Funds Final
A nurse is teaching a client who has lower extremity weakness how to use a four-point crutch gait. Which of the following instructions should the nurse include in the teaching? "Support the majority of your weight on the axillae." "Keep your elbows extended." "Bear weight on both of your legs." "Move both crutches forward at the same time."
"Support the majority of your weight on the axillae." Pressure on the axillae increases risk to underlying nerves, which could result in partial paralysis of the arms. "Keep your elbows extended." The client should keep his elbows flexed about 30°. CORRECT ANSWER "Bear weight on both of your legs." The client has three points on the ground at all times. Therefore, he must be able to bear weight on both legs. "Move both crutches forward at the same time." The client should move each leg alternately with each opposite crutch so that three points of support are on the floor at all times.
A nurse is called away for an emergency while conversing with a client who is concerned about his medical diagnosis. The nurse returns to the client promptly, as promised. Which of the following ethical principles is the nurse demonstrating? Autonomy Fidelity Nonmaleficence Justice
Autonomy The ethical principle of autonomy is the nurse's responsibility to ensure that the client has the right to make his own decisions. CORRECT ANSWER Fidelity The nurse is demonstrating the ethical principle of fidelity by keeping a promise that was made. Nonmaleficence The ethical principle of nonmaleficence is the nurse's responsibility to do no harm. Justice The ethical principle of justice is the nurse's responsibility to treat everyone fairly.
A nurse is planning to document care provided for a client. Which of the following abbreviations should the nurse use? BT for bedtime SC for subcutaneously PC for after meals HS for half-strength
BT for bedtime (The nurse should avoid using this abbreviation because it can be mistaken for BID, which means twice daily. It is an error prone abbreviation. The nurse should use the word bedtime.) SC for subcutaneously (The nurse should avoid using this abbreviation because it can be mistaken for sublingual. It is an error prone abbreviation. The nurse should use subcut or subcutaneously.) CORRECT ANSWER PC for after meals (The nurse can use this abbreviation. It is an approved, not an error prone, abbreviation.) HS for half-strength (The nurse should avoid using this abbreviation because it can be mistaken for bedtime. It is an error prone abbreviation. The nurse should use half-strength or bedtime.)
A nurse is providing teaching about food choices to a client who has a prescription for a clear liquid diet. Which of the following selections by the client indicates an understanding of the teaching? Cream of rice Cottage cheese Gelatin Ice cream
Cream of rice (Cream of rice is allowed on a full liquid diet.) Cottage cheese (Cottage cheese is allowed on a soft diet.) CORRECT ANSWER Gelatin (Foods allowed on a clear liquid diet are those that are clear and liquid at room temperature.) Ice cream (Ice cream is allowed on a full liquid diet.)
A nurse is caring for a client who is receiving IV therapy via a peripheral catheter. The nurse should identify that which of the following findings is an indication of infiltration? Redness at the infusion site Edema at the infusion site Warmth at the infusion site Oozing of blood at the infusion site
Redness at the infusion site (Redness at the infusion site is an indication of phlebitis or infection.) CORRECT ANSWER Edema at the infusion site (Edema due to fluid entering subcutaneous tissue is an indication of infiltration.) Warmth at the infusion site (Warmth at the infusion site is an indication of phlebitis or infection.) Oozing of blood at the infusion site (Oozing of blood at the infusion site is an indication that the IV system is not intact.)
A nurse is planning care for a client who has a single-lumen nasogastric (NG) tube for gastric decompression. Which of the following actions should the nurse include in the plan of care? (Select all that apply.) Set the suction machine at 120 mm HG Provide oral hygiene frequently Measure the drainage from the NG tube every shift Secure the NG tube to the client's gown Apply petroleum jelly to the client's nares
Set the suction machine at 120 mm HG is incorrect. Single lumen NG tubes are used for intermittent suction with the machine being set at 80 to 100 mm Hg. Higher suction settings can traumatize the gastric lining. CORRECT Provide oral hygiene frequently is correct. Frequent oral hygiene provides comfort for the client since mucous membranes easily become dry and uncomfortable when a client cannot drink fluids. CORRECT Measure the drainage from the NG tube every shift is correct. Measuring the drainage at least every shift helps the provider to calculate fluid loss and prescribe appropriate replacement therapy. CORRECT Secure the NG tube to the client's gown is correct. An unsecured NG tube can irritate the nares if the tube is pulled or caught on the bed or other equipment. The tube can also be dislodged if not secured appropriately. Apply petroleum jelly to the client's nares is incorrect. The client could aspirate an oil-based lubricant like petroleum jelly into the lungs, which could possibly result in lipid pneumonia. A water-soluble lubricant should be applied to the nares to help prevent or relieve dry skin.
A nurse is caring for a client who has a terminal illness. Which of the following findings indicates that the client's death is imminent? Urinary retention Cold extremities Hypertension Tachycardia
Urinary retention Urinary incontinence is a physical change that occurs when a client's death is imminent. CORRECT ASNWER Cold extremities Cold extremities, first in the feet and then in the hands, are a physical change that occurs when a client's death is imminent. Hypertension Hypotension is a physical change that occurs when a client's death is imminent. Tachycardia A slow, weak pulse is a physical change that occurs when a client's death is imminent.
A nurse is using the I-SBAR communication tool to provide the client's provider with information about the client. The nurse should convey the client's pain status in which portion of the report? Assessment Situation Recommendation
CORRECT ANSWER Assessment The nurse provides information about assessment findings in this portion of the report. This includes vital signs, pain assessment, and changes in assessment findings. Assessment The nurse provides information about pertinent medical history, laboratory findings, allergies, and code status in this portion of the report. Situation The nurse provides information about problems the client is experiencing in this portion of the report. Recommendation The nurse makes recommendations about treatment and asks the provider about additional treatment in this portion of the report.
A nurse in a provider's office is assessing a client who has heart failure. The client has gained weight since her last visit and her ankles are edematous. Which of the following findings by the nurse is another clinical manifestation of fluid volume excess? Sunken eye balls Hypotension Poor skin turgor Bounding pulse
Sunken eye balls Sunken eye balls are a clinical manifestation of fluid volume deficit. Hypotension Hypotension is a clinical manifestation of fluid volume deficit. Poor skin turgor Poor skin turgor is a clinical manifestation of fluid volume deficit. CORRECT ANSWER Bounding pulse Bounding pulse is an expected finding of fluid volume excess.
A nurse is planning to insert a nasogastric tube for a client after explaining the procedure. The client states, "You are not putting that hose down my throat." Which of the following statements should the nurse make? "I would try to get it over with because you won't get better without this tube." "You should talk to your provider about it." "Why don't you want the tube inserted?" "I can see that this is upsetting you."
"I would try to get it over with because you won't get better without this tube." This is a nontherapeutic response because the nurse is blocking communication by giving advice and by threatening the client. "You should talk to your provider about it." This response by the nurse is blocking communication by rejecting the client's concerns and putting the client's feelings on hold, referring them to another person at a later time. "Why don't you want the tube inserted?" The nurse should avoid "why" questions. This response is also passing judgment, which is a barrier to communication. CORRECT ANSWER "I can see that this is upsetting you." The nurse is using the therapeutic communication techniques of reflecting and restating, which encourages communication by the client.
A nurse is providing education about cultural and religious traditions and rituals related to death for the assistive personnel on the unit. Which of the following information should the nurse include? "People who practice the Islamic faith pray over the deceased for a period of 5 days before burial." "People who practice the Hindu faith bury the deceased with their head facing north." "People who practice Judaism stay with the body of the deceased until burial." "People who are practicing the Buddhist faith have the female family members prepare the body following death."
"People who practice the Islamic faith pray over the deceased for a period of 5 days before burial." (For those who practice the Islamic faith, the body of the deceased is washed and wrapped during a ritual and then buried as soon as possible following death.) "People who practice the Hindu faith bury the deceased with their head facing north." (People who practice the Hindu faith may place the body with the head facing north following death. However, cremation rather than burial is practiced by those of the Hindu faith.) CORRECT ANSWER "People who practice Judaism stay with the body of the deceased until burial." In the Jewish faith, a family member often stays with the body until burial occurs. "People who are practicing the Buddhist faith have the female family members prepare the body following death." (Male family members prepare the body following death for individuals practicing the Buddhist faith.)
A nurse on a telemetry unit is caring for a client who had a myocardial infarction. The client states "All this equipment is making me nervous." Which of the following responses should the nurse make? "You won't need the equipment very long." "All of this equipment can be frightening." "Why does the equipment bother you?" "Let me tell you about what each machine does."
"You won't need the equipment very long." This statement illustrates the communication block of giving false reassurances. The nurse cannot accurately predict how long the client will need the equipment. CORRECT ANSWER "All of this equipment can be frightening." This statement is therapeutic because the nurse is reflecting the client's statement. The client is feeling fearful, and this response shows that the nurse understands those feelings, which will encourage the client to communicate more. "Why does the equipment bother you?" This illustrates the communication block of requesting an explanation. The client has already said the equipment makes him nervous. "Let me tell you about what each machine does." This response does not address the client's concerns about feeling nervous. The nurse is changing the subject.
A nurse is teaching a client how to self-administer insulin. Which of the following actions should the nurse take to evaluate the client's understanding of the process within the pyschomotor domain of learning? Ask the client if he wants to self-administer his insulin. Have the client list the steps of the procedure Have the client demonstrates the procedure. Ask the client if he understands the purpose of insulin.
Ask the client if he wants to self-administer his insulin. (Asking the client if he wants to self-administer his insulin evaluates the client's understanding within the affective domain of learning.) Have the client list the steps of the procedure (Having the client list the steps of the procedure evaluates the client's learning within the cognitive domain of learning.) CORRECT ANSWER Have the client demonstrates the procedure. (Having the client demonstrate the procedure provides the nurse the ability to evaluate the client's understanding within the psychomotor domain of learning.) Ask the client if he understands the purpose of insulin. (Asking the client if he understands the purpose of insulin evaluates the client's understanding within the cognitive domain of learning.)
A nurse is explaining the use of written consent forms to a newly-licensed nurse. The nurse should ensure that a written consent form has been signed by which of the following clients? A client who has a prescription for a transfusion of packed red blood cells A client who is being transported for a radiography of the kidneys, ureters, and bladder A client who has a prescription for a tuberculin skin test A client who has a distended bladder and needs urinary catheterization
CORRECT ANSWER A client who has a prescription for a transfusion of packed red blood cells (Administration of blood is a procedure that carries risk; therefore, the client must sign a consent form prior to the procedure.) A client who is being transported for a radiography of the kidneys, ureters, and bladder (Clients admitted to a hospital sign a general consent form when admitted. This form allows consent for this diagnostic examination.) A client who has a prescription for a tuberculin skin test (Implied consent is given when the client cooperates through actions, such as holding out an arm to allow the nurse to perform the procedure.) A client who has a distended bladder and needs urinary catheterization (Implied consent is given when the client cooperates through actions, such as positioning herself to allow the nurse to perform the procedure.)
A nurse is caring for a client who has a prescription for a vest restraint. Which of the following actions should the nurse take? Fasten the ties on the restraint to the side rails of the bed. Tie the restraint with a quick-release knot. Allow one finger's breadth between the restraint and the client's chest. Place the restraint under the client's clothing.
Fasten the ties on the restraint to the side rails of the bed. (The nurse should not fasten the ties on the restraint to the side rails. If the side rails are lowered the client could be injured.) CORRECT ANSWER Tie the restraint with a quick-release knot. (The nurse should use a quick-release knot that can be untied easily in case the client's well-being requires quickly removing the restraints.) Allow one finger's breadth between the restraint and the client's chest. (The nurse should allow two finger breadths between the restraint and the client's chest.) Place the restraint under the client's clothing. (The nurse should apply the restraint over the client's clothing.)
A nurse is preparing to administer a cleansing enema to a client. Which of the following actions should the nurse plan to take? Insert the rectal tube 15.2 cm (6 in). Wear sterile gloves to insert the tubing. Position the client on his left side. Hold the solution bag 91 cm (36 in) above the client's rectum.
Insert the rectal tube 15.2 cm (6 in). (The nurse should insert the rectal tube 7 to 10 cm (3 to 4 in).) Wear sterile gloves to insert the tubing. (The nurse should wear clean (nonsterile) gloves to prevent contamination.) CORRECT ANSWER Position the client on his left side. (Positioning is an important aspect of administering an enema. Having the client lie on his left side facilitates the flow of the enema solution into the sigmoid and descending colon. Hold the solution bag 91 cm (36 in) above the client's rectum. (The nurse should hold the solution bag 30 cm (12 in) above the client's rectum for a low enema and 45 cm (18 in) for a high enema. If the nurse holds the solution bag too high, the solution might run in too fast, causing discomfort and spasms that make it more difficult for the client to retain the enema.)
A nurse is planning care for a client who is postoperative and has a history of poor nutritional intake. Which of the following actions should the nurse include in the plan of care to promote wound healing? Limit total caloric intake to 25 kcal/kg of body weight. Provide an intake of 500 mg/day of vitamin E. Limit fluid intake to 20 mL/kg of body weight per day. Provide a protein intake of 1.5 g/kg of body weight per day.
Limit total caloric intake to 25 kcal/kg of body weight. (A caloric intake of 35 to 40 kcal/kg of body weight per day is necessary to maintain a positive nitrogen balance, which promotes wound healing.) Provide an intake of 500 mg/day of vitamin E. (Vitamin E is not essential for wound healing.) Limit fluid intake to 20 mL/kg of body weight per day. (The nurse should encourage a fluid intake of 30 to 35 mL/kg of body weight per day as water is essential to the wound healing process.) CORRECT ANSWER Provide a protein intake of 1.5 g/kg of body weight per day. (A protein intake of 1 to 1.5 g/kg of body weight per day is necessary to maintain a positive nitrogen balance, which promotes wound healing.)
A nurse is reviewing measures to prevent back injuries with assistive personnel (AP). Which of the following instructions should the nurse include? Stand 3 feet from the client when assisting with lifting. Lock your knees when standing for long periods. Lift up to 22.6 kg (50 lbs) without the use of assistive devices. When lifting an object, spread your feet apart to provide a wide base of support.
Stand 3 feet from the client when assisting with lifting. (The AP should stand as close as possible to the client to reduce the strain on his back.) Lock your knees when standing for long periods. (The AP should bend his knees and hips and rest his feet one at a time on a foot rest when standing for long periods of time.) Lift up to 22.6 kg (50 lbs) without the use of assistive devices. (The AP should use an assistive device or another person to lift an object weighing more than 15.8 kg (35 lbs)) CORRECT ANSWER When lifting an object, spread your feet apart to provide a wide base of support. The AP should spread his feet apart because a wide base of support increases stability.
A nurse is providing discharge teaching to a client who is recovering from lung cancer. The provider instructed the client that he could resume lower-intensity activities of daily living. Which of the following activities should the nurse recommend to the client? Sweeping the floor Shoveling snow Cleaning windows Washing dishes
Sweeping the floor (Sweeping the floor is a moderate-intensity activity.) Shoveling snow (Shoveling snow is a high-intensity activity.) Cleaning windows (Cleaning windows is a moderate-intensity activity.) CORRECT ANSWER Washing dishes (Washing dishes requires a low level of activity and is appropriate for this client.Cleaning windows)
A nurse is performing a neurological assessment for a client. Which of the following examinations should the nurse use to check the client's balance? Two-point discrimination test Glasgow coma scale Babinski reflex Romberg test
Two-point discrimination test Two-point discrimination is tested by touching the skin with two sharp, pointed objects. The purpose of the test is to determine when the client can differentiate between the two points. Glasgow coma scale The Glasgow coma scale is used to measure a client's level of consciousness. Babinski reflex The Babinski reflex is tested by using an object to strike the sole of the foot. When the test is negative, all of the toes bend. The test is positive if the toes spread outward. CORRECT ANSWER Romberg test When using the Romberg test, the nurse instructs the client to stand with his feet together and arms at sides, first with his eyes open and then with eyes closed. The inability to maintain balance is a positive Romberg test.
A client is being discharged home with oxygen therapy via a nasal cannula. Which of the following instructions should the nurse provide to the client and family? Use battery-operated equipment for personal care. Apply mineral oil to protect the facial skin from irritation. Remove the television set from the client's bedroom. Wear cotton clothing to avoid static electricity.
Use battery-operated equipment for personal care. (Electrical equipment in good condition with no frayed wires is acceptable for personal care when oxygen is administered.) Apply mineral oil to protect the facial skin from irritation. (Most oils and petroleum products are flammable when used on the body, which is a contraindication for their use because oxygen is a highly combustible gas.) Remove the television set from the client's bedroom. (As long as the television is in proper working order, there is no oxygen-related need to remove it from the client's bedroom.) CORRECT ANSWER Wear cotton clothing to avoid static electricity. (The use of cotton clothing will limit the buildup of static electricity. Oxygen is a highly combustible gas. The use of oxygen in high concentrations has great combustion potential and readily fuels fire. Although it will not spontaneously burn or cause an explosion, it can easily cause a fire in a client's room if it contacts a spark.)
A nurse in the emergency department is caring for a client who has abdominal trauma. Which of the following assessment findings should the nurse identify as an indication of hypovolemic shock? Warm, dry skin Increased urinary output Tachycardia Bradypnea
Warm, dry skin (Cool, clammy skin is an indication of hypovolemic shock.) Increased urinary output (Urine output of 30 mL/hr or less is an indication of hypovolemic shock.) CORRECT ANSWER Tachycardia (Due to the decrease in circulating blood volume that occurs with internal bleeding, the oxygen-carrying capacity of the blood is reduced. The body attempts to relieve the hypoxia by increasing the heart rate and cardiac output, along with increasing the respiratory rate.) Bradypnea (Tachypnea is an indication of hypovolemic shock.)
A nurse is caring for a client who has Clostridium difficile and is in contact isolation. Which of the following actions should the nurse take? Wear gloves when changing the client's gown. Use alcohol-based sanitizer to cleanse the hands. Wear a mask when assisting the client with his meal tray. Place the client on complete bed rest.
CORRECT ANSWER Wear gloves when changing the client's gown. (The nurse should wear gloves when handling articles that have the potential to contaminate the hands when caring for a client who is in contact isolation.) Use alcohol-based sanitizer to cleanse the hands. (The nurse should use soap and water to cleanse the hands. Alcohol-based hand sanitizer is ineffective against the spores of C. difficile.) Wear a mask when assisting the client with his meal tray. (The nurse should wear a mask when working within 3 feet of the client who has an infection, such as influenza, and droplet precautions are required.) Place the client on complete bed rest. (The nurse should not place the client on complete bed rest because this places him at risk for the hazards of immobility, such as impaired skin integrity and retained respiratory secretions. The nurse should instruct the client to remain in his room, but to move, cough, and deep breathe at least every 2 hr. There is no indication the client should be on complete bed rest.)
A nurse is caring for a client who has a fecal impaction. Before digital removal of the mass, which of the following types of enemas should the nurse plan to administer to soften the feces? Carminative Hypertonic Oil retention Sodium polystyrene sulfate
Carminative The nurse should administer a carminative enema to assist a client to expel flatus. Hypertonic The nurse should administer a hypertonic fluid solution to cleanse the client's bowels. One use for this type of enema is preparation for surgery. CORRECT ASNWER Oil retention The nurse should administer an oil retention enema prior to removal of a fecal impaction to soften the stool. This makes the procedure less painful for the client. Sodium polystyrene sulfate The nurse should administer a sodium polystyrene sulfate enema to a client who has very high levels of potassium.
A nurse on a surgical unit is receiving a client who had abdominal surgery from the postanesthesia care unit. Which of the following assessments should the nurse make first? Pain level Hydration status Airway Urinary output
Pain level The nurse should assess the pain level of a client who is postoperative; however, another assessment should be made first. Hydration status The nurse should assess the hydration status of a client who is postoperative; however, another assessment should be made first. CORRECT ANSWER Airway The nurse should apply the ABC priority-setting framework when caring for this client. This framework emphasizes the basic core of human functioning and prioritizes having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these can indicate a threat to life. Therefore, this is the nurse's priority concern. When applying the ABC priority-setting framework, airway is always the highest priority because the airway must be clear and open for oxygen exchange to occur. Breathing is the second highest priority in the ABC priority-setting framework because adequate ventilatory effort is essential in order for oxygen exchange to occur. Circulation is the third highest priority in the ABC priority-setting framework because delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them; therefore, the nurse should first assess the client's airway. Urinary output The nurse should assess the urinary output of a client who is postoperative; however, another assessment should be made first.
An assistive personnel (AP) is assisting a nurse with the care of a female client who has an indwelling urinary catheter. Which of the following actions by the AP indicates a need for further teaching? The AP uses soap and water to clean the perineal area. The AP tapes the catheter to the client's inner thigh. The AP hangs the collection bag at the level of the bladder. The AP ensures that there are no kinks in the drainage tubing.
The AP uses soap and water to clean the perineal area. (The AP should cleanse the client's perineal area with soap and water at least three times per day to reduce the risk of infection.) The AP tapes the catheter to the client's inner thigh. (The AP should tape the catheter to the inner thigh of a female client to prevent pulling on the urethra as the client moves around. When the catheter tugs and pulls on the urethra, it increases the risk of infection and of dislodging the catheter.) CORRECT ANSWER The AP hangs the collection bag at the level of the bladder. (The AP should place the drainage bag below the level of the bladder to ensure proper drainage by gravity.) The AP ensures that there are no kinks in the drainage tubing. (The AP should make sure there are no kinks in the tubing to ensure proper drainage by gravity.)
A nurse is reviewing the correct use of a fire extinguisher with a client. Which of the following actions should the nurse direct the client to take first? Aim the hose at the base of the fire. Squeeze the handle of the extinguisher. Remove the safety pin from the extinguisher. Sweep the hose from side to side to dispense material.
Aim the hose at the base of the fire. Evidenced-based practice indicates aiming the hose of the fire extinguisher is the second step the client should take. Squeeze the handle of the extinguisher. Evidenced-based practice indicates squeezing the handle of the extinguisher is the third step the client should take. CORRECT ANSWER Remove the safety pin from the extinguisher. Evidenced-based practice indicates removing the safety pin from the extinguisher is the first action to take when using a fire extinguisher; therefore, this is the action the nurse should instruct the client to take first. Sweep the hose from side to side to dispense material. Evidenced-based practice indicates sweeping the hose from side to side to dispense material is the fourth step the client should take.
A nurse is caring for a client who, while sitting in a chair, starts to experience a seizure. Which of the following actions should the nurse take? Place a padded tongue blade in the client's mouth. Lower the client to the floor and place a pad under the client's head. Seek the help of a coworker and lift the client back into bed. Use an oropharyngeal airway to keep upper airway passages open.
Place a padded tongue blade in the client's mouth. (The nurse should avoid placing a padded tongue blade in the client's mouth because this can cause injury, such as broken teeth.) CORRECT ANSWER Lower the client to the floor and place a pad under the client's head. (To reduce the risk of injury to the client, the nurse should lower the client to the floor and place a pillow or other soft object under the client's head.) Seek the help of a coworker and lift the client back into bed. (The nurse should not attempt to lift the client while he is experiencing a seizure.) Use an oropharyngeal airway to keep upper airway passages open. (The nurse should avoid inserting an oropharyngeal airway because this can cause injury, such as broken teeth.)
A nurse in a provider's office is collecting information from an older adult client who reports that he has been taking acetaminophen 500 mg/day for severe joint pain. The nurse should instruct the client that large doses of acetaminophen could cause which of the following adverse effects? Constipation Gastric ulcers Respiratory depression Liver damage
Constipation (Constipation is an adverse effect of opioid analgesics.) Gastric ulcers (Gastric ulcers are an adverse effect of aspirin and other nonselective NSAIDs.) Respiratory depression (Respiratory depression is an adverse effect of opioid analgesics.) CORRECT ANSWER Liver damage (Acetaminophen in large doses can be toxic to the liver. Daily intake should be limited to less than 3 to 4 grams per day for healthy individuals and 2.4 grams per day for older adults and those with a history of liver impairment.)
A nurse is teaching a client who is postoperative how to use a flow-oriented incentive spirometer. Which of the following instructions should the nurse include? Blow into the spirometer to elevate the balls in the device. Cough deeply after each use. Clean the mouth piece with an alcohol swab after each use. Use the spirometer every 8 hr.
Blow into the spirometer to elevate the balls in the device. (The nurse should instruct the client to inhale deeply to elevate the balls in the device.) CORRECT ANSWER Cough deeply after each use. (Proper use of the incentive spirometer loosens secretions in the client's lungs. The client should cough deeply to facilitate removal of secretions from his lungs). Clean the mouth piece with an alcohol swab after each use. (The nurse should instruct the client to clean the mouth piece with water and dry it after each use.) Use the spirometer every 8 hr. (The nurse should instruct the client to use the spirometer several times every hour while awake.)
A nurse is responding to a parent's question about his infant's expected physical development during the first year of life. Which of the following information should the nurse include? A 2-month-old infant can turn from his abdomen to his back. A 10-month-old infant can pull up to a standing position. A 4-month-old infant can sit up without support. A 6-month-old infant can crawl on his hands and knees.
A 2-month-old infant can turn from his abdomen to his back. (An infant cannot turn from his abdomen to his back until he is 5 months old.) CORRECT ANSWER A 10-month-old infant can pull up to a standing position. (An 8 to 10-month-old infant can pull himself to a standing position.) A 4-month-old infant can sit up without support. (A 6 to 8-month-old infant can sit up without support.) A 6-month-old infant can crawl on his hands and knees. (An 8 to 10-month-old infant can creep on his hands and knees.)
A home health nurse is planning to provide health promotion activities for a group of clients in the community. Which of the following activities is an example of the nurse promoting primary prevention? Teaching clients to perform self-examinations of breasts and testicles Educating clients about the recommended immunization schedule for adults Teaching clients who have type 1 diabetes mellitus about care of the feet Recommending that clients over the age of 50 have a fecal occult blood test annually
Teaching clients to perform self-examinations of breasts and testicles (This activity is an example of secondary prevention. Secondary prevention focuses on measures that identify the early stages of a condition.) CORRECT ANSWER Educating clients about the recommended immunization schedule for adults (Primary prevention includes health education about disease prevention.) Teaching clients who have type 1 diabetes mellitus about care of the feet (This activity is an example of tertiary prevention. Tertiary prevention occurs after diagnosis of a condition and the focus is to limit complications from the condition.) Recommending that clients over the age of 50 have a fecal occult blood test annually (This activity is an example of secondary prevention. Secondary prevention focuses on measures that identify the early stages of a condition.)
A nurse in a long-term care facility is admitting a client who is incontinent and smells strongly of urine. His partner, who has been caring for him at home, is embarrassed and apologizes for the smell. Which of the following responses should the nurse make? "A lot of clients who are cared for at home have the same problem." "Don't worry about it. He will get a bath, and that will take care of the odor." "It must be difficult to care for someone who is confined to bed." "When was the last time that he had a bath?"
"A lot of clients who are cared for at home have the same problem." (This response is an automatic response. It also implies that caregivers in the home are not able to keep clients odor-free. It is a judgmental statement that is not therapeutic.) "Don't worry about it. He will get a bath, and that will take care of the odor." (Telling the partner not to worry blocks communication by devaluing her feelings and her concern about the odor.) CORRECT ANSWER "It must be difficult to care for someone who is confined to bed." (This response addresses the feelings of the partner by reflecting on her feelings. It facilitates therapeutic communication because it is nonjudgmental and encourages the partner to express her feelings.) "When was the last time that he had a bath?" (This response implies to the partner that the odor of urine developed because she has not bathed her husband for some time. This approach is judgmental and nontherapeutic.)
A nurse is caring for a client who is 48 hr postoperative following a small bowel resection. The client reports gas pains in the periumbilical area. The nurse should plan care based on which of the following factors contributing to this postoperative complication? Blood loss NPO status after surgery Nasogastric tube suctioning Impaired peristalsis of the intestines
Blood loss Blood loss can cause shock but it does not contribute to the findings demonstrated by this client. NPO status after surgery NPO status after surgery can cause dehydration but it does not contribute to the findings demonstrated by this client. Nasogastric tube suctioning Nasogastric tube suctioning keeps the stomach and intestines decompressed and can help prevent the findings demonstrated by this client. CORRECT ANSWER Impaired peristalsis of the intestines Normal bowel function is delayed for up to several days following a bowel resection. When peristalsis is absent or sluggish, intestinal gas builds up, producing pain and abdominal distention. The nurse should plan to assist the client to ambulate to promote peristalsis.
A nurse is providing oral care for a client who is unconscious. Which of the following actions should the nurse take? Place the client in a lateral position with the head turned to the side before beginning the procedure. Use the thumb and index finger to keep the client's mouth open. Rinse the client's mouth with an alcohol-based mouth wash following the procedure. Cleanse the client's mucous membranes with lemon-glycerin sponges.
CORRECT ANSWER Place the client in a lateral position with the head turned to the side before beginning the procedure. (The nurse should place the client in a lateral position with the head turned to the side to reduce the risk of aspiration of fluids and secretions.) Use the thumb and index finger to keep the client's mouth open. (The nurse should use a padded tongue blade, not a thumb or an index finger, to keep the client's mouth open. If the client suddenly bites down, the nurse's fingers could be injured.) Rinse the client's mouth with an alcohol-based mouth wash following the procedure. (The nurse should use either water or alcohol-free mouth wash to rinse the client's mouth.) Cleanse the client's mucous membranes with lemon-glycerin sponges. (The nurse should use a foam swab because lemon-glycerin swabs dry and irritate the mouth and can cause damage to the teeth.)
A nurse in a provider's office is reviewing the laboratory findings of a client who reports chills and aching joints. The nurse should identify which of the following findings as an indication that the client has an infection? WBC 15,000 mm3 Erythrocyte sedimentation rate (ESR) 15 mm/hr Urine pH 7.2 Urine specific gravity 1.0063
CORRECT ANSWER WBC 15,000 mm3 This finding is above the expected reference range and is an indication of infection. Erythrocyte sedimentation rate (ESR) 15 mm/hr Although an elevated ESR can indicate an infection, this finding is within the expected reference range. Urine pH 7.2 A urine pH of 7.2 is within the expected reference range. Urine specific gravity 1.0063 A urine specific gravity of 1.0063 is within the expected reference range.
A client who reports shortness of breath requests her nurse's help in changing positions. After repositioning the client, which of the following actions should the nurse take next? Encourage the client to take deep breaths. Observe the rate, depth, and character of the client's respirations. Prepare to administer oxygen. Give the client a back rub to help her relax.
Encourage the client to take deep breaths. (Encouraging the client to take deep breaths can increase the client's intake of oxygen. However, there is another action the nurse should take first.) CORRECT ANSWER Observe the rate, depth, and character of the client's respirations. (The nurse should apply the nursing process priority-setting framework when caring for this client. The nurse can use the nursing process to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's status, the nurse must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with knowledge to make an appropriate decision; therefore, the first action the nurse should take is to assess the client's respiratory status.) Prepare to administer oxygen. (Preparing to administer oxygen is important because oxygen is frequently administered when a client is experiencing dyspnea. However, there is another action the nurse should take first.) Give the client a back rub to help her relax. (Giving the client a back rub is a relaxation technique that can reduce dyspnea. However, there is another action the nurse should take first.)
A nurse is applying an ice bag to the ankle of a client following a sports injury. Which of the following actions should the nurse take? Leave the bag in place for 45 min. Fill the bag two-thirds full with ice. Place the ice bag uncovered on the client's ankle. Tell the client that it is expected to feel numbness when the ice bag is in place.
Leave the bag in place for 45 min. (To reduce the risk of injury to the to the client's skin, the nurse should leave the ice bag in place no longer than 30 min.) CORRECT ANSWER Fill the bag two-thirds full with ice. (The nurse should fill the bag two-thirds full with ice, which makes it possible to mold the bag around the client's ankle.) Place the ice bag uncovered on the client's ankle. (The nurse should cover the ice bag with a towel or other type of cover before placing the ice bag on the client's ankle to prevent injury to the client's skin.) Tell the client that it is expected to feel numbness when the ice bag is in place. (The nurse should remove the ice bag if the client feels numbness because numbness is an indication that the client's skin is too cold and at risk for injury.)
A nurse is preparing to administer an intramuscular injection to a young adult client. Which of the following injection sites is the safest for this client? Vastus lateralis Dorsogluteal Deltoid Ventrogluteal
Vastus lateralis The vastus lateralis is safe for adults because it is thick and away from major blood vessels and nerves. However, according to evidence-based practice, it is not the safest injection site. Dorsogluteal The dorsogluteal site is close to the sciatic nerve, as well as the superior gluteal nerve and artery. Therefore, according to evidence-based practice, it is not the safest injection site. Deltoid The deltoid site is easy to access. However, according to evidence-based practice, it is not the safest site because the muscle is small and sometimes poorly developed. Additionally, it is close to numerous arteries and nerves. CORRECT ANSWER Ventrogluteal According to evidence-based practice, the ventrogluteal site is the safest injection site for all adults because it contains thick gluteal muscles and it does not contain major nerves or blood vessels.
An adolescent client in an outpatient mental health facility tells the nurse that it is hard to follow his treatment plans because his friends discourage him. Which of the following statements should the nurse make? "Don't worry, teenagers often have friends who give them bad advice." "I think you should stop seeing those friends since they discourage you from following your treatment plan." "Tell me more about how your friends discourage you." "Tell me where you met these friends."
"Don't worry, teenagers often have friends who give them bad advice." (This response is a barrier to communication. It is a stereotypical response and will not encourage open communication.) "I think you should stop seeing those friends since they discourage you from following your treatment plan." (While it is probably wise for the adolescent to stop seeing these friends, the nurse is giving personal advice and this response will probably be rejected by the adolescent and will not encourage open communication.) CORRECT ANSWER "Tell me more about how your friends discourage you." (The nurse should ask an open-ended question that encourages the client to elaborate about the problems that he is having.) "Tell me where you met these friends." (This response is a barrier to communication. The nurse has changed the subject and this response will not encourage open communication.)
A newly licensed nurse is preparing to administer medications to a client. The nurse notes that the provider has prescribed a medication that is unfamiliar to her. Which of the following actions should the nurse take? Consult the medication reference book available on the unit. Ask a more experienced nurse for information about the medication. Call the client's provider and verify the prescription. Ask the client if she takes this medication at home.
CORRECT ANSWER Consult the medication reference book available on the unit. A nurse must have knowledge about medications to administer them safely. The nurse should become familiar with the medication by looking it up it in the medication reference on the unit. Ask a more experienced nurse for information about the medication. Even if the more experienced nurse has knowledge of the medication, information from the source is not sufficient for the nurse to safely administer the medication. Call the client's provider and verify the prescription. There is no reason to believe that the medication prescription is in error; therefore, it is unnecessary for the nurse to confirm it with the provider. Ask the client if she takes this medication at home. Even if the client has knowledge of the medication, information from the client is not sufficient for the nurse to safely administer the medication.
A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following actions should the nurse take first after discovering that the client's wound has eviscerated? Cover the incision with a moist sterile dressing. Have the client lie on his back with his knees flexed. Call the client's surgeon. Reassure the client.
CORRECT ANSWER Cover the incision with a moist sterile dressing. (The nurse should apply the safety and risk reduction priority-setting framework when caring for this client. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. An open wound places the client at risk for peritonitis, and any exposed organ tissue could dry out. Therefore, covering the wound with a moist sterile dressing is the first action the nurse should take to protect the client.) Have the client lie on his back with his knees flexed. (The nurse should use this position to reduce pressure on the incision. However, the nurse should take another action first.) Call the client's surgeon. (The nurse should notify the surgeon or direct a colleague to notify the surgeon while tending to the client's immediate need. However, the nurse should take another action first.) Reassure the client. (The nurse should respond to the client's emotional needs. However, the nurse should take another action first.)
A nurse is reviewing the laboratory values for a client who has a positive Chvostek's sign. Which of the following laboratory findings should the nurse expect? Decreased calcium Decreased potassium Increased potassium Increased calcium
CORRECT ANSWER Decreased calcium Calcium is necessary for nerve conduction and muscle contractions. When the client's total calcium level is below 8.4 mg/dL, tetany and muscle spasms may occur. The nurse should tap the facial nerve in front of the client's ear. If facial muscle twitching follows this stimulus, it is a positive Chvostek's sign and an indication of hypocalcemia. Decreased potassium Hypokalemia occurs when the client's potassium is below 3.5 mEq/L. The nurse should assess the client for muscle weakness and other clinical manifestations of hypokalemia, but not a positive Chvostek's sign. Increased potassium Hyperkalemia occurs when the client's potassium is above 5.0 mEq/L. The nurse should assess the client for muscle weakness and cardiac dysthymias, as well as other clinical manifestations of hyperkalemia, but not a positive Chvostek's sign. Increased calcium Hypercalcemia occurs when the client's total calcium level is above 10.5 mg/dL. The nurse should assess the client for lethargy, weakness, and other clinical manifestation of hypercalcemia, but not a positive Chvostek's sign.
A nurse is caring for a client who is receiving a blood transfusion. The client reports flank pain and the nurse notes reddish-brown urine in the client's urinary catheter bag. The nurse recognizes these manifestations as which of the following types of transfusion reactions? Hemolytic Febrile Circulatory overload Sepsis
CORRECT ANSWER Hemolytic A hemolytic reaction occurs when the client's blood is incompatible with the donor's blood. Chills, low back pain, hypotension, and tachycardia are indications of a hemolytic transfusion reaction. Febrile A febrile reaction occurs when the client's blood is sensitive to the WBCs and platelets in the donor's blood. Fever, chills, headache, and flushing are indications of a febrile reaction. Circulatory overload Circulatory overload occurs when blood is administered too quickly for the client's circulatory system to handle. Dyspnea, cough, headache, and hypertension are indications of circulatory overload. Sepsis Sepsis occurs when the blood is contaminated with bacteria. High fever, vomiting, and diarrhea are indications of sepsis.
A nurse is planning to assess the abdomen of a client who reports feeling bloated for several weeks. Which of the following methods of assessment should the nurse use first? Inspection Auscultation Percussion Palpation
CORRECT ANSWER Inspection According to evidence-based practice, the nurse should inspect the abdomen first by observing the contour of the abdomen, the condition of the skin, and the position of the umbilicus. Findings from this step of assessment are used by the nurse in the subsequent steps. Auscultation The nurse should auscultate the client's abdomen before percussion or palpation, both of which can stimulate peristalsis, yielding inaccurate results. This sequence is different from that of other body systems. Percussion The nurse should not percuss the client's abdomen first because percussion can cause pain and stimulate peristalsis, yielding inaccurate results in auscultation. Palpation The nurse should not palpate the client's abdomen first because palpation can cause pain and stimulate peristalsis, yielding inaccurate results in auscultation.
A nurse on a mental health unit is preparing to terminate the nurse-client relationship with a client who no longer requires care. Which of the following concepts should the nurse and client discuss in the termination phase of the relationship? Loss Trust Self-disclosure Risk-taking
CORRECT ANSWER Loss (At the close of a relationship, even one that is planned, loss is an expected feeling for both the client and the nurse. It is important for both the nurse and the client to terminate the relationship without feelings of guilt or anxiety.) Trust (The nurse should address the concept of trust during the introductory phase of the relationship.) Self-disclosure (The nurse should address the concept of appropriate self-disclosure during the working phase of the relationship.) Risk-taking (The nurse should address the concept of risk-taking in the working phase of the nurse-client relationship.)
A nurse is planning to perform passive range-of-motion exercises for a client. Which of the following actions should the nurse take? Repeat each joint motion five times during each session. Move the joint to the point of considerable resistance. Sit approximately 2 feet from the side of the bed closest to the joint being exercised. Exercise the smaller joints first.
CORRECT ANSWER Repeat each joint motion five times during each session. (To maintain the client's joint mobility the nurse should repeat each motion three to five times.) Move the joint to the point of considerable resistance. (The nurse should move the joint to the point of slight resistance.) Sit approximately 2 feet from the side of the bed closest to the joint being exercised. (The nurse should stand at the side of the bed closest to the joint being exercised.) Exercise the smaller joints first. (The nurse should exercise the large joints first.)
A nurse is caring for a client who has bilateral casts on her hands. Which of the following actions should the nurse take when assisting the client with feeding? Sit at the bedside while feeding the client. Order pureed foods. Make sure feedings are at room temperature. Offer the client a drink of fluid after every bite.
CORRECT ANSWER Sit at the bedside while feeding the client. (The nurse should avoid appearing to be in a hurry. Sitting at the bedside provides the client with the nurse's full attention during the feeding.) Order pureed foods. (Without any mouth or throat injuries that make it difficult to chew or swallow, the client should be served foods of an appropriate variety of textures. Pureed foods are for clients who cannot chew, have difficulty swallowing, or do not have teeth.) Make sure feedings are at room temperature. (The nurse should ask the client if the food is the correct temperature.) Offer the client a drink of fluid after every bite. (If the client is unable to communicate, the nurse should offer the client fluids after every three to four mouthfuls. However, there is no indication that this client is unable to communicate. Therefore, the client should tell the nurse when she would like a drink.)
A nurse is caring for a client who has acute renal failure. Which of the following assessments provides the most accurate measure of the client's fluid status? Daily weight Blood pressure Specific gravity Intake and output
CORRECT ASNWER Daily weight According to the evidence-based priority-setting framework, daily weight provides important information about the client's fluid status. A gain or loss of 1 kg (2.2 lb) indicates a gain or loss of 1 liter of fluid; therefore, weighing the client daily will provide the nurse with the most accurate fluid status measurement. Blood pressure (While blood pressure can indicate a client's fluid gains or losses, it is not the most accurate method used to measure fluid changes. Evidence-based practice indicates that another assessment provides the most accurate information.) Specific gravity (Specific gravity reflects the kidney's ability to concentrate urine. While specific gravity reflects client's fluid gains or losses, it is not the most accurate method used to measure fluid changes. Evidence-based practice indicates that another assessment provides the most accurate information.) Intake and output (Intake and output reflects a client's fluid status. However, it's not the most accurate method to measure fluid changes. Evidence-based practice indicates that another assessment provides the most accurate information.)
A nurse is preparing to provide chest physiotherapy for a client who has left lower lobe atelectasis. Which of the following actions should the nurse plan to take? Place the client in Trendelenburg's position. Perform percussions directly over the client's bare skin. Use a flattened hand to perform percussions. Remind the client that chest percussions can cause mild pain.
CORRECT ASNWER Place the client in Trendelenburg's position. (The nurse should place the client in right side lying position in Trendelenburg's position to promote drainage from the client's left lower lobe.) Perform percussions directly over the client's bare skin. (The nurse should perform percussions over a single layer of clothing.) Use a flattened hand to perform percussions. (The nurse should use a cupped hand to provide percussions.) Remind the client that chest percussions can cause mild pain. (Chest percussions should not cause pain when the procedure is performed correctly.)