Hesi Final Review from Spring 2016

A physician orders heparin 6,000 units subcutaneously daily. The pharmacy dispenses a vial containing 10,000 units per milliliter. To ensure the patient's safety, how many milliliters of heparin should the nurse administer? Include a leading zero if applicable. Record your answer using one decimal place. _____ mL

Dose on hand/Quantity on hand = Dose desired/x 10,000 units/1 mL = 6,000 units/x 10,000 units (x) = 6,000 units (mL) x = 6,000 units (mL) / 10,000 units x = 0.6 mL

Which assessment question will provide the best information regarding a client's risk for waking in the night and interrupted sleep related to lifestyle choices? 1. "Do you consider yourself a deep sleeper?" 2. Do you smoke cigarettes, cigars, or a pipe?" 3. "Do you adhere to a regular bedtime routine?" 4. "Do you keep the television on when you're falling asleep?"

2. "Do you smoke cigarettes, cigars, or a pipe?" Tobacco use leads to nicotine addiction. An addiction to nicotine can result in interrupted sleep as the nicotine level declines through the night; the individual is awakened with mild withdrawal symptoms. Lack of a bedtime routine and the presence of environmental noise will likely cause difficulty in falling asleep rather than in staying asleep. An individual who is a deep sleeper will likely have difficulty awakening rather than staying asleep.

An 85-year-old client has just been admitted to a nursing home. When designing a plan of care for this older adult the nurse recalls what expected sensory losses associated with aging? Select all that apply. 1. Difficulty in swallowing 2. Diminished sensation of pain 3. Heightened response to stimuli 4. Impaired hearing of high-frequency sounds 5. Increased ability to tolerate environmental heat

2. Diminished sensation of pain 4. Impaired hearing of high-frequency sounds Because of aging of the nervous system an older adult has a diminished sensation of pain and may be unaware of a serious illness, thermal extremes, or excessive pressure. As people age they experience atrophy of the organ of Corti and cochlear neurons, loss of the sensory hair cells, and degeneration of the stria vascularis, which affects an older person's ability to perceive high-frequency sounds. An interference with swallowing is a motor, not a sensory, loss, nor is it an expected response to aging. There is a decreased, not heightened, response to stimuli in older adults. There is a decreased, not increased, ability to physiologically adjust to extremes in environmental temperature.

A nurse is caring for a terminally ill client who is angry with everything and everyone. The nurse, who has been encouraging the client to make decisions about daily activities, determines that some of the anger may have resolved when the client says: 1. "Leave me alone! i want to do it myself." 2. "You've got a busy morning ahead of you! I'm really a mess." 3. "I can do my face, hands, arms, and chest today, but I think you'd better do the rest." 4. "It's so hard to let someone do so much for me. I don't like it when others do things for me."

3. "I can do my face, hands, arms, and chest today, but I think you'd better do the rest." Allowing the nurse to take care of some of the responsibility demonstrates the client's diminished anger and is a realistic assessment and acceptance of current capabilities and limitations. Anger is still apparent when the client tells the nurse to leave her alone. Telling the nurse that she is a mess shows the client's dependency; the client either has given up or is being sarcastic. Expressing dismay at having to let someone help shows dependency and suggests that the client is still angry.

Non-weight-bearing with crutches has been prescribed for a client with a leg injury. The nurse provides teaching before ambulation is begun. To facilitate walking with crutches, the most important activity the nurse should teach the client is to: 1. Sit up in a chair to help strengthen back muscles 2. Keep the unaffected leg in extension and abduction 3. Exercise the triceps, finger flexors, and elbow extensors 4. Use a trapeze frequently to strengthen the biceps muscles

3. Exercise the triceps, finger flexors and elbow extensors The triceps, finger flexors, and elbow extensors are used in crutch walking and therefore need strengthening. Although back muscles keep the person erect, the most important muscles for walking with crutches are the triceps, elbow extensors, finger flexors, and the muscles in the unaffected leg. Keeping the unaffected leg in extension and abduction will do nothing to promote crutch walking. A pushing, not a pulling, motion is used with crutches; the triceps, not the biceps, are used.

The nurse recognizes that a common conflict experienced by the older adult is the conflict between: 1. Youth and old age 2. retirement and work 3. Independence and dependence 4. Wishing to die and wishing to live

3. Independence and dependence A common conflict confronting the older adult is between the desire to be taken care of by others and the desire to be in charge of one's own destiny. The conflict between the young and old age may occur but is not common. The conflict between the retired and working may occur but is not common. The conflict between those wishing to die and those wishing to live may occur but is not common.

The nurse should place the client in which position to obtain the most accurate reading of jugular vein distention? 1. Upright at 90 degrees 2. Supine position 3. Raised to 30 degrees 4. Raised to 10 degrees

3. Raised to 30 degrees Jugular vein pressure is measured with a centimeter ruler to obtain the vertical distance between the sternal angle and the point of highest pulsation. This procedure is most accurate when the head of the bed is elevated between 30 and 45 degrees. The internal and external jugular veins should be inspected while the client is gradually elevated from a supine position to an upright 30-45 degrees. Jugular vein distention cannot accurately be assessed if the client is supine, at 90 degrees or 10 degrees.

A nurse is assessing the grief response of a family member whose relative has died. What must the nurse consider first about the family to conduct an effective assessment? 1. Personality traits 2. Educational level 3. Socioeconomic class 4. Cultural background

4. Cultural background The degree of anguish experienced or expressed is most often set or imposed by the cultural background of the individual, so cultural background must be assessed before care is planned. Although personality traits do enter into the grief process, they are not as important in the developing awareness stage as is cultural background. Educational level has no relationship to the grieving process; nor does socioeconomic class.

A client in a detoxification unit has an alcohol withdrawal seizure. Diazepam (Valium) 7.5 mg intramuscularly stat is prescribed. Valium is available as 5 mg/mL. How many milliliters should the nurse administer? Record your answer using one decimal place. ___ mL Solve for x with the "desire over have" formula of ratio and proportion.

Desire 7.5 mg x mL --------------- = ----- Have 5 mg 1 mL 5x = 7.5 x = 7.5/5 x = 1.5 mL

A routine urinalysis is prescribed for a client. What should the nurse do if the specimen cannot be sent immediately to the laboratory? 1. Take no special action 2. Refrigerate the specimen 3. Store it in the dirty utility room and send it later 4. Discard the specimen and collect another specimen later

2. Refrigerate the speciman Refrigeration retards the growth of bacteria and may preserve the specimen for several hours. Growth of bacteria will alter the pH and the glucose and protein levels in the urine; it must be refrigerated to retard growth. Discarding the specimen and collecting another specimen later represents an unnecessary waste of time, effort, and money.

A nurse assesses drainage on a surgical dressing and documents the findings. Which documentation is most informative? 1. "Moderate amount of drainage." 2. "No change in drainage since yesterday." 3. "A 10-mm-diameter area of drainage at 1900 hours." 4. "Drainage is doubled in size since last dressing change."

3. "A 10-mm-diameter area of drainage at 1900 hours." A 10-mm-diameter area of drainage at 1900 hours is objective data and gives specific details regarding the assessment and a time frame. By providing size, it establishes parameters to compare with previous assessments and to further evaluate the drainage. "Moderate amount of drainage," "No change in drainage since yesterday," and "Drainage is doubled in size since last dressing change" are not specific, objective, or measurable.

A health care provider prescribes a standard walker (pick-up walker with rubber tips on all four legs). The nurse identifies what clinical findings that indicate the client is capable of using a standard walker? 1. Weak upper arm strength and impaired stamina 2. Weight bearing as tolerated and unilateral paralysis 3. Partial weight bearing on the affected extremity and kyphosis 4. Strong upper arm strength and non-weight bearing on the affected extremity

4. Strong upper arm strength and non-weight bearing on the affected extremity A walker with four rubber tips on the legs requires more upper body strength than a rolling walker. A client who is non-weight bearing on the affected extremity is able to use a standard walker. A rolling walker is more appropriate for a client with weak upper arm strength and impaired stamina who is less able to lift up and move a walker with four rubber tips. A client with unilateral paralysis is not a candidate for a standard walker; the client must be able to grip and lift the walker with both upper extremities and move the walker forward. A rolling walker is more appropriate for this client. A client with kyphosis is less able to lift up and move a walker with four rubber tips.

Which is the best advice the nurse can give regarding foot care to a client diagnosed with diabetes? 1. Remove corns on the feet 2. Wear shoes that are larger than the feet 3. Examine the feet weekly for potential sores 4. Wear synthetic fiber socks when exercising

4. Wear synthetic fiber socks when exercising Research demonstrates that socks with synthetic fibers wick away moisture better than other fabrics when participating in vigorous activities. Self-removal of corns can result in injury to the feet. Shoes that do not fit appropriately will create friction causing sores, blisters, and calluses. The feet should be examined daily, not weekly.

A client with terminal cancer is to receive 2 mg of hydromorphone (Dilaudid) IV every 4 hours as needed for severe breakthrough pain. The vial contains10 mg/mL. When the client complains of severe pain, how much solution of hydromorphone should the nurse administer? Record your answer using one decimal place. Include a leading zero if applicable. ___ mL Solve the problem using ratio and proportion.

Desire 2 mg x mL ------------ = ----- Have 10mg 1 mL 10x = 2 x = 2 /10 x = 0.2 mL

A client is to receive 0.25 mg of digoxin intramuscularly. The ampule is labeled 0.5 mg = 2 mL. How many mL should the nurse administer? Record your answer using a whole number. ___ mL Use ratio and proportion to solve the problem.

0.25 mg = x mL --------- = ----- 0.5 mg 2 mL 0.5 x = 0.5 x = 0.5/0.5 x = 1 mL

Typically discussions of the topic of suicide are geared to the younger or middle-aged adult, but older adults actually account for 20% of suicide deaths in the United States. What questions should a nurse ask when, during the assessment of an older adult, the nurse suspects suicidal intent? Select all that apply. 1. "Do you think about killing yourself?" 2. "How often do you have these thoughts?" 3. "Do you have the means to kill yourself?" 4. "Have you thought about your loved ones?" 5. "How would you kill yourself if you decided to do it?" 6. "Why do you think you won't be around much longer?"

1. "Do you think about killing yourself?" 2. "How often do you have these thoughts?" 3. "Do you have the means to kill yourself?" 5. "How would you kill yourself if you decided to do it?" A nurse who suspects that an elder is suicidal must use straightforward questions such as "Have you ever thought about killing yourself?" Asking how often the client has had thoughts of suicide is also straightforward and will elicit a clear answer. Many times people who intend to commit suicide have already decided how they are going to kill themselves. Being direct in this line of questioning encourages the client to discuss his suicidal intentions. Knowing whether the client has the means to kill himself will provide a good idea of how serious his intention to commit suicide is. Trying to put the client on a guilt trip by asking about loved ones does not directly address the issue of suicide. "Why do you think you won't be around much longer?" does not directly ask about suicide.

Which clinical indicators identified by the nurse support the probable presence of a fecal impaction in a client? Select all that apply. 1. Abdominal cramps 2. Fecal liquid seepage 3. Hyperactive bowel sounds 4. Bright red blood in the stool 5. Decreased number of bowel movements

1. Abdominal cramps 2. Fecal liquid seepage 3. Hyperactive bowel sounds Peristalsis increases in an attempt to evacuate the hardened feces; spasms of the intestine may occur. When the bowel is impacted with hardened feces, there often is seepage of liquid feces around the obstruction and thus uncontrolled diarrhea. Intestinal gas builds up behind the obstruction; peristaltic waves initiate movement of intestinal contents that cause gurgling sounds in the intestine (borborygmi). Bright red blood in the stool is indicative of lower gastrointestinal (GI) bleeding. There are often frequent liquid bowel movements in the presence of an impaction.

A nurse is preparing a lecture for a group of nursing students related to ethics and legal principles. Which statement would be appropriate to include? 1. Beneficence emphasizes the importance of preventing harm and ensuring the client's well-being. 2. After the nurse has delegated a task or activity, the unlicensed assistive personnel (UAP) is accountable for the task or activity. 3. Social justice is an obligation to protect a client as an advocate when a client is not capable of self-determination. 4. There is a universal list that all states use that describes tasks that can be safely delegated and assigned to nursing team members.

1. Beneficence emphasizes the importance of preventing harm and ensuring the client's well-being. Beneficence is the ethical principle that emphasizes the importance of preventing harm and ensuring the client's well-being. The nurse is always accountable for the task or activity that is delegated. Social justice refers to equality; that is, all patients should be treated equally and fairly. Each state designates which tasks may be safely delegated and assigned to nursing team members. Test-Taking Tip: Try putting questions and answers in your own words to test your understanding.

Nurses who care for the terminally ill apply the theories of Kübler-Ross in planning care. According to Kübler-Ross, individuals who experience a terminal illness go through a grieving process. Place the stages of this process in the order identified by Kübler-Ross. 1. Denial 2. Anger 3. Depression 4. Bargaining

1. Denial 2. Anger 3. Bargaining 4. Depression The initial response is shock, disbelief, and denial , and the client seeks additional opinions to negate the diagnosis. When negating the diagnosis is unsuccessful, the client becomes angry and negative. Bargaining for wellness follows in an attempt to prolong life. As the reality of the situation becomes more apparent, depression sets in and the client may become withdrawn. Test-Taking Tip: In this question type, you are asked to prioritize (put in order) the options presented. For example, you might be asked the steps of performing a nursing action or skill such as those involved in medication administration.

Health promotion efforts with the chronically ill client should include interventions related to primary prevention. What should this include? 1. Encouraging daily physical exercise 2. Performing yearly physical examinations 3. Providing hypertension screening programs 4. Teaching a person with diabetes how to prevent complications

1. Encouraging daily physical exercise Primary prevention activities are directed toward promoting healthful lifestyles and increasing the level of well-being. Performing yearly physical examinations is a secondary prevention. Emphasis is on early detection of disease, prompt intervention, and health maintenance for those experiencing health problems. Providing hypertension screening programs is a secondary prevention. Emphasis is on early detection of disease, prompt intervention, and health maintenance for those experiencing health problems. Teaching a person with diabetes how to prevent complications is a tertiary prevention. Emphasis is on rehabilitating individuals and restoring them to an optimum level of functioning.

What drug should a nurse anticipate that the health care provider will prescribe for a client demonstrating clinical manifestations associated with an opioid overdose? 1. Naloxone 2. Methadone 3. Epinephrine 4. Amphetamine

1. Naloxone Naloxone is a narcotic antagonist that displaces opioids from receptors in the brain, thereby reversing respiratory depression. Methadone is a synthetic opioid that causes central nervous system depression; it will add to the problem of overdose. Epinephrine and amphetamine will have no effect on respiratory depression related to opioid overdose. Test-Taking Tip: Calm yourself by closing your eyes, putting down your pencil, and relaxing. Deep-breathe for a few minutes (or as needed, if you feel especially tense) to relax your body and to relieve tension.

A woman who was sexually assaulted by a stranger in the elevator of her apartment building is brought by her husband to the emergency department. What is the priority nursing intervention? 1. Obtaining information about her perception of the incident 2. Notifying legal authorities that a sexual assault has occurred 3. Talking with the husband about his feelings concerning sexual assault 4. Teaching the client how to obtain a midstream clean-catch urine specimen

1. Obtaining information about her perception of the incident In a crisis situation it is important for the individual to talk about the situation to enable her to move past shock and disbelief. Notifying the legal authorities that a sexual assault has occurred is the client's decision. Although the nurse might talk with the husband, the priority is the woman not the husband. Teaching the client how to obtain a midstream clean-catch urine specimen is contraindicated because the use of water or an antiseptic solution during the procedure will wash away sperm or blood evidence.

A nurse administers the first series of immunizations to a 2-month-old infant. The nurse tells the mother that if the site becomes inflamed she should give the prescribed acetaminophen (Tylenol). What else should the nurse instruct the mother to do? 1. Place a warm compress on the area. 2. Put a witch hazel compress on the site. 3. Give a cool sponge bath for 15 minutes. 4. Apply an ice pack to the area for 2 minutes.

1. Place a warm compress on the area A warm compress will promote circulation, reduce swelling, and relax muscles, thereby easing the inflammation. Witch hazel will not ease inflammation or promote muscle relaxation. Fever is not an expected response; therefore the cooling effect of a sponge bath is not necessary. The application of cold will not provide relief because it reduces circulation to the area.

The primary objective of nursing intervention for clients with dementia, delirium, and other cognitive disorders is to maintain: 1. Safety within the environment 2. Diminished psychological facilities 3. Participation in educational activities 4. Face-to-face contact with other clients

1. Safety within the environment Clients with cognitive disorders need an environment that will keep them safe because their own abilities to interpret and respond appropriately are diminished. People with dementia, delirium, and other cognitive disorders usually have a declining level of function in all areas. Maintaining psychological function is often not possible. People with dementia, delirium, and other cognitive disorders have a limited ability to participate in educational activities and may also have a limited ability to interact socially with other clients.

What safety instruction should a nurse teach a 10-year-old child with diminished sensation in the legs because of cerebral palsy? 1. Test the temperature of the water before a bath. 2. Tighten brace straps securely before ambulating 3. Set the clock twice during the night to change position 4. Lock down at the legs when crutch walking to check how they are positioned

1. Test the temperature of the water before a bath. Individuals whose thermoreceptive senses are impaired are unable to detect changes or degrees of temperature. They must be taught to first test the temperature in any water-related activity to prevent scalding and burning. Overtightening of brace straps may lead to circulatory impairment or skin breakdown. The child with cerebral palsy has uncontrolled movement of voluntary muscles and does not need to change positions at night to prevent skin breakdown. Looking down at the legs when crutch walking is dangerous because this action alters the center of gravity; with practice the child will be able to place the legs in the appropriate position for walking without looking down.

During an admission assessment the nurse discovers that a client has a stage 1 pressure ulcer. Which is the priority nursing action? 1. Turn and reposition the client every 2 hours. 2. Cover the ulcer with an occlusive transparent dressing. 3. Clean the ulcer with hydrogen peroxide and leave it open to the air. 4. Provide the client with a diet high in vitamin C, zinc, and protein.

1. Turn and reposition the client every 2 hours. Turning and repositioning immobile clients at least every 2 hours is the best initial nursing action for preventing further skin breakdown. Other measures should also be taken to relieve pressure on the area to prevent progression and promote healing. Covering the area with an occlusive transparent dressing or cleansing the area with hydrogen peroxide are not recommended for this situation. Providing a diet high in vitamin C, zinc, and protein will also aid in tissue healing and help prevent further breakdown but is not the priority action

A client is admitted to the postanesthesia care unit after surgery and electronic blood pressure monitoring is to be performed. The nurse should assess the client's blood pressure every: 1. 3 to 5 minutes 2. 10 to 15 minutes 3. 20 to 30 minutes 4. 40 to 60 minutes

2. 10 to 15 minutes During the first two postoperative hours the blood pressure is monitored every 10 to 15 minutes to detect unstable vital signs that might indicate shock. Every 3 to 5 minutes is unnecessary. Every 20 to 30 minutes and every 40 to 60 minutes are unsafe because it is too long a period of time between blood pressure readings for a client who just had surgery.

A client who had a cerebrovascular accident (also known as a "brain attack") becomes incontinent of feces. What is the most important nursing action to support the success of a bowel training program? 1. Using medication to induce elimination 2. Adhering to a definite time for attempted evacuations 3. Considering previous habits associated with defecation 4. Timing of elimination to take advantage of the gastrocolic reflex

2. Adhering to a definite time for attempted evacuations. Bowel training is a program for the development of a conditioned reflex that controls regular emptying of the bowel. The key to success is adherence to a strict time for evacuation based on the client's individual schedule. The indiscriminate use of laxatives can result in dependency. Although previous habits should be considered, the brain attack affects the responses of the client by altering motility, peristalsis, and sphincter control despite adherence to previous habits. The passage of food into the stomach does stimulate peristalsis, but it is only one factor that should be considered when planning a specific time for evacuation.

A 78-year-old client who had a right above the knee amputation (AKA) 2 days ago is complaining of crushing pain in the right foot. How should the nurse respond to this? 1. Measure blood pressure 2. Administer prescribed pain medication 3. Notify the client's health care provider 4. Explain to the client that this is a normal occurrence after an amputation

2. Administer prescribed pain medication Phantom limb pain (PLP) is a complication of amputation in which a painful sensation is felt in the amputated part after surgery. The client's phantom limb pain is real and should be treated aggressively with drug and alternative therapies. Blood pressure measurement and health care provider notification are not necessary. Although phantom pain is a frequent occurrence immediately, explanation to the client does not address the need for pain relief.

A nurse auscultates a client's lungs and hears a fine crackling sound in the left lower lung during respiration. The nurse charts, "crackles and rhonchi in the left lower lung." What does this documentation represent? 1. A nursing diagnosis 2. An inaccurate interpretation 3. a correct nursing assessment 4. An accurate conclusion if crepitus was ruled out

2. An inaccurate interpretation Rhonchi are coarse sounds heard over the larger airways; including rhonchi in the record makes the documentation inaccurate. Crackles and rhonchi are clinical indicators, not a nursing diagnosis. It is incorrect to use the term rhonchi to refer to crackling sounds in the lower lung. Crepitus, which indicates subcutaneous emphysema, is unrelated to auscultated breath sounds.

The nurse is caring for a client with vascular dementia. What does the nurse identify as the cause of this problem? 1. A long history of inadequate nutrition 2. Disruptions in cerebral blood flow, resulting in thrombi or emboli 3. A delayed response to severe emotional trauma in early adulthood 4. Anatomical changes in the brain that produce acute, transient symptoms

2. Disruptions in cerebral blood flow, resulting in thrombi or emboli Vascular dementia results from the sudden closure of the lumen of arterioles, causing infarction of the brain tissue in the affected area. Inadequate nutrition may be one of the factors that bring about a general decline of health; however, there is no direct evidence that avitaminosis causes primary degenerative dementia. Severe emotional trauma may contribute to but does not necessarily cause primary degenerative dementia. Neural degeneration leads to permanent, not transient, changes.

A 10-year-old child is receiving oxygen 2 L/min by way of nasal cannula. The health care provider asks that pulse oximetry be started. What is the appropriate placement for the oximetry probe in a child of this age? 1. Great toe 2. Index finger 3. Radial pulse point 4. Popliteal pulse point

2. Index finger When pulse oximetry is instituted for a child or adult, the index finger is used because the probe is easy to apply and an accurate reading is obtained. The great toes of most 10-year-olds are too large for the probe; the great toes of infants are used for pulse oximetry. The probe must be placed on tissue away from a pulse point. Test-Taking Tip: Start by reading each of the answer options carefully. Usually at least one of them will be clearly wrong. Eliminate this one from consideration. Now you have reduced the number of response choices by one and improved the odds. Continue to analyze the options. If you can eliminate one more choice in a four-option question, you have reduced the odds to 50/50. While you are eliminating the wrong choices, recall often occurs. One of the options may serve as a trigger that causes you to remember what a few seconds ago had seemed completely forgotten.

To reduce the risk of recurrent painful gout attacks, the nurse teaches the client to avoid which foods? Select all that apply. 1. Eggs 2. Liver 3. Cheese 4. Salmon 5. Shellfish

2. Liver 5. Shellfish Like other organ meats, liver is a high-purine food (range of 150 to 1000 mg/100 g) and should be avoided. Shellfish (e.g., shrimp, lobster) are high-purine foods and should be avoided. Eggs have insignificant amounts of purine and are unrestricted. Cheese has insignificant amounts of purine and is unrestricted. Foods that contain a moderate amount of purine (50 to 150 mg/dL), such as salmon, may be eaten four times a week.

When entering a room on a medical unit, the nurse identifies that a client is having a seizure. What should the nurse do in addition to protecting the client from self-injury? Select all that apply. 1. Insert an oral airway 2. Monitor the seizure activity 3. Turn the client on the left side 4. Begin oxygen by mask at 8 L/min 5. Restrain the client's movement

2. Monitor the seizure activity 3. Turn the client on the left side Monitoring of the seizure activity, the body parts involved, the area of its progression, and the length of the episode, as well as the activity of the head and eyes, characteristics of the respiration, and alteration in consciousness provide information that assists in the identification of the type of seizure and, thus, its treatment. Turning the client on the side should be done in order to keep the airway clear. Insertion of an oral airway is contraindicated. Attempting to insert an oral airway may injure the client or the nurse. Do not restrain or try to stop the patient's movement; guide movements if necessary. Beginning oxygen by mask at 8 L/min is unnecessary because breathing does not occur during a seizure; this may be done after the seizure.

Which statement by the unlicensed assistive personnel (UAP) indicates a correct understanding of the UAP's role? "I will: 1. Turn off clients' IVs that have infiltrated." 2. Take clients' vital signs after their procedures are over." 3. Use unit written materials to teach clients before surgery." 4. Help by giving medications to clients who are slow in taking pills."

2. Take clients' vital signs after their procedures are over." Monitoring vital signs after procedures is within the scope of a UAP's role. Registered professional nurses or licensed practical nurses, not UAPs, should perform turning off clients' IVs that have infiltrated. Using unit written materials to teach clients before surgery should be performed by registered professional nurses or licensed practical nurses, not UAPs. Helping by giving medications to clients who are slow in taking pills should be performed by registered professional nurses or licensed practical nurses, not UAPs.

What is the first activity of daily living (ADL) that the nurse should help teach a developmentally disabled 8-year-old child? 1. Dressing 2. Toileting 3. Self-feeding 4. Combing hair

2. Toileting Self-feeding is an early step in the progression of growth and developmental skills. All the steps for acquiring the skills needed to fulfill ADLs should progress in the same order as they do for a child who is not mentally challenged. The difference is the age when the skill is acquired and the difficulty in learning to acquire the skill. Dressing is a more advanced skill than self-feeding; it requires mastery of gross and fine motor skills and hand-eye coordination Toileting is a more advanced skill than self-feeding; it requires control of the anal and urethral sphincters, readiness of psychophysiological factors, and motivation. Combing the hair is a more advanced skill than self-feeding. It requires control of gross and fine motor skills and muscle coordination.

The nurse has provided instructions about back safety to a client. Which client statement indicates understanding of the instructions? 1. "I should carry objects about 18 inches from my body." 2. "I should sleep on my stomach with a firm mattress." 3. "I should carry objects close to my body." 4. "I should pull rather than push when moving heavy objects."

3. "I should carry objects close to my body." By carrying objects close to the center of the body, the client can lessen back strain. Sleeping on the stomach and pulling objects and carrying objects too far away from the body add pressure and strain to the back muscles.

A 20-year-old college student tells the nurse at the college health clinic that he has become increasingly anxious, cannot sleep, and has lost his appetite. He also reports that he cannot concentrate and that his grades have dropped. What question should the nurse ask? 1. "With whom have you shared your feelings of anxiety?" 2. "What have you identified as the cause of your anxiety?" 3. "It must be difficult for you. How long has this been going on?" 4. "Sounds like you're having problems adjusting. Shall we talk about it?"

3. "It must be difficult for you. How long has this been going on?" Expressing sympathy and asking how long the problem has persisted shows recognition of the client's feelings and attempts to collect data. Whom the client has shared the problem with is irrelevant and will not elicit data about the extent of the anxiety. The client may not be able to identify the cause of his anxiety. Anxiety is most often a response to a vague, nonspecific threat. It is too early to identify the cause of the anxiety; crisis intervention with anxious clients requires a more structured approach than "Shall we talk?"

While teaching parents about the developmental milestones of a 15-month-old child, the nurse informs the parents about various activities that their child should be able to do. Which statement of the parent indicates effective learning? 1. "My child can jump with both feet." 2. "My child can walk up stairs with one hand held." 3. "My child can creep up stairs and kneel without support." 4. "My child goes up and down stairs alone with two feet on each step."

3. "My child can creep up stairs and kneel without support." A 15-month-old child has the ability to creep up stairs and kneel without support due to the development of gross motor skills. The child starts jumping with both feet at the age of 30 months. The child will start walking up stairs with one hand held at the age of 18 months. The calf muscles develop sufficiently for the child to walk up and down stairs alone at the age of 24 months.

A nurse hired to work in a metropolitan hospital provides services for a culturally diverse population. One of the nurses on the unit says it is the nurses' responsibility to discourage "these people" from bringing all that "home medicine stuff" to their family members. Which response by the recently hired nurse is most appropriate? 1. "Hospital policies should put a stop to this." 2. Everyone should conform to the prevailing culture." 3. "Nontraditional approaches to health care can be beneficial." 4. "You are right because they may have a negative impact on people's health."

3. "Nontraditional approaches to health care can be beneficial." Studies demonstrate that some nontraditional therapies are effective. Culturally competent professionals should be knowledgeable about other cultures and beliefs. Many health care facilities are incorporating both Western and nontraditional therapies. The statement "Everyone should conform to the prevailing culture" does not value diversity. The statement "You are right because they may have a negative impact on people's health" is judgmental and prejudicial. Some cultural practices may bring comfort to the client and may be beneficial, and they may not interfere with traditional therapy.

A 67-year-old man with type 2 diabetes sadly confides in the nurse that he has been unable to have an erection for several years. What is the best response by the nurse? 1. "At your age sex isn't that important." 2. "Sex isn't everything it's cracked up to be." 3. "You sound upset about not being able to have an erection." 4. "Maybe it's time for you to speak to your doctor about this."

3. "You sound upset about not being able to have an erection." When a client reveals something, it is important for the nurse to gather more information. The response, "You sound upset about not being able to have an erection" promotes further communication. Assessment is the first step of the nursing process. "At your age sex isn't that important" is a subjective, judgmental response that reflects the nurse's view of sexuality in older adults. "Sex isn't what all it's cracked up to be" interjects the nurse's view and violates the concept of neutrality when counseling clients. Having the client speak to his health care provider may be indicated eventually, but first the nurse must obtain more information.

After a mild brain attack (cerebrovascular accident, CVA) a client has difficulty grasping objects with the dominant hand. To increase hand mobility and strength, the nurse should teach the client range-of-motion exercises, specifically: 1. Eversion 2. Supination 3. Opposition 4. Circumduction

3. Opposition Opposition occurs when the thumb, a saddle joint, sequentially touches the tip of each finger of the same hand; the thumb joint movements involved are abduction, rotation, and flexion. Strengthening the thumb facilitates grasping and holding objects in the hand. Eversion involves turning the sole of the foot outward by moving the ankle joint, which is a gliding joint. Supination involves moving the bones of the forearm so that the palm of the hand faces upward when held in front of the body. Circumduction involves movement of the distal part of the bone in a circle while the proximal end remains fixed; circumduction is used with ball-and-socket joints, such as the shoulder and hip.

A client with the diagnosis of dementia of the Alzheimer type, stage 1, is living at home with a grown daughter. To best address the functional and behavioral changes associated with this stage, the nurse should encourage the daughter to: 1. Place the mother in a long-term care facility. 2. Provide for the mother's basic physical needs. 3. Post a schedule of the mother's daily activities. 4. Perform care so the mother does not need to make decisions.

3. Post a schedule of the mother's daily activities. In stage 1, clients have mild cognitive impairment with short-term memory loss; establishing a daily routine, posting it, and adhering to it provides a concrete, structured approach. Placing the mother in a long-term care facility may be required during stage 3 or the end of stage 2 if the daughter is unable to cope with the mother's functional and behavioral changes. In stage 1, clients can provide for their own basic activities of daily living such as bathing, dressing, and eating. These clients can make simple decisions in stage 1, and they have the right to make choices; an authoritarian approach may promote regression, anxiety, depression, or anger. Test-Taking Tip: Be alert for details. Details provided in the stem of the item, such as behavioral changes or clinical changes (or both) within a certain time period, can provide a clue to the most appropriate response or, in some cases, responses.

The bed alarm is ringing because of an elderly client attempting to get out of bed. A nurse enters the room and finds the client agitated and confused. The family member is upset and states, "He has never been like this. I don't know what to do." After getting the client back into bed, which of these nursing actions are appropriate? 1. Explain to the family that it is common for elderly clients to get confused while in the hospital. 2. Ask the family member to step out of the room so the client can rest. 3. Request the nursing assistant to stay with the client, while the nurse calls the primary health care provider. 4. Place a vest restraint on the client to prevent the client from falling out of bed

3. Request the nursing assistant to stay with the client, while the nurse calls the primary health care provider. Because this is new for the client, the nurse should notify the primary health care provider. The client should be monitored continually to prevent falling or injuring himself. This is an appropriate task to delegate to a nursing assistant. Since this is new for the client, reassuring the family that elderly clients often get confused in the hospital is not helpful. Evidence-based practice has shown that having a family member with the client is helpful. Therefore, the family member should be encouraged to stay with the client. Placing a restraint on the client should be done as a last resort and not instituted without a primary health care provider's prescription.

A client with cancer of the prostate requests the urinal at frequent intervals but either does not void or voids in very small amounts. What does the nurse conclude is most likely the causative factor? 1. Edema 2. Dysuria 3. Retention 4. Suppression

3. Retention An enlarged prostate constricts the urethra, interfering with urine flow and causing retention. When the bladder fills and approaches capacity, small amounts can be voided, but the bladder never empties completely. Edema does not cause the client to void frequently in small amounts. Dysuria is painful or difficult urination, which is not part of the client's responses. The urge to void is caused by stimulation of the stretch receptors as the bladder fills with urine; in suppression, little or no urine is produced. Test-Taking Tip: Practicing a few relaxation techniques may prove helpful on the day of an examination. Relaxation techniques such as deep breathing, imagery, head rolling, shoulder shrugging, rotating and stretching of the neck, leg lifts, and heel lifts with feet flat on the floor can effectively reduce tension while causing little or no distraction to those around you. It is recommended that you practice one or two of these techniques intermittently to avoid becoming tense. The more anxious and tense you become, the longer it will take you to relax.

A client is prescribed the benzodiazepine Alprazolam (Xanax) for the management of panic attacks. The nurse is confident that the medication information discussed has been understood when the client: 1. is observed removing the pepperoni from his pizza 2. asks for an extra bottle of flavored water to drink with dinner 3. requests a prescription for oral birth control before being discharged 4. is heard saying that chewable antacids may be taken to relieve heartburn

3. requests a prescription for oral birth control before being discharged Benzodiazepines increase the risk of congenital anomalies and so should not be taken by pregnant women. Refraining from eating pepperoni is appropriate for people taking monoamine oxidase inhibitors, by whom tyramine is to be strictly avoided. Appropriate hydration is critical for those taking lithium. Antacids can affect both absorption and metabolism of benzodiazepines and should be avoided.

A nurse teaches a teenager who is undergoing chemotherapy about the need for special mouth care because of the potential for lesions. The nurse concludes that the instructions have been understood when the teenager says: 1. "I'll brush my teeth with baking soda." 2. "I"ll use mouthwash to rinse my mouth." 3. "I'll swish my mouth out with hydrogen peroxide." 4. "I'll use a soft-bristled toothbrush to clean my teeth."

4. "I'll use a soft-bristled toothbrush to clean my teeth." Soft bristles are less irritating to the oral mucosa and less likely to cause trauma than irritating substances are. Baking soda, mouthwash, and hydrogen peroxide are all caustic substances that may irritate the mucosa.

Several recently licensed registered nurses are discussing whether they should purchase personal professional liability insurance. Which statement indicates the most accurate information about professional liability insurance? 1. "If you have liability insurance, you are more likely to be sued." 2. "Your employer provides you with the liability insurance you will need." 3. "Liability insurance is not available for nursing professionals working in a hospital." 4. "Personal liability insurance offers representation if the State Board of Nursing files charges against you."

4. "Personal liability insurance offers representation if the State Board of Nursing files charges against you." Personal liability insurance will represent a nurse before the State Board of Nursing, whereas employee liability insurance will not. A nurse can be sued whether or not the nurse has liability insurance. Employer liability insurance will represent the nurse in charges related to employment, not charges brought by the State Board of Nursing. Liability insurance is available for all nurses.

What should a nurse recommend to best help a client during the period immediately after a spouse's death? 1. Crisis counseling 2. Family counseling 3. Marital counseling 4. Bereavement counseling

4. Bereavement counseling Bereavement counseling involves being a part of a group of people who also have sustained a loss; members provide support to each other. Individual counseling will not provide the support that a group provides; group counseling may last longer than crisis intervention. The information provided did not indicate other family members. Marital counseling involves both a husband and a wife.

A client has a large open abdominal wound. The health care provider's prescription states to cleanse the wound with normal saline, pack the wound with damp gauze, cover with abdominal pads, and secure with Montgomery straps twice a day. What should the nurse do to maintain sterility when changing the dressing? 1. Use a separate square gauze to cleanse each half of the wound. 2. Apply new Montgomery straps each time the dressing is changed. 3. Hold the wet gauze with the tips of the forceps higher than the wrist. 4. Cleanse the wound with wet sterile gauze from the center of the wound outward.

4. Cleanse the wound with wet sterile gauze from the center of the wound outward. Wounds should be cleansed from the center outward or from the top to the bottom; this ensures that cleansing is done from the least to the most contaminated area. A new sterile gauze square should be used for each swipe of the wound. More than two gauze squares will be needed to cleanse a large abdominal wound. Using the same gauze square again will contaminate the wound. Montgomery straps are changed only when they become soiled or begin to loosen from the client's skin. Montgomery straps are applied to each side of a wound. The central sections are folded back when the dressing is changed. When folded back in place over the new dressing and secured with a tie they keep the dressing in place without having to replace the tape each time the dressing is changed. Forceps should always be held with the tips lower than the wrist. If held with the wrist lower than the tips of the forceps, cleansing solution can flow down the instrument and hand and arm of the nurse, contaminating the fluid. When the wrist is then raised above the forceps, the contaminated fluid will flow back down the forceps into the wound.

A nurse is caring for a postoperative client who had general anesthesia during surgery. What independent nursing intervention may prevent an accumulation of secretions? 1. Postural drainage 2. Cupping the chest 3. Nasotracheal suctioning 4. Frequent changes of position

4. Frequent changes of position Frequent changes of position minimize pooling of respiratory secretions and maximize chest expansion, which aids in the removal of secretions; this helps maintain the airway and is an independent nursing function. Postural drainage and cupping the chest are part of pulmonary therapy that requires a health care provider's prescription. Nasotracheal suctioning will remove secretions once they accumulate in the upper airway, not prevent their accumulation.

During change of shift report the night nurse indicates that a client cannot tolerate the prescribed intermittent tube feedings. The nurse receiving report should first: 1. Suggest that an antiemetic be prescribed 2. Change the feeding schedule to omit nights 3. Request that the type of solution be changed 4. Gather more data from the night nurse about the technique used

4. Gather more data from the night nurse about the technique used Rapid administration, incorrect positioning, and inadequate solution temperature are common causes of intolerance to tube feedings. Although suggesting that an antiemetic be prescribed may be done eventually, the feeding technique should be assessed first. Feedings generally are tolerated better if given frequently in small amounts over the entire 24 hours. Although changing the feeding schedule to omit nights and requesting that the type of solution be changed may be done eventually, the feeding technique should be assessed first.

A nurse is caring for an elderly client who has constipation. Which independent nursing intervention helps to reestablish normal bowel pattern? 1. Administer a mineral oil enema. 2. Offer one cup of fluid every hour. 3. Manually remove fecal impactions. 4. Offer a cup of prune juice

4. Offer a cup of prune juice Prune juice does not require a health practitioner order and helps to promote bowel movement because it contains sorbitol that increases water retention in feces. Administration of mineral enema requires an order from a health care provider. Encouraging the client's fluid intake by offering one cup of fluid every hour is helpful in preventing constipation but not as effective in resolving constipation as a prune juice. Removing impactions does not establish regular bowel patterns

A client using fentanyl (Duragesic) transdermal patches for pain management in late-stage cancer dies. What should the hospice nurse who is caring for this client do about the patch? 1. Tell the family to remove and dispose of the patch 2. Leave the patch in place for the mortician to remove 3. Have the family return the patch to the pharmacy for disposal 4. Remove and dispose of the patch in an appropriate receptacle

4. Remove and dispose of the patch in an appropriate receptacle. The nurse should remove and dispose of the patch in a manner that protects self and others from exposure to the fentanyl. Having the family remove and dispose of the patch or having the mortician remove the patch are not the responsibility of nonprofessionals because they do not know how to protect themselves and others from exposure to the fentanyl. It is unnecessary to return a used fentanyl patch.

A laboring client has asked the nurse to help her use a nonpharmacological strategy for pain management. Name the sensory simulation strategy. 1. Gently massage of the abdomen 2. Biofeedback-assisted relaxation techniques 3. Application of a heat pack to the lower back 4. Selecting a focal point and beginning breathing techniques

4. Selecting a focal point and beginning breathing techniques Use of a focal point and breathing techniques are sensory simulation strategies. Heat and massage are cutaneous stimulation strategies; biofeedback-assisted relaxation is a cognitive strategy.