The nurse should wear clean gloves to collect a wound culture specimen. The nurse's hands will not touch the wound or the culture swab. Pooled drainage can collect microorganisms that are not the pathogens causing the wound infection. 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.

During a physical examination of a client, the nurse suspects strabismus. Which of the following tests should the nurse use to collect additional data?

Corneal light reflex The corneal light reflex requires the nurse to shine a penlight at the client's eyes and visualize whether the light shines on the same spot bilaterally. This test will indicate the alignment of the client's eyes as well as any deviation inward or outward. With strabismus, the eyes will not align when the client focuses.

A nurse observes an assistive personnel (AP) preparing to obtain blood pressure with a regular-sized cuff for a client who is obese. Which of the following explanations should the nurse give the AP?

D. "Using a cuff that is too small will result in an inaccurately high reading." Blood pressure cuffs come in various sizes, and the correct size cuff is necessary to obtain a reliable measurement. Blood pressure readings can be falsely high if the cuff is too small for the client. Incorrect Answers: A. Although the BP reading for a client who is obese may be difficult to hear with any cuff, a cuff that is too small for the client will not yield an inaudible reading. B. The width of the cuff bladder should be 40% of the circumference of the client's arm. C. A cuff that is an incorrect size for the client will not yield an accurate reading.

A nurse is collecting data from a client whose potassium level is 2.8 mEq/L. Which of the following findings should the nurse expect?

Decreased bowel sounds This potassium level is below the expected reference range of 3.5 to 5 mEq/L, indicating hypokalemia. Classic manifestations of this electrolyte imbalance are muscle weakness and decreased bowel sounds.

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?

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 reading

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 client's head of bed 45° before the feeding The nurse should elevate the client's head of bed between 30° and 45° to prevent aspiration. Incorrect Answers: A. The nurse should auscultate for bowel sounds before each feeding to ensure the client has peristalsis bowel activity for the digestive system to digest or absorb the enteral nutrition. B. The nurse should ensure the formula is at room temperature before administering because cold formula might cause intestinal cramping and discomfort. D. The nurse should flush the tubing with at least 30 mL of water after the enteral feeding to maintain patency of the feeding t

A nurse is assisting with the admission of a client who will undergo a craniotomy. During the planning phase of the nursing process, to which of the following areas should the nurse contribute?

Establishing client outcomes The planning phase of the nursing process includes developing goals and outcomes that help the nurse contribute to the client's plan of care. Incorrect Answers: B. The nurse should collect information about the client's past health problems during the data-collection phase of the nursing process. determine whether the client has met goals during the evaluation phase of the nursing process. The nurse should help identify the client's specific health problems during the data-collection phase of the nursing process.

A nurse is collecting data on a client. The nurse should recognize that which of the following findings places the client at risk for impaired skin integrity?

Faint pedal pulses Faint pedal pulses can indicate poor circulation and tissue perfusion that puts the client at risk for impaired skin integrity. Incorrect Answers: A. A 3+ Achilles reflex does not indicate a risk of impaired skin integrity. Reflex testing provides information about the sensory and motor functions of the neurological system. A 3+ reflex indicates a more active reflex than expected. C. Feet that are warm to the touch bilaterally do not indicate a risk of impaired skin integrity. This finding provides an indication of the adequacy of the client's peripheral circulation. D. A capillary refill of less than 2 seconds does not indicate a risk of impaired skin integrity. This finding provides information about the adequacy of tissue perfusion.

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.

A nurse is preparing to change the bed linens of a client who has AIDS and is incontinent of stool. Which of the following personal protective equipment (PPE) items should the nurse don prior to providing client care? (Select all that apply.)

Gown B. Gloves The nurse should follow standard precautions when caring for a client who has AIDS. Because the bed linens might be soiled, the nurse should don a gown in addition to other necessary PPE. Because the nurse's hands will come in contact with the soiled bed linens, the nurse should also don clean gloves in addition to other necessary PPE. Incorrect Answers: C. The nurse should practice standard precautions when caring for a client who has AIDS. AIDS is not transmitted by droplets or inhalation, so a mask is not necessary when changing the client's bed linens. D. The nurse should practice standard precautions when caring for a client who has AIDS. A hair cover is not necessary when changing the client's bed linens. E. The nurse should practice standard precautions when caring for a client who has AIDS. Goggles are not necessary since splashing of bodily fluids is unlikely when changing the client's bed linens.

A nurse is instilling antibiotic ear drops for a client who has an ear infection. Which of the following actions should the nurse take?

Have the client lie on the side opposite the infected ear This position allows optimal access for instilling the drops. A sitting position with the client's head leaning toward the unaffected ear is also acceptable. The nurse should warm the medication before instillation to avoid nerve stimulation and discomfort. B. The nurse should wear clean gloves during the instillation.

At a well-child visit, a nurse is collecting data from a 6-month-old infant. Which of the following findings should the nurse report to the provider?

Head lagging when the parent pulls the infant up to sit Between 4 and 6 months, there should be no head lag when the parent pulls the infant to a sitting position. Between the ages of 6 months and 8 months, the infant should be able to sit without support.

A tracheostomy cover protects the client's airway from dust, chilly air, and any other airborne particles that could otherwise enter the airway.

Incorrect Answers: A. Within the home environment, clean gloves are sufficient. B. Within the home environment, tap water is sufficient for rinsing the inner cannula. C. At home, the client should perform tracheostomy care daily

A nurse is collecting baseline data about a client's chest as part of a physical examination. Which of the following actions should the nurse take first?

Inspect the thorax According to evidence-based practice, the first action the nurse should take when collecting baseline data about a client's chest and lungs is to look at the anterior and posterior chest from the front, back, and sides. The nurse should observe any abnormalities, asymmetrical shapes, or unusual alignment. Incorrect Answers: A. The nurse should auscultate the thorax with the diaphragm of the stethoscope to collect data about breath sounds; however, evidence-based practice indicates that the nurse should take a different data-collection action first. B. The nurse should palpate the thorax to evaluate the skin and check for any masses, lesions, or painful areas; however, evidence-based practice indicates that the nurse should take a different data-collection action first. D. The nurse should percuss the thorax to identify areas of dullness over lung fields; however, evidence-based practice indicates that the nurse should take a different data-collection action first

A nurse in the emergency department is caring for an inmate who has a laceration and is bleeding. The client was brought to the facility by a guard who asks the nurse about the client's HIV infection status. Which of the following actions should the nurse take?

Instruct the guard to ask the inmate The nurse is not able to supply this information to the guard. In order for the guard to obtain this information, the client must offer the information freely. Therefore, the nurse should instruct the guard to ask the client for this information. Incorrect Answers: A. The nurse cannot discuss the client's HIV status with the guard or the warden without the client's consent. The client can share personal medical information if desired. B. The client can sign a release of information form to obtain medical records. Asking the guard to sign this form does not give the nurse permission to share the client's HIV status. D. The nurse would have no cause to complete an incident report in this situation. Incident reports are completed to record an event that is not consistent with standard procedures. An incident report would need to be completed if the nurse were to share the client's HIV status with the guard.

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?

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. empty the pouch when it is a third to half full replace the pouch twice a week to prevent leakage. If the client has a skin breakdown around the appliance, the pouch will require replacement every 24 to 48 hours for skin treatment. cut an opening in the barrier that is no more than 1/8 inch larger than the stoma.

A nurse is collecting data from a client. Which of the following statements by the nurse reflects the communication technique of clarifying?

It sounds like your pain is intermittent." This response reflects the communication technique of clarifying. The nurse should use this technique to ensure an understanding of the client's message. Incorrect Answers: A. This is an example of the communication technique of focusing. The nurse can use this technique to keep the conversation moving in an organized direction. B. This is an example of the communication technique of asking a relevant question. These kinds of questions are open-ended, allowing the client to offer more information to the nurse. D. This communication technique is an example of sharing empathy. With this technique, the nurse is able to convey understanding and acceptance of what the client is or has been experiencing

A nurse on a medical-surgical unit is caring for a client who develops deep, rapid respirations. Arterial blood gas analysis includes the following values: pH 7.25, PaCO2 40, and HCO3- 18. Which of the following acid-base imbalances should the nurse identify and report to the provider?

Metabolic acidosis A pH of 7.25 indicates acidosis. If the cause is respiratory, the pH and PaCO2 values deviate in opposite directions. Since the PaCO2 is within the expected range, despite the low pH, the cause must be metabolic. Therefore, the nurse should report to the provider that the client has metabolic acidosis. Incorrect Answers: A. With respiratory alkalosis, the pH is elevated. B. With metabolic alkalosis, the pH is elevated. C. With respiratory acidosis, the PaCO2 is elevated

A nurse is caring for a client who had a stroke and is at risk of falling. Which of the following actions should the nurse take?

Monitor the client at least once every hour The nurse should monitor the client frequently as a means of reducing the client's fall risk. Other measures can include keeping the client's bed in a low position, creating elimination schedules, and using a gait belt when the client is ambulating. Incorrect Answers: A. The client does not need to have a private room due to an increased risk of falls. Increased social interaction can decrease the client's fall risk. The nurse should place the client in a room near the nurses' station for improved visual contact of the client. B. The use of 4 raised side rails on the client's bed is considered a physical restraint that the nurse cannot employ without a prescription from the provider. Bed rails can increase a client's fall risk if the client attempts to climb over the rails to get out of bed. D. The nurse should consider and attempt any potential alternatives prior to implementing restrains. The use of restraints can contribute to an increased risk of complications for a client such as incontinence and the development of pressure ulcers due to immobilization.

A nurse is collecting data from a term newborn who is 8 hours old. Which of the following reflexes should the nurse identify as a preliminary indication that during gestation, the newborn developed the ability to hear?

Moro The newborn extends both arms and legs outward and then draws them back inward in response to a loud noise such as a sudden clap. This is a general indication that the newborn heard the noise. Incorrect Answers: A. With this reflex, the newborn's toes fan out when the nurse strokes the sole of the foot. If this response persists after the age of 1 year, it could indicate upper motor neuron damage. It does not, however, confirm the ability to hear. B. When a newborn is supine and his head turns to one side, the opposite side's arm and leg are in flexion. This postural reflex disappears between the ages of 4 and 6 months. It does not, however, confirm the ability to hear. C. Touching the newborn's cheek makes the head turn to the side where the touch occurs. This feeding reflex disappears after the age of 4 months. It does not, however, confirm the ability to hear.

Incontinence is a parameter on the

Norton scale, not on the Braden scale

During a client care staff meeting, a charge nurse discusses potential problems with data security that affect confidential client information. Which of the following environments should the charge nurse identify as an acceptable area for discussing clients' information?

Nurses should only communicate clients' information in areas where no one else can overhear the discussion. A unit medication room is a nonpublic area where nurses can privately discuss information that pertains to the client's care.

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. Incorrect Answers: A. . B. C.

A nurse is obtaining the blood pressure in a client's lower extremity. Which of the following actions should the nurse take?

Place the bladder of the cuff over the posterior aspect of the thigh This is the correct position for the nurse to place the bladder of the cuff when measuring lower-extremity blood pressure. The nurse should auscultate for the blood pressure at the popliteal artery. The nurse should measure the blood pressure with the client prone if possible. Otherwise, the client should lie supine with the knee flexed. The nurse should position the cuff 2.5 cm (1 in) above the popliteal artery.

A nurse is assisting with planning a community presentation for parents. When suggesting a discussion of controlling impulses and cooperating with others, the nurse should plan to relate it to Erikson's developmental task for which of the following age groups?

Preschoolers Helping children control impulses and cooperate with others relates to Erikson's developmental task for preschoolers, which is initiative vs guilt. Altered development during this stage can result from harsh punishment and excessive limits on behavior, leading to guilt and frustration.

A nurse at a screening clinic is collecting data for a client who reports a history of a heart murmur related to aortic valve stenosis. At which of the following anatomical areas should the nurse place the stethoscope to auscultate the aortic valve?

Second intercostal space to the right of the sternum The aortic valve is located in the second intercostal space to the right of the sternum. Aortic stenosis produces a midsystolic ejection murmur that can be heard clearly at the aortic area with the client leaning forward. Incorrect Answers: A. The mitral valve is located in the fifth intercostal space just medial to the midclavicular line. B. The pulmonic valve is located in the second intercostal space to the left of the sternum. C..

A nurse is examining a client for signs of costovertebral angle tenderness. The nurse should place the client in which of the following positions for evaluation?

Sitting The costovertebral angle is the area where the spine and the twelfth rib intersect. A sitting position promotes relaxation and allows access to the back for percussion of that region. Incorrect Answers: A. Sims' position facilitates rectal examinations and procedures. B. Supine positioning facilitates other types of assessment such as thoracic and abdominal examinations. D. A standing position facilitates observation of the client's posture

A nurse is caring for a client who is receiving an IV infusion of 5% dextrose in lactated Ringer's. The nurse notices that the area around the catheter insertion site is edematous and cooler than the surrounding skin on the forearm. Which of the following actions should the nurse take?

Stop the infusion Coolness and swelling at the insertion site indicate an infiltration. The nurse should stop the infusion, remove the catheter, and report the situation to the charge nurse and the provider. Incorrect Answers: A. Switching the IV fluid from a hypertonic to an isotonic solution will not correct the edema and coolness at the catheter's insertion site. B. When there is swelling from an IV infusion, the nurse should elevate the extremity. C. Providers prescribe diuretic therapy when there is evidence of circulatory overload such as from a rapid infusion rate. Diuretics will not remove the fluid causing the edema at the catheter's insertion site.

A nurse is reinforcing teaching with a client about the use of a straight-legged cane. Which of the following client actions indicates an understanding of the teaching?

The client holds the cane on the unaffected side. The nurse should instruct the client to hold the cane on the unaffected side to provide a wide base of support and stability. The nurse should instruct the client to walk by stepping with the affected leg before the unaffected leg to maintain stability. The nurse should instruct the client to place the cane at about 15 cm (6 in) from the side of the foot to provide balance and support. The nurse should instruct the client to hold the cane with the elbow slightly flexed to provide support and stability.

A nurse is administering a cleansing enema to a client who is scheduled for a diagnostic procedure. Which of the following actions should the nurse take?

The nurse should insert the tip of the tubing 7 to 10 cm (3 to 4 in) along the rectal wall to prevent dislodging of the tube during the procedure and injury to the rectal mucosa. lubricate 5 to 8 cm (2 to 3 in) of the tip of the rectal tube before inserting to decrease the risk of irritation or injury to the mucosa. position the client on the left side in the Sims' position to allow the solution to flow downward into the sigmoid colon and rectum and to promote retention of the enema. hold the enema container a maximum of 45 cm (18 in) above the rectum to prevent painful distention of the colon

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

A nurse is reinforcing teaching about bladder retraining for a client who has urinary incontinence. Which of the following instructions should the nurse include?

Try to block the urge to urinate until the next scheduled time When the client is following a schedule of voiding intervals and feels the urge to urinate before the next scheduled time, the client should try to practice slow, deep breathing to help reduce the urge. The client can also try 5 or 6 strong and quick pelvic muscle exercises. Incorrect Answers: A. The client should wake up every 4 hours to urinate during the night; for most clients, this will occur just once during sleeping hours. B. Citrus juices can irritate the bladder, increasing the likelihood of incontinence episodes. D. The client should reduce fluid intake for 4 hours before bedtime; however, the client should drink plenty of fluids during other waking hours and avoid drinking large amounts at once

A nurse is preparing to irrigate a client's wound. Which of the following actions should the nurse take?

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 reinforcing teaching for a client about managing her tracheostomy care. Which of the following instructions should the nurse include?

Wear a tracheostomy cover when outdoors A tracheostomy cover protects the client's airway from dust, chilly air, and any other airborne particles that could otherwise enter the airway. Within the home environment, clean gloves are sufficient. tap water is sufficient for rinsing the inner cannula. C. At home perform tracheostomy care daily.

Not inflating the cuff to a high enough level can result in

a falsely low systolic reading

Laughing and babbling when content is

a social developmental task for infants by the age of 4 months; therefore, it is an expected finding for a 6-month-old infant

In paralytic ileus, bowel sounds are

absent, and there is no flatus or stool

Establishing a sense of sexual identity relates to Erikson's developmental task for

adolescents, which is identity vs role confusion

The posterior tibial pulse is located on the inner side of the

ankle. It is best felt with the client's foot relaxed and extended slightly

The nurse should percuss the thorax to identify

areas of dullness over lung fields;

Erikson's developmental task for toddlers is

autonomy vs shame and doubt. At this stage, they are not yet ready for mastering the behaviors of controlling impulses and cooperating with others.

The nurse should auscultate the thorax with the diaphragm of the stethoscope to collect data about

breath sounds

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.

Clients who have hypokalemia have

depressed deep-tendon reflexes. lethargic and fatigued.

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.

ear drops for a client For children younger than 3 years, pulling the pinna

down and back will straighten the canal.

The palpebral fissure is the space between the

eyelids; it is unequal in clients who have ptosis, which is drooping of a single eyelid or both eyelids.

Using a bladder cuff that is too wide can result in

falsely low blood-pressure readings

Holding the bell of the stethoscope too tightly against the skin of the client's antecubital fossa can result in

falsely low diastolic reading

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.

Erikson's developmental task for adolescents is

identity vs role confusion. At this stage, they should have already mastered the behaviors of controlling impulses and cooperating with others.

Learning a socially productive skill relates to Erikson's developmental task for school-aged children, which is

industry vs inferiority.

Erikson's developmental task for school-aged children is

industry vs inferiority. At this stage, they should have already mastered the behaviors of controlling impulses and cooperating with others.

The femoral pulse is located in the

inguinal area. It is best felt with the client lying down and the inguinal area exposed.

The popliteal pulse is located behind the

knee. It is best felt with the client's knee slightly flexed and the foot resting on an examination table.

A third heart sound (S3) is a

low-pitched sound after the second heart sound.

Bringing objects from a hand to the mouth is a

motor developmental task for infants between the ages of 2 and 4 months; therefore, it is an expected finding for a 6-month-old infant.

The test for accommodation determines whether the client's pupils constrict as they focus on an

object the examiner brings closer to the eyes.

Clients who have hyperkalemia, not hypokalemia, have

paresthesias.become irritable and confused

An audible clicking sound occurs in clients who have

prosthetic valve replacement surgery

Turning from the side to the back is a motor developmental task for infants between

the ages of 2 and 4 months

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 macular degeneration include changes in

the sharp and central vision. These findings are often associated with aging.

The nurse should palpate the thorax to evaluate

the skin and check for any masses, lesions, or painful areas; however, evidence-based practice indicates that the nurse should take a different data-collection action first.

Supine positioning facilitates other types of assessment such as

thoracic and abdominal examinations.

An inflated cuff does not prevent tracheal injury. If the cuff is overinflated and exerting a pressure that exceeds 25 mmHg, it can cause

tracheal ischemia and necrosis.

A heart murmur has a swishing or a whistling sound. Heart murmurs are caused by

turbulent blood flow through valves or ventricular outflow tracts valvular disease. 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.

ear drops for a client adult

upward to straighten the ear canal.

confrontation test compares the

visual fields of the client with that of the examiner.

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. Incorrect Answers: A. The nurse should inform the parent that children's dietary habits can change from day to day. It is important to feed the child healthy foods and focus on the quality of food rather than the quantity of food during this time. B. The nurse should inform the client that calorie and fluid requirements decrease slightly in a preschool-aged child. The nurse should not promote an increase of calories and water in the child's diet. D. The nurse should inform the parent that excessive consumption of sweetened beverages, including fruit juices, can be associated with adverse health effects such as dental caries, obesity, and metabolic syndrome.

Eye examination every 2 years This screening is essential not only for monitoring vision but also for checking for glaucoma. The client should have annual eye examinations from the age of 65 onward.

Eye examination every 2 years This screening is essential not only for monitoring vision but also for checking for glaucoma. The client should have annual eye examinations from the age of 65 onward. Incorrect Answers: A. Women age 30 to 65 years should have a Pap test every 3 years. B. Women age 45 years and older should have an annual mammogram. At age 55, clients might decide to change to every 2 years or continue with annual mammograms. D. The client should have a colonoscopy every 10 years; testing

A nurse is caring for an older adult client who has an in-the-canal hearing aid. The client states that the hearing aid is making a whistling sound. The nurse should identify which of the following factors as the source of this sound?

Factors that can make a hearing aid whistle include a poor seal with the ear mold, an ear infection, excessive wax in the ear canal, an improper fit, or a malfunction. Incorrect Answers: A. A hearing aid with low battery power will not work effectively, but it will not whistle. Removing the battery at night can help extend the life of the battery. C. A hearing aid might whistle if the volume is too high, not too low. D. A crack in the ear tube of an in-the-canal hearing aid can impair the hearing aid's amplification of sound; however, it would not cause whistling.

A nurse is caring for a middle adult client. Which of the following statements indicates that the client has completed Erikson's developmental task for her age group? think I have done a good job with my children since they are all independent now." According to Erikson, the developmental task for middle adults is generativity vs. stagnation. Middle adults help shape future generations through community involvement, parenting, mentoring, and teaching. The client talking about helping her children achieve independence reflects that she has accomplished this developmental task.

Incorrect Answers: A. This statement relates to Erikson's developmental task of young adults, which is intimacy vs. isolation. C. This statement relates to Erikson's developmental task of older adults, which is integrity vs. despair. D. This statement relates to Erikson's developmental task of older adults, which is integrity vs. despair.

A nurse is changing the dressings for a client who has 2 Penrose drains near an abdominal incision. Which of the following adhering devices is the best choice for the nurse to use to decrease skin irritation?

Montgomery straps

Mental state is a parameter on the

Norton scale, not on the Braden scale.

A nurse is caring for a client who is hospitalized and has a new tracheostomy. Which of the following actions should the nurse take when performing tracheostomy care for the client?

Soak the inner cannula of the tracheostomy tube in normal saline The inner cannula of the tracheostomy tube should be soaked in normal saline or a mixture of normal saline and hydrogen peroxide to loosen secretions. Tracheostomy care for a client with a new tracheostomy should be performed using surgical asepsis, or sterile technique. The nurse should allow room to insert one to two fingers under the tracheostomy ties so that they are not too restrictive. A cut gauze pad should not be used near a tracheostomy tube because the client can aspirate loose threads. The nurse should use a commercially prepared tracheostomy dressing under the tracheostomy tube.

A nurse is reinforcing teaching with a client about how to use an albuterol metered-dose inhaler. After removing the cap from the inhaler and shaking the canister, the nurse should instruct the client to take the following steps in which order? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Step 1. The client should hold the mouthpiece 2 to 4 cm (1 to 2 in) from the mouth Step 2. The client should tilt the head back slightly, and then open the mouth. Step 3. The client should depress the medication canister while taking a deep breath to facilitate delivery of the medication through the airway. Step 4. After holding a breath for 10 seconds, the client should resume the usual breathing pattern.

A nurse is changing the dressings for a client who has 2 Penrose drains near an abdominal incision. Which of the following adhering devices is the best choice for the nurse to use to decrease skin irritation?

The nurse should apply the least restrictive priority-setting framework, which assigns priority to nursing interventions that are least restrictive to the client, as long as those interventions do not jeopardize client safety. Least restrictive interventions promote client safety without using restraints. The nurse should only use physical or chemical restraints when the safety of the client, staff, or others is at risk. The nurse should plan to use Montgomery straps to minimize irritation to the skin near the incisional area. Montgomery straps are adhesive strips applied to the skin on either side of the surgical wound. The adhesive strips have holes for using gauze to tie the dressing securely. When the dressing is changed, the ties are released, the dressing is replaced, and the ties are secured again without removing the adhesive strips. Incorrect Answers: A. An abdominal binder can hold the dressings in place and decrease skin irritation while the client rests in bed; however, when the client ambulates, the dressings tend to slide. Securing the dressings first is the preferred method when applying a binder. Therefore, the nurse should use a less restrictive intervention first. C. Hypoallergenic tape is used when a client is sensitive to adhesive material; however, hypoallergenic tape can cause skin sensitivity when frequently removed and reapplied. Therefore, the nurse should use a less restrictive intervention first. D. Plastic tape adheres well to skin and can cause skin sensitivity when frequently removed and reapplied. Therefore, the nurse should use a less restrictive intervention first.

A nurse is preparing to insert an indwelling urinary catheter for a male client. Which of the following locations should the nurse secure the urinary catheter tubing?

The nurse should secure with tape the client's indwelling urinary catheter to the lower abdomen or the upper aspect of the thigh to eliminate the penoscrotal angle and prevent tissue injury.

A nurse is collecting data from a client at admission. The client reports a latex allergy. Which of the following precautions should the nurse take when caring for this client?

Wrap IV tubing with tape Although latex-free products are widely available, the nurse might encounter some products that contain latex such as IV tubing and monitoring cords and devices. The nurse should create a barrier between these items and the client (e.g. by wrapping them in non-latex tape or stockinette). Incorrect Answers: A. The nurse should not snap gloves on and off because these actions disperse any allergens in the gloves into the environment. B. Latex gloves that have "hypoallergenic" on the label still contain latex. Powder and cornstarch are dangerous because the latex allergen attaches to them and becomes an airborne carrier, enabling easy inhalation. The nurse should wear non-latex gloves such as nitrile gloves. C.

which sound The nurse will hear over the trachea.

bronchial sounds over the trachea. These sounds are high-pitched, hollow, and loud.

which sounds The nurse will hear on either side of the sternal border anteriorly and between the scapulae posteriorly.

bronchovesicular. These sounds are moderately loud with a medium pitch.

A nurse is reinforcing teaching for a client about performing range-of-motion exercises of the wrist. To have the client demonstrate adduction, which of the following instructions should the nurse give?

"With your palm facing down, move your wrist sideways toward your thumb." This motion is adducting the wrist. move her wrist 30º to 50º with this motion.

A nurse is collecting data from a client who has a total calcium level of 12.7 mg/dL. Which of the following findings should the nurse expect?

A total calcium level of 12.7 mg/dL is above the expected reference range. Manifestations of hypercalcemia include depressed deep-tendon reflexes, nausea, vomiting, bone pain, lethargy, and weakness. Incorrect Answers: A. Muscle tremors are manifestations of hypocalcemia, not hypercalcemia. B. Positive Chvostek's and Trousseau's signs are manifestations of hypocalcemia, not hypercalcemia. D. Numbness and tingling around the mouth and in the extremities are manifestations of hypocalcemia, not hypercalcemia.

A nurse is reinforcing teaching about body mechanics with assistive personnel. Which of the following instructions should the nurse include? (Select all that apply.)

A. "Sit with your back supported." B. "Keep your knees at hip level." C. "Use an ergonomically designed computer keyboard."

A nurse is collecting baseline data of a client's peripheral vascular system. In which of the following locations should the nurse palpate the posterior tibial pulse?

Below the medial malleolus The nurse should palpate the posterior tibial pulse by curving the fingers around the medial malleolus on the inner surface of the client's ankle.

A nurse is collecting data about a client's peripheral pulses. Which of the following descriptions should the nurse use to document the findings?

C. Peripheral pulses bilaterally symmetric, equal, and strong in all 4 extremities The nurse does not evaluate the peripheral pulses routinely when measuring vital signs. Peripheral pulse evaluation is for specific clinical indications such as circulatory impairment to an extremity or during a comprehensive physical examination. A full evaluation of peripheral pulses typically includes palpation of the radial, brachial, ulnar, femoral, popliteal, tibial, and dorsalis pedal pulses. Documentation of peripheral pulse evaluation should include the strength of pulsations as well as their equality and symmetry in all 4 extremities. Incorrect Answers: A. D. The nurse measures the client's pulse rate at the apical and radial sites. Determination of rate is not a component of peripheral pulse evaluation. B. The nurse does not need to specify details about all pulse points, but the evaluation should include the upper portion of the lower extremities.

A nurse is preparing to collect data about the function of a client's trigeminal nerve or cranial nerve (CN) 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 test recognition of pain and a cotton wisp to evaluate recognition of touch sensations. To test motor abilities of CN V, the nurse should ask the client to clench the teeth.

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?

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.

Women age 30 to 65 years should have a

Pap test every 3 years

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.

manifestations of hypocalcemia

Muscle tremors, Positive Chvostek's and Trousseau's and Numbness and tingling around the mouth and in the extremities

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?

Plasma volume expanders Dextran and albumin are plasma volume expanders. They help correct hypovolemia in emergency situations such as after hemorrhage or burns.

A nurse is reinforcing teaching with a client who is postoperative following a knee arthroplasty about the muscles he will need to strengthen in physical therapy. Which of the following muscle groups are responsible for movement at the knee joint?

The nurse should reinforce with the client that the antagonistic muscle group is responsible for the movement of the knee joint by contracting while other muscles relax.

which valve is located in the second intercostal space to the left of the sternum.

The pulmonic valve

Kinesthesia is the

ability to sense the position and movement of body parts without visualizing them

Abstract reasoning develops during

adolescence

Acceptance of body changes should take place during

adolescence.

Ethylene oxide can cause an

allergic reaction in latex-sensitive clients. The nurse should rinse any items that had this type of sterilization with sterile water before use.

Women age 45 years and older should have an

annual mammogram. At age 55, clients might decide to change to every 2 years or continue with annual mammograms.

Peripheral pulse evaluation is for specific clinical indications such as

circulatory impairment to an extremity or during a comprehensive physical examination.

The nurse should collect information about the

client's past health problems during the data-collection phase of the nursing process.

The client should have every 10 years

colonoscopy

The synergistic muscle group is responsible for

contracting in sync to cause the same movement

which nerve the nurse is testing by asking the client to clench his teeth and palpating the masseter muscles for contraction.

cranial nerve V (trigeminal)

using the Rinne and Weber tests and asking the client if he can hear a whisper which nerve are we testing

cranial nerve VIII (vestibulocochlear)

which nerve is The nurse checking when asking the client to vocalize

cranial nerve X (vagus)

by innervates the tongue, by observing a range of tongue movements which verve are we testing

cranial nerve XII (hypoglossal),

Gradual memory loss is a common finding in

dementia rather than delirium

Difficulty with abstract thought is a common finding in

dementia rather than delirium.

Manifestations of hypercalcemia include

depressed deep-tendon reflexes, nausea, vomiting, bone pain, lethargy, and weakness.

Verbalization of feelings of hopelessness is a common finding in

depression rather than delirium

According to Erikson, the developmental task for middle adults is

generativity vs. stagnation.

Stress causes an increase in the secretion of cortisol, which can cause

hypertension and hyperglycemia. platelet aggregation( risk of myocardial infarction and stroke).weakens the immune response, placing the client at risk for various infections and worsening the severity of those infections

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

Erikson's developmental task of older adults, which is

integrity vs. despair.

Young adults need to develop

intimacy outside of the family

Erikson's developmental task of young adults, which is

intimacy vs. isolation

Concrete thinking develops during

middle childhood.

The nurse should use coffee to test the function

of the olfactory nerve or CN I

The nurse should evaluate the client's popliteal pulse by

palpating behind the knee in the area of the popliteal fossa.

The nurse should evaluate the client's brachial pulse by

palpating in the groove between the biceps and triceps muscles in the area of the antecubital fossa

The nurse should evaluate the client's dorsalis pedis pulse by

palpating on the dorsum of the foot

A full evaluation of peripheral pulses typically includes

palpation of the radial, brachial, ulnar, femoral, popliteal, tibial, and dorsalis pedal pulses.

The antigravity muscle group is responsible for

stabilizing the knee joint.

The skeletal muscle group is responsible for

supporting posture and producing voluntary movement.

Gustation is

the ability to taste

Proprioception is

the awareness of the position of the body.

Discuss the meaning of a common proverb This part of the mental-status examination evaluates

the client's ability to think abstractly.

A nurse is preparing to administer an otic antibiotic to an adult client who has otitis media. Which of the following actions should the nurse plan to take?

A. Hold the dropper 1 cm (0.5 in) above the ear canal during administration The nurse should administer the otic medication by holding the dropper 1 cm (0.5 in) above the ear canal. apply pressure to the nasolacrimal duct following the administration of eye drops, not for an otic antibiotic. If necessary, the nurse can apply a cotton ball into the outermost part of the ear canal and remove it after 15 minutes. straighten the ear canal by pulling the auricle down and back prior to administering otic medication for a child who is younger than 3 years of age.

The nurse should identify that the skin can excrete approximately 500 to 600 mL of insensible fluid. This type of fluid loss is continuous and can increase if the client is experiencing a fever or has had a recent burn to the skin.

A. The kidneys excrete approximately 1,200 to 1,500 mL of urine daily. However, urine is not considered insensible fluid loss. This can increase depending on the client's intake of water. B. The lungs excrete approximately 400 mL of insensible fluid loss each day. C. The gastrointestinal tract loses approximately 100 to 200 mL of fluid each day through feces. However, this is not considered insensible fluid loss.

A nurse is caring for a middle adult client. The nurse should evaluate the client for progress toward which of the following developmental tasks? Middle adults usually feel more comfortable with themselves and cease to make comparisons with others.

A. Young adults should focus on learning to manage a home. B. Young adults should focus on establishing themselves in the adult world. C. Young adults should focus on forming new friendships

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?

ABGs are drawn to determine the acid-base balance in the arterial blood. This client's pH is elevated above the expected reference range of 7.35 to 7.45, indicating alkalosis. The client's PaCO2 is below the expected reference range of 35 to 45 mmHg, which indicates a respiratory origin. The nurse should conclude that the client's elevated pH and decreased PaCO2 indicate respiratory alkalosis. Incorrect Answers: B. Acidosis is determined by measuring a pH lower than the expected reference range of 7.35 to 7.45. This client has a pH of 7.5 and therefore does not have acidosis. C. This client's pH is elevated above the expected reference range of 7.35 to 7.45. Acidosis is presented by a lower pH, usually below 7.35. D. This client's abnormal ABGs do not have a metabolic origin. Metabolic origin is determined by examining the HCO3- levels. The client's bicarbonate is within the expected reference range of 22 to 26 mEq/L.

A nurse is reinforcing teaching with a group of young adults. Which of the following should the nurse identify as an expected developmental task for this age group?

According to Kohlberg's theory of moral development, making individual decisions about moral issues is a function of the highest level of moral development, the post-conventional level. Young adults who have reached this level separate themselves from the rules and tenets of others and make decisions according to their own beliefs and principles. Incorrect Answers: B. Acceptance of body changes should take place during adolescence. C. Young adults need to develop intimacy outside of the family. D. Concrete thinking develops during middle childhood. Abstract reasoning develops during adolescence.

A nurse is using a portable ultrasound bladder scanner to measure a client's postvoid residual. Which of the following actions should the nurse take?

Apply light pressure to the scanner head once it is in position The nurse should apply light pressure and hold the scanner steadily while pointing it slightly downward toward the client's bladder. urinate 10 minutes before the bladder-scanning procedure. document the amount of urine the client passed at that time. supine position with the head slightly elevated. position the scanner head 2.5 to 4 cm (1 to 1.6 in) above the symphysis pubis.

A nurse is removing a dressing over the surgical incision of a client who is postoperative following abdominal surgery. Today, the client reported that "something opened up." The nurse finds that the incision has separated and intestinal tissue is protruding. After calling for help, which of the following actions should the nurse take?

C. Position the client supine with the knees in flexion This position reduces any strain that could cause further opening of the incision and worsening of the evisceration. soak sterile gauze in sterile 0.9% sodium chloride irrigation and apply it to the wound.

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.

A nurse is talking with a client whose provider recently informed him that he has terminal pancreatic cancer. When the client expresses that he understands the full impact of this diagnosis, the nurse should identify that he is in which of the following stages of dying?

Depression During the stage of depression, the client has realized the full impact of the loss and might express hopelessness and despair. During the stage of anger, the client shows resistance or blames other people, a higher power, or the situation itself. During the stage of bargaining, the client stalls awareness of the loss by trying to keep it from occurring. During the stage of acceptance, the client will integrate the loss (e.g. by making final arrangements).

A nurse is caring for a client who has a methicillin-resistant Staphylococcus aureus (MRSA) infection. A dietary assistant asks the nurse what precautions are necessary for entering the client's room with the lunch tray. Which of the following instructions should the nurse give the dietary assistant?

Don gloves when entering the room and use hand sanitizer when exiting Clients who have a MRSA infection require contact precautions. In addition to the use of standard precautions and meticulous hand hygiene, contact precautions require any staff member who will have contact with the client's environment to don gloves prior to entering the room. Additional precautions such as a gown are required for contact with the client, and a mask and goggles are needed if secretions from the infected area could spray into the worker's face. Since delivering the tray will require contact with the environment, the dietary assistant must wear gloves. Incorrect Answers: A. Anyone who will have actual contact with this client must wear a gown. If the dietary assistant is just placing the lunch tray on the client's table, donning a gown is not necessary. B. MRSA does not spread via droplet or aerosol; therefore, the dietary assistant does not need to wear a mask. D. Infections with multidrug-resistant organisms such as MRSA require special precautions to prevent transmission of the pathogen through contact with the client or the client's environment.

A nurse is reinforcing teaching about how to use an incentive spirometer with a client who is recovering from gallbladder surgery. Which of the following pieces of information should the nurse include in the teaching?

Hold a breath for 5 seconds after goal volume is reached The nurse should instruct the client to hold her breath for 3 to 5 seconds after reaching maximal inspiratory volume. This decreases the collapse of alveoli, which helps prevent the risk of atelectasis and pneumonia. Incorrect Answers: A. The nurse should instruct the client to inhale slowly to reach goal volume and to decrease the collapse of alveoli in the client's lungs. C. The nurse should instruct the client to breathe normally for short periods of time between each cycle of breaths to reduce hyperventilation and fatigue. D. The nurse should instruct the client to repeat the patterns for 10 to 20 breaths every hour while awake to prevent the risk of atelectasis and pneumonia.

A nurse is collecting data from a client whose calcium level is 7.1 mg/dL. Which of the following findings should the nurse expect?

Hypocalcemia causes hyperactive deep-tendon reflexes and a positive Chvostek's sign, which is a tightening of the muscles in the face when the nurse taps the client's facial nerve. anxiety and confusion, paresthesias numbness and tingling of the fingers and toes as well as around the mouth.

Discuss the meaning of a common proverb This part of the mental-status examination evaluates the client's ability to think abstractly.

Incorrect Answers: A. This part of the mental status examination evaluates the client's attention span. B. This part of the mental status examination evaluates the client's remote memory. C. This part of the mental-status examination evaluates the client's judgment.ndemn

General physical condition is a parameter on the

Norton scale, not on the Braden scale

Stereognosis is the ability to identify an object's size, shape, and texture via tactile sensation.

Stereognosis is the ability to identify an object's size, shape, and texture via tactile sensation.

which valve is located in the second intercostal space to the right of the sternum.

The aortic valve is located

which valve is located in the fifth intercostal space just medial to the midclavicular line.

The mitral valve

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.)

The nurse should turn off the vacuum on the NPWT device to loosen the dressing and administer the prescribed analgesic. gently remove the soiled dressing and perform hand hygiene. apply sterile or clean gloves and irrigate the wound to remove debris. apply a skin protectant or a barrier film to the surrounding skin to ensure an airtight seal and provide protection. place foam in the wound bed and cover with a transparent dressing to provide an airtight seal. attach the drainage tube to the transparent dressing and turn on the NPWT unit. Finally, the nurse should check for air leaks and patch the dressing as needed with transparent film.

which valve is located in the fifth intercostal space to the left of the sternum

The tricuspid valve

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. Therefore, the nurse should first escort the client back to his room to protect the client from injury due to wandering

This client is at risk for inadequate nutrition because of the fluid and calorie expenditure from wandering; however, there is another action that the nurse should take first. C. This client is at risk for anxiety because of possible disorientation; however, there is another action that the nurse should take first. D. The client is at risk for escalating anxiety because of possible disorientation; however, there is another action that the nurse should take first.

To ensure adequate distribution of the vaginal medication, the nurse should insert the suppository until the length of the nurse's index finger is inside the vagina or as far inside as possible.

To ensure adequate distribution of the vaginal medication, the nurse should insert the suppository until the length of the nurse's index finger is inside the vagina or as far inside as possible. clean gloves. use the non-dominant hand to retract the labia and the dominant hand to insert the suppository. should ease the suppository along the posterior vaginal wall

A nurse is caring for an older adult client who has an in-the-canal hearing aid. The client states that the hearing aid is making a whistling sound. The nurse should identify which of the following factors as the source of this sound?

poor seal with the ear mold, an ear infection, excessive wax in the ear canal, an improper fit, or a malfunction.

which sound The nurse will hear over the trachea and the bronchi)

rhonchi (gurgling sounds over the trachea and the bronchi) only if the airways are narrowed due to secretions or swelling.

The nurse should use the Snellen chart to test the function of

the optic nerve or CN II.

Documentation of peripheral pulse evaluation should include

the strength of pulsations as well as their equality and symmetry in all 4 extremities. the strength of pulsations as well as their equality and symmetry in all 4 extremities.

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.