HESI Fundamentals

The nurse plans to administer diazepam, 4 mg IV push, to a client with severe anxiety. How many milliliters should the nurse administer? _____ (Round to the nearest tenth.) Available: diazepam injection 2 mL dosette ampule, 10 mg/2 mL (5 mg/mL)

Answer: 0.8 mL Rationale: (1 mL x 4 mg) / 5 mg = 0.8 mL.

The nurse is making an initial daily assessment at 07:15 and notes 550 mL of LR running at 75 mL an hour. At what time, in military time, will the nurse hang the next bag of IV fluid? _____

Answer: 14:35 Rationale: X hr = 1 hr x 550 mL / 75 mL = 7.33 hr 60 min. x 0.33333 = 19.99 min. = 20 min. 7 hr 20 min + 07:15 = 14:35

How many mL will the nurse document on the client's intake and output record from the items listed? _____ 1200 mL water 4-ounce container of gelatin 8 ounces of orange juice 355 mL can of soda 1 cup of soup

Answer: 2155 mL Rationale: 1200 + 240 (8 oz.) + 240 (1 cup) + 120 (4 oz.) + 355 = 2155 mL

The goal is for the client to take in 1500 calories/day administered through by a feeding tube. The concentration of the feeding is 1.5 calories/mL. How many mL per hour will the nurse need to set the infusion pump to deliver the feeding over 18 hours? _____ Enter a whole number.

Answer: 56 mL/hr. Rationale: X mL/hr = 1 mL/1.5 cal x 1500 cal/18hr = 1500/27 = 55.55 = 56 mL/hr.

Which nonverbal action should the nurse implement to demonstrate active listening? A. Sit facing the client. B. Cross arms and legs. C. Avoid eye contact. D. Lean back in the chair.

Answer: A Rationale: Active listening is conveyed using attentive verbal and nonverbal communication techniques. To facilitate therapeutic communication and attentiveness, the nurse should sit facing the client, which lets the client know that the nurse is there to listen. Active listening skills include postures that are open to the client, such as keeping the arms open and relaxed, not option B, and leaning toward the client, not option D. To communicate involvement and willingness to listen to the client, eye contact should be established and maintained.

The nurse is obtaining a lie-sit-stand blood pressure reading on a client. Which action is most important for the nurse to take for this client? A. Stay with the client while the client is standing. B. Record the findings on the graphic sheet in the chart. C. Keep the blood pressure cuff on the same arm. D. Record changes in the client's pulse rate.

Answer: A Rationale: Although all these measures are important, option A is most important because it helps ensure client safety. Option B is necessary but does not have the priority of option A. Options C and D are important measures to ensure accuracy of the recording but are of less importance than providing client safety.

An older client who had abdominal surgery 3 days earlier was given a barbiturate for sleep and is now requesting to go to the bathroom. What is the priority nursing action for this client? A. Assist the client to walk to the bathroom and do not leave the client alone. B. Request that the UAP assist the client onto a bedpan. C. Ask if the client needs to have a bowel movement or void. D. Assess the client's bladder to determine if the client needs to urinate.

Answer: A Rationale: Barbiturates cause central nervous system (CNS) depression, and individuals taking these medications are at greater risk for falls. The nurse should assist the client to the bathroom. A bedpan is not necessary as long as safety is ensured. Whether the client needs to void or have a bowel movement, option C is irrelevant in terms of meeting this client's safety needs. There is no indication that this client cannot voice her or his needs, so assessment of the bladder is not needed.

In taking a client's history, the nurse asks about the stool characteristics. Which description should the nurse report to the healthcare provider as soon as possible? A. Daily black, sticky stool. B. Daily dark brown stool. C. Firm brown stool every other day. D. Soft light brown stool twice a day.

Answer: A Rationale: Black sticky stool (melena) is a sign of gastrointestinal bleeding and should be reported to the healthcare provider promptly. Option C indicates constipation, which is a lesser priority. Options B and D are variations of normal.

The nurse is working at a community-based clinic. Which client's spiritual well-being concerns the nurse the most? A. Roman Catholic woman considering an abortion. B. Jewish man considering hospice care for his wife. C. Seventh-day Adventist who needs a blood transfusion. D. Muslim man who needs a total knee replacement.

Answer: A Rationale: In the Roman Catholic religion, any type of abortion is prohibited, so facing this decision may place the client at risk for spiritual distress. There is no prohibition of hospice care for members of the Jewish faith. Jehovah's Witnesses, not Seventh-day Adventists, prohibit blood transfusions. There is no conflict in the Muslim faith with regard to joint replacement.

A hospitalized client has had difficulty falling asleep for two nights and is becoming irritable and restless. Which action by the nurse is best? A. Determine the client's usual bedtime routine and include these rituals in the plan of care as safety allows. B. Instruct the UAP not to wake the client under any circumstances during the night. C. Place a "Do Not Disturb" sign on the door and change assessments from every 4 to 8 hours. D. Encourage the client to avoid pain medication during the day, which might increase daytime napping.

Answer: A Rationale: Including habitual rituals that do not interfere with the client's care or safety may allow the client to go to sleep faster and increase the quality of care. Options B, C, and D decrease the client's standard of care and compromise safety.

The nurse is planning care for a client with an indwelling urinary catheter. Which nursing action has the highest priority? A. Assist the client with daily cleansing. B. Tell the client that incontinence happens with aging. C. Offer 200 mL of fluid every 2 hours while awake. D. Take the client's temperature every 4 hours.

Answer: A Rationale: Indwelling urinary catheters are a major source of infection so cleaning is important. So Option A is correct. Option B may or may not be true for the client. Option C is not affected by an indwelling catheter. Option D is not routine practice unless ordered.

A nurse is working in an occupational health clinic when an employee walks in and states, "I was walking outside, and I believe I was just struck by lightning." The client is alert but reports feeling faint. Which assessment will the nurse perform first? A. Pulse characteristics. B. Open airway. C. Entrance and exit wounds. D. Cervical spine injury.

Answer: A Rationale: Lightning is a jolt of electrical current and can produce a "natural" defibrillation, so assessment of the pulse rate and regularity is a priority. Because the client is talking, he has an open airway so that assessment is not necessary. Assessing for options C and D should occur after assessing for adequate circulation.

The nurse is aware that malnutrition is a common problem among clients served by a community health clinic for the homeless. Which laboratory value is the most reliable indicator of chronic protein malnutrition? A. Low serum albumin level. B. Low serum transferrin level. C. High hemoglobin level. D. High cholesterol level.

Answer: A Rationale: Long-term protein deficiency is required to cause significantly lowered serum albumin levels. Albumin is made by the liver only when adequate amounts of amino acids (from protein breakdown) are available. Albumin has a long half-life, so acute protein loss does not significantly alter serum levels. Option B is a serum protein with a half-life of only 8-10 days, so it will drop with an acute protein deficiency. Options C and D are not clinical measures of protein malnutrition.

A client is laughing at a television program when the evening nurse enters the room. The client states, "My foot is hurting. I would like a pain pill." How should the nurse respond? A. Ask the client to rate the pain using a 1-10 scale. B. Encourage the client to wait until bedtime for the pill. C. Attend to an acutely ill client's needs first because this client is laughing. D. Instruct the client in the use of deep breathing exercises for pain control.

Answer: A Rationale: Obtaining a subjective estimate of the pain experience by asking the client to rate his pain helps the nurse determine which pain medication should be administered and also provides a baseline for evaluating the effectiveness of the medication. Medicating for pain should not be delayed so that it can be used as a sleep medication. Option C is judgmental. Option D should be used as an adjunct to pain medication, not instead of medication.

While reviewing the side effects of a newly prescribed medication, a 72-year-old client notes that one of the side effects is a reduction in sexual drive. Which is the best response by the nurse? A. "How will this affect your present sexual activity?" B. "How active is your current sex life?" C. "How has your sex life changed as you have become older?" D. "Tell me about your sexual needs as an older adult."

Answer: A Rationale: Option A offers an open-ended question most relevant to the client's statement. Option B does not offer the client the opportunity to express concerns. Options C and D are even less relevant to the client's statement.

The nurse manager of a skilled nursing (chronic care) unit is instructing UAPs on ways to prevent complications of immobility. Which action should be included in this instruction? A. Perform range-of-motion exercises to prevent contractures. B. Decrease the client's fluid intake to prevent diarrhea. C. Massage the client's legs to reduce embolism occurrence. D. Turn the client from side to back every shift.

Answer: A Rationale: Performing range-of-motion exercises is beneficial in reducing contractures around joints. Options B, C, and D are all potentially harmful practices that place the immobile client at risk of complications.

The nurse is providing care to a client receiving sq heparin every 12 hours at 8:00 am and 8:00 pm. The healthcare provider prescribes an aPTT test. At what time will the nurse plan on drawing the test? A. 7:00 am. B. 9:00 am. C. 12:00 noon. D. 2:00 pm.

Answer: A Rationale: The aPTT test should be drawn 1 hour before the scheduled dose.

When emptying 350 mL of pale-yellow urine from a client's urinal, the nurse notes that this is the first time the client has voided in 4 hours. Which action should the nurse take next? A. Record the amount on the client's fluid output record. B. Encourage the client to increase oral fluid intake. C. Notify the healthcare provider of the findings. D. Palpate the client's bladder for distention.

Answer: A Rationale: The amount and appearance of the client's urine output are within normal limits, so the nurse should record the output, but no additional action is needed.

The nurse is concerned the client will develop a nosocomial infection. Which nursing action is best for the nurse to take when providing care for an incontinent client? A. Maintain standard precautions. B. Initiate contact isolation measures. C. Insert and indwelling urinary catheter. D. Instruct client in the use of adult diapers.

Answer: A Rationale: The best action to decrease the risk of infection in vulnerable clients is handwashing. Option B is not necessary unless the client has an infection. Option C increases the risk of infection. Option D does not reduce the risk of infection.

The nurse is using the Glasgow Coma Scale to perform a neurologic assessment. A comatose client winces and pulls away from a painful stimulus. Which action should the nurse take next? A. Document that the client responds to painful stimulus. B. Observe the client's response to verbal stimulation. C. Place the client on seizure precautions for 24 hours. D. Report decorticate posturing to the healthcare provider.

Answer: A Rationale: The client has demonstrated a purposeful response to pain, which should be documented as such. Response to painful stimulus is assessed after response to verbal stimulus, not before. There is no indication for placing the client on seizure precautions. Reporting decorticate posturing to the healthcare provider is a non-purposeful movement.

While conducting an intake assessment of an adult client at a community mental health clinic, the nurse notes that the client's affect is flat, responds to questions with short answers, and reports problems with sleeping. At the end of the intake assessment, the client reveals the loss of a life partner 1 month ago. What is the nurse's best action for this client? A. Encourage the client to see the clinic's grief counselor. B. Determine if the client has a family history of suicide attempts. C. Inquire about whether the life partner was suffering from AIDS. D. Consult with the healthcare provider about the client's need for antidepressant medications.

Answer: A Rationale: The client is exhibiting normal grieving behaviors, so referral to a grief counselor is the most important intervention for the nurse to implement. Option B is indicated but is not a high-priority intervention. Option C is irrelevant at this time but might be important when determining the client's risk for contracting the illness. An antidepressant may be indicated, depending on further assessment, but grief counseling is a better action at this time because grief is an expected reaction to the loss of a loved one.

By rolling contaminated gloves inside-out, the nurse is affecting which step in the chain of infection? A. Mode of transmission. B. Portal of entry. C. Reservoir. D. Portal of exit.

Answer: A Rationale: The contaminated gloves serve as the mode of transmission from the portal of exit of the reservoir to a portal of entry.

The nurse is preparing to administer a new medication through an existing IV line containing a vasopressor. What action must the nurse take first? A. Flush the line with normal saline at the same rate as the vasopressor. B. Administer the medication at the prescribed IV rate. C. Start a second IV line to administer the new medication. D. Call the healthcare provider to change the order for the new medication to PO.

Answer: A Rationale: The medication in the IV line between the post and the patient contains the vasopressor medication. The nurse must continue to administer the vasopressor medication at the prescribed rate by injecting normal saline at that rate. Once the line is clear of the vasopressor medication, then the nurse can inject the new medication at the prescribed rate. There is no need to start a second IV or change the route of administration.

After the nurse tells an older client that an IV line needs to be inserted, the client becomes very apprehensive, loudly verbalizing a dislike for all healthcare providers and nurses. How should the nurse respond? A. Ask the client what about the IV makes her anxious. B. Concentrate on completing the insertion as efficiently as possible. C. Calmly reassure the client that the discomfort will be temporary. D. Tell the client a joke as a means of distraction from the procedure.

Answer: A Rationale: The nurse should respond by asking why the client is apprehensive. After responding calmly to the client's apprehension, the nurse may implement to ensure safe completion of the procedure.

The nurse is preparing to change the bed of a client who is nonresponsive and receiving continuous enteral tube feedings. What step must the nurse take prior to changing the bed? A. Stop the feeding for 15 minutes prior to changing the bed. B. Obtain extra linens to absorb any feeding that leaks out of the mouth. C. Ask another nurse to help with changing the bed. D. Ask the client's spouse to leave the room during the bed change.

Answer: A Rationale: This client is at risk for aspiration during the bed change as the head of the bed must be lowered. Stopping the feeding will help decompress the stomach and decrease the risk. The client should not be leaking fluid out of the mouth. Check the feeding for residual. If the feeding is not moving out of the stomach, notify the healthcare provider. Assistance with changing a bed is nice for the nurse but is not imperative for the client's safety. The spouse does not need to leave the room.

In assisting an older adult client prepare to take a tub bath, which nursing action is most important? A. Check the bath water temperature. B. Shut the bathroom door. C. Ensure that the client has voided. D. Provide extra towels.

Answer: A Rationale: To prevent burns or excessive chilling, the nurse must check the bath water temperature. Options B, C, and D promote comfort and privacy and are important interventions but are of less priority than promoting safety.

Which steps should the nurse take when administering ear drops to an adult client? (Select all that apply.) A. Place the client in a side-lying position. B. Pull the auricle upward and outward. C. Hold the dropper 6 cm above the ear canal. D. Place a cotton ball into the inner ear canal. E. Pull the auricle down and back.

Answer: A, B Rationale: The correct answers (A and B) are the appropriate administration of ear drops. The dropper should be held 1 cm (½ inch) above the ear canal (C). A cotton ball should be placed in the outermost canal (D). The auricle is pulled down and back for a child younger than 3 years of age, but not an adult (E).

The nurse is performing an intake interview for a newly admitted client to the rehabilitation unit. Which questions will the nurse include in the interview? (Select all that apply.) A. "When do you usually go to bed? And, when do you usually wake up?" B. "Do you usually bathe/shower in the morning or in the evening?" C. "Do you have any intolerance to food that we need to know about?" D. "How long do you think you will be here on the rehabilitation unit?" E. "Do you urinate every hour, on the hour, when you are awake?"

Answer: A, B, C, D Rationale: The goal of the intake interview is to understand the client's daily routines so those routines can be observed and upheld while residing on the rehabilitation unit. Asking about how long the client will be on the rehabilitation unit helps the nurse to understand the client's expectations of the duration of the stay. Urinary and bowel patterns are important to understand, but the issue with this assessment is the frequency of urination. The better question is, "How often do you urinate when you are awake?"

The nurse is talking with the spouse of a client admitted to the long-term care center. The client has end-stage renal cancer and is admitted for palliative care while awaiting hospice placement. The client often moans and groans but is otherwise noncommunicative and somnolent. What will the nurse include in the spouse's teaching regarding the care of the client? (Select all that apply.) A. Repositioning every 2 hours. B. Round-the-clock pain medication administration. C. Assessment for skin breakdown. D. Back rubs three times a day. E. Bathing twice a day.

Answer: A, B, C, D Rationale: The nurse must cleanse soiled areas to remove any irritants; a bath twice a day can dry out the skin. The goal of palliative care is to make the client comfortable, and not treat the cause of the condition. The client will be on bed rest because of the client's debilitated condition. Skin breakdown is a nursing concern. Measures to prevent skin breakdown should be included in this client's plan of care.

The nurse is providing care to clients at a day treatment center. One of the clients who is usually talkative and eats well is now confused and did not eat lunch. The nurse learns these are new findings as of today. What are the next nursing actions? (Select all that apply.) A. Obtain a clean catch urine sample. B. Take the client's vital signs. C. Assess for the initiation of any new medications. D. Obtain an oxygen saturation. E. Call the client's children to report the confusion. F. Call the facility's bus service to return the client home.

Answer: A, B, C, D Rationale: Until the assessment is complete, there is no need to contact the client's children. With the client's state of confusion, the nurse cannot dismiss the client to home. The client is exhibiting signs of an infection with the confusion and anorexia. The remaining assessments will help the nurse determine if the client has an infection or if there is another reason for the confusion.

The nurse is reviewing a client's lab results from 2 hours ago. The sodium level is 128 mEq/L. The nurse should be alert for which findings? (Select all that apply.) A. Weakness in the hands and feet. B. +1 reflexes to the patella. C. Headache. D. Muscle twitching. E. Nausea. F. Facial redness.

Answer: A, B, C, E Rationale: The client is hyponatremic. All are signs of hyponatremia except muscle twitching and facial redness.

The clinic nurse is reviewing an antibiotic medication prescribed to a client with a urinary tract infection. What instructions will the nurse include in the client's teaching? (Select all that apply.) A. Take all of the medication as prescribed, especially when you start feeling better. B. Take the medication with 8 ounce/240 mL of water. C. Call poison control if you start itching, develop hives, or have difficulty swallowing. D. Keep this medication out of the reach of small children, preferably in a locked cabinet. E. Call your healthcare provider (HCP) when your symptoms subside.

Answer: A, B, D Rationale: Once symptoms subside, it is sometime hard to remember to take antibiotics. The client needs to take the full course of antibiotics to achieve the maximum effect. Drinking a glass of water will help keep the body hydrated. All medication should be kept out of reach, preferably in a locked cabinet. The client needs to call the healthcare provider in the event of an allergic reaction to the antibiotic. The medication is prescribed to treat the infection. There is no need to notify the HCP when the medication is having the desired effects.

The postoperative client states to the nurse, "When I had surgery last year I got constipated. It was miserable. What can I do to avoid constipation after this surgery this time?" (Select all that apply.) A. "Drink approximately 3000 mL of non-caffeinated fluid per day." B. "I will make sure that you get out of your bed and walk for 10 minutes, six times per day." C. "I will administer your pain medication even if you do not have any pain." D. "I will ask your healthcare provider for a prescription of docusate." E. "When you are on a regular diet, make sure you order plenty of fruits and vegetables." F. "When you are resting in bed, make sure you are flat on your back."

Answer: A, B, D, E Rationale: Pain medication can be constipating, and should only be taken when needed. When in bed, use gravity to help move the contents of the bowel by sitting upright. The remaining selections are correct. When postoperative, it may take up to 48 hours after a general diet is started to have a bowel movement.

A 75-year-old client states to the nurse, "I am just not hungry anymore." The client has lost 10 pounds/4.53 kg in the past 4 months. Which snacks will the nurse recommend to the client? (Select all that apply.) A. Nuts B. Milkshakes C. Chocolate candy bar. D. Peanut butter and crackers. E. Glass of whole fat milk.

Answer: A, B, D, E Rationale: The nurse must recommend high calorie/high nutrition foods for this client who is unintentionally losing weight. The candy bar is high calorie, but empty in nutritional value. The remaining selections are high calorie/high nutrition.

A 76-year-old client has returned from surgery. The nurse plans on decreasing the chance of respiratory compromise for this client. What will the nurse include in this client's plan of care? (Select all that apply.) A. Raise the head of the bed to no less than a 45 angle. B. Have the client use an incentive spirometer 10 times every hour while awake. C. Limit total fluid intake to no more than 1000 mL/day. D. Have the client sit on the side of the bed instead of getting up and walking. E. Ask the client to take deep breaths and cough five times every hour while awake.

Answer: A, B, E Rationale: As long as the client is not on a fluid restriction, offer no less than 2000 mL of fluid to keep the body well hydrated and keep respiratory secretions loose. Ambulation is key for this client. Sitting at the side of the bed is not a replacement for ambulating. Having the client sit up helps expand the lungs. Taking deep breaths, through coughing or incentive spirometry, helps expand the lungs and decrease atelectasis.

The postoperative client is placed on a clear liquid diet. Which selections will the nurse select for the client? (Select all that apply.) A. Apple juice. B. Popsicles. C. Vanilla pudding. D. Tomato soup. E. Gelatin. F. Black coffee.

Answer: A, B, E, F Rationale: Clear liquids are transparent and liquid at room temperature. Tomato soup and vanilla pudding are included in a full liquid diet.

The nurse is preparing to administer a bolus tube feeding. What steps must the nurse include prior to administering the feeding? (Select all that apply.) A. Aspirate the stomach contents. B. Assess bowel sounds. C. Position the client in semi-Fowler's position. D. Irrigate the lumen after the contents are replaced. E. Warm the feeding to room temperature. F. Assess the pH of the stomach contents.

Answer: A, B, E, F Rationale: The client needs to be in high Fowler's position to decrease the risk of aspiration. Irrigation of the lumen is only necessary if there is an obstruction. The contents were replaced, so there is no suspicion of obstruction. The remaining steps are correct.

For the client with a sodium level of 128 mEq/L, which meal selections should the nurse suggest to the client? (Select all that apply.) A. Bacon, egg, and cheese biscuit. B. Chinese chicken and vegetables, with rice and soy sauce. C. Strawberry, spinach salad with yogurt-based blue cheese dressing. D. Chicken salad stuffed fresh tomato with a side of celery stalks. E. Grilled tilapia with a fresh green side salad. F. Grilled hot dog on a bun with ketchup and mustard.

Answer: A, B, F Rationale: The client is hyponatremic and additional salt is needed in the diet. Fresh fruits and vegetables are low in sodium. Bacon, soy, and hot dogs with ketchup and mustard are high in sodium.

The nurse is providing care to a client immediately after a total right mastectomy. What steps will the nurse include when positioning the client? (Select all that apply.) A. Raise the head of the bed 30-45 degrees. B. Roll the client to her right side and place a pillow behind her back. C. Elevate her right arm under two pillows. D. Require the client to stay in bed for 72 hours post procedure. E. Place a sandbag on the incision.

Answer: A, C Rationale: The client must stay on her back or on the unaffected side, not on the operative side. Mobility as tolerated; there is no need to remain immobile. A sandbag is used when there is risk of bleeding from the wound. There is no mention of that risk in the stem. Sitting up and elevating the arm will help lymph drainage.

The postoperative nurse is reviewing the use of an incentive spirometer. Which instructions will the nurse include in the client's teaching plan? (Select all that apply.) A. Sit in an upright position. B. Cough deeply three times. C. Hold breath for 5 seconds after inhaling on the spirometer. D. Place mouth securely around the mouthpiece of the spirometer. E. Remove mouth from mouthpiece and exhale through the nose.

Answer: A, C, D Rationale: After the spirometer is used the nurse can encourage deep coughing. The client should exhale through pursed lips. The remaining steps are correct.

The spouse is at the bedside of the client who just died. The hospice nurse states to the spouse, "I know your children want to come over and say goodbye before we call the funeral home. Just let me know when you are ready for me to prepare the body." What steps will the nurse include in the postmortem care? (Select all that apply.) A. Remove the existing indwelling urinary catheter. B. Wash the genitalia only. C. Close the client's eyes. D. Remove soiled padding under the client. E. Place a dressing over the abdominal scar.

Answer: A, C, D Rationale: Postmortem care includes making the client ready for the family to view prior to the client's transfer to the mortuary. The nurse need to make sure the client's body is completely washed, and all dressings and all tubes, i.e. indwelling urinary, NG, IV, are removed. As the client may excrete contents from the bowel and the bladder during the dying process, remove all soiled pads and bedding from under the client and replace with fresh items. Make sure the client's eyes are closed.

The nurse evaluates the insertion site of an IV catheter and suspects the IV is infiltrated. Which findings support the evaluation? (Select all that apply.) A. The area around the insertion site is swollen. B. There is bruising 1 inch below the insertion site. C. The insertion site is cool to the touch. D. The client complains of a burning pain at the site. E. Redness is noted in the area of the insertion site. F. Blood is noted in the IV tubing when the IV bag is lowered.

Answer: A, C, D, E Rationale: Bruising is an accumulation of blood under the skin, most likely from oozing with the insertion of the IV. When blood is noted in the IV tubing when the IV bag is lowered, that is a sign of patency. The remaining signs are related to infiltration.

The nurse is providing care to a client who had major abdominal surgery. Upon return from the recovery room, the client's vital signs were at the preoperative baseline. The client was sleepy, but arousable, and the skin was warm and dry to the touch. At the 1-hour post admission assessment the nurse notes: heart rate 120 and thready, B/P 70/40 mm Hg, and the skin is cool and clammy to the touch. What are the priority nursing actions? (Select all that apply.) A. Call the healthcare provider. B. Elevate the head of the bed. C. Observe for restlessness/confusion. D. Administer oxygen by re-breather mask. E. Observe the abdominal bandage.

Answer: A, C, D, E Rationale: The client is showing signs of hemorrhagic shock. This is a medical emergency. The head of bed may need to be lowered or placed in Trendelenburg position to increase circulation to the brain. The remaining selections are correct.

The client reports to the clinic nurse, "I sleep for about 2 hours and then I have to get up to use the bathroom. I repeat that pattern about three to four times per night." What questions will the nurse include in this client's assessment? (Select all that apply.) A. "How much fluid do you drink after 8:00 in the evening?" B. "Does your spouse wake up with you, and use the bathroom after you?" C. "What time of day do you take your water pill?" D. "Do you drink any alcoholic beverages in the evening?" E. "When did this pattern of urination start?" F. "Do you have any itching or burning when you urinate?"

Answer: A, C, D, E, F Rationale: Asking if the spouse also gets up at night does not relate to the clients' pattern of frequency of urination at night. The goal of the assessment is to try and understand the client's urinary usual patterns and to determine if there are any modifiable factors that can decrease the frequency of urinating at night. Urinary frequency is also a sign of a urinary tract infection.

The nurse is orienting a new graduate to the reporting regulations often seen in the emergency department. Which clients will the nurse need to report to the nurse manager/supervisor to alert the proper authorities? (Select all that apply.) A. A 7-year-old who states, "I get beat up by my parents all the time." The child has bruising on the back in various stages of healing. B. An 88-year-old who states, "My child lives 5 minutes away no longer stops to visit. My days are long and lonely." C. A 40-year-old who states, "I was in an argument with my sibling and the next thing I knew I was shot in the shoulder." D. An 18-year-old who states, "Once I turned 18 my parents demanded I leave their home. I was no longer welcomed there." E. A 30-year-old who states, "The brawl was worth the stab wound I got. My family has never liked that family. It is just that way."

Answer: A, C, E Rationale: Nurses are mandatory reporters and must notify in the event of child and elder abuse, domestic violence, animal bites, gun shot and stab wounds, assault, and homicides.

The nurse is preparing an IV solution containing 10 mEq of potassium in 100 mL of normal saline. Which findings would concern the nurse? (Select all that apply.) A. A red and swollen peripheral IV site. B. An order to infuse the solution at 50 mL/hr. C. Starting the infusion without an infusion device. D. Inverting the potassium solution every 30 minutes while infusing. E. The solution is a lemon-yellow color.

Answer: A, C, E Rationale: Potassium can cause phlebitis. The red swollen IV site is showing signs infection. The IV site would need to be changed before starting the solution. Potassium solutions must infuse with an infusion devise to avoid an accidental bolus infusion. Potassium solution should be clear, and not lemon yellow. The remaining selections are not concerning to the nurse.

The nurse is preparing to administer 0.32 mL of medication subcutaneously. What supplies will the nurse need to deliver the medication? (Select all that apply.) A. A 1 mL syringe. B. A 3 mL syringe. C. Alcohol prep pads. D. Sterile gloves. E. A 24-gauge 3/4" needle. F. A 20-gauge 1" needle.

Answer: A, C, E Rationale: The best syringe is a 1 mL syringe as it is marked in 100ths; 3 mL syringes are marked off in 10ths. Clean, not sterile gloves are needed. For sub-q, the ¾″ needle is sufficient and less painful for the client.

The nurse prepares to insert a nasogastric tube in a client with hyperemesis who is awake and alert. Which nursing actions are correct? (Select all that apply.) A. Place the client in a high Fowler position. B. Explain that placement of the tube is painless. C. Measure the tube from the tip of the nose to the umbilicus. D. Instruct the client to swallow after the tube has passed the pharynx. E. Assist the client in extending the neck back so the tube may enter the larynx.

Answer: A, D Rationale: (A and D) are the correct steps to follow during nasogastric intubation. Placement of an NG tube can be uncomfortable and can induce gagging. The tube should be measured from the tip of the nose to behind the ear and then from behind the ear to the xiphoid process (C). The neck should only be extended back prior to the tube passing the pharynx and then the client should be instructed to position the neck forward (E).

The nurse is at a teen event. Which teen's statement would cause the nurse to input some safety tips? (Select all that apply.) A. "My boyfriend and I fool around on occasion, but he never comes when he is inside me." B. "I hang around with my friends after the games, like football and baseball." C. "I work until 10:00 pm at a local fast-food restaurant." D. "I never use my seatbelt while I am driving. I hate the way it feels." E. "We often go and play beach volleyball when it is nice out."

Answer: A, D Rationale: Sexual exploration is not uncommon as a teen. However, pregnancy can occur with ejaculation on the perineal area. Accidents are the leading cause of death in the teen years and seatbelt use must be encouraged at all times. The remaining statements demonstrate normal growth and development for the teen years.

The nurse is working with one LPN and two aides on a 20-bed unit. Which are the appropriate tasks to delegate to the appropriate person? (Select all that apply.) A. Feeding an elderly and confused client to the aide. B. Toileting the client for the first time after surgery to the LPN. C. Placing the bathroom supplies in the room of the new admission to the LPN. D. Reinforcing the discharge teaching instructions to the LPN. E. Administering a PO pain medication to the LPN. F. Performing the routine dressing change 5 days after surgery to the LPN.

Answer: A, D, E, F Rationale: There are 5 rights of delegation: the right task, circumstances, person, direction, and supervision. The aide can perform routine tasks, the LPN can deliver skilled care, the RN performs the assessment and does the teaching. Toileting the client for the first time requires the assessment of the RN. The bathroom supplies can be delegated to the aide. The remaining selections are appropriate. The LPN can reinforce teaching; the initial teaching must be done by the RN.

The nurse is preparing to initiate parenteral nutrition (PN) for a client. What actions will the nurse consider when administering PN? (Select all that apply.) A. Remove the PN from the refrigerator 30 minutes before infusing. B. Have a second nurse double check the PN before connecting the solution. C. Have a second IV line in place for administering IV medications. D. Assure the infusion time for the PN does not exceed 24 hours. E. Tell the client a feeling of being full should occur with PN. F. Return amber and cloudy solutions of PN to the pharmacy.

Answer: A, D, F Rationale: There are no issues with antibody incompatibility with PN, so there is no need to double check the PN or start a second IV line. PN is administered through the venous system and does not satiate the client. The remaining selections are true about the administration of PN.

The nurse notes in the client's plan of care altered sleep patterns related to nocturia. Which nursing actions are important for the nurse to provide? (Select all that apply.) A. Decrease intake of fluids after the evening meal. B. Drink a glass of cranberry juice every day. C. Drink a glass of warm decaffeinated beverage at bedtime. D. Consult the healthcare provider about a sleeping pill. E. Assess the client's usual sleep pattern.

Answer: A, E Rationale: Nocturia is urination during the night. Option A is helpful to decrease the production of urine, thus decreasing the need to void at night. Option E gives the nurse the client's baseline sleep pattern. Option B helps prevent bladder infections. Option C may promote sleep, but the fluid will contribute to nocturia. Option D may result in urinary incontinence if the client is sedated and does not awaken to void.

The clinic nurse is taking the vital signs of a 1-year-old. Which finding should the nurse bring to the attention of the healthcare provider? A. Temperature: 97.5F/36.4C B. Pulse: 80 beats/min. C. Respirations: 26 breaths/min. D. Blood pressure: 90/53 mm Hg.

Answer: B Rationale: A normal pulse rate for a 1-year-old is 90-130. This child's heartbeat is below the normal range. The remaining vital signs are within the normal limits for a 1-year-old.

After a needle stick occurs while removing the cap from a sterile needle, which action should the nurse take next? A. Complete an incident report. B. Select another sterile needle. C. Disinfect the needle with an alcohol swab. D. Notify the supervisor of the department immediately.

Answer: B Rationale: After a needle stick, the needle is considered used, so the nurse should discard it and select another needle. Because the needle was sterile when the nurse was stuck and the needle was not in contact with any other person's body fluids, the nurse does not need to complete an incident report or notify the occupational health nurse. Disinfecting a needle with an alcohol swab is not in accordance with standards for safe practice and infection control.

The nurse is assessing several clients prior to surgery. Which factor in a client's history poses the greatest threat for complications to occur during surgery? A. Taking birth control pills for the past 2 years. B. Taking anticoagulants for the past year. C. Recently completing antibiotic therapy. D. Having taken laxatives PRN for the last 6 months.

Answer: B Rationale: Anticoagulants increase the risk for bleeding during surgery, which can pose a threat for the development of surgical complications. The healthcare provider should be informed that the client is taking these drugs. Although clients who take birth control pills may be more susceptible to the development of thrombi, such problems usually occur postoperatively. A client with option C or D is at less of a surgical risk than with option B.

The healthcare provider has changed a client's prescription from the PO to the IV route of administration. The nurse should anticipate which change in the pharmacokinetic properties of the medication? A. The client will experience increased tolerance to the drug's effects and may need a higher dose. B. The onset of action of the drug will occur more rapidly, resulting in a more rapid effect. C. The medication will be more highly protein-bound, increasing the duration of action. D. The therapeutic index will be increased, placing the client at greater risk for toxicity.

Answer: B Rationale: Because the absorptive process is eliminated when medications are administered via the IV route, the onset of action is more rapid, resulting in a more immediate effect. Drug tolerance, protein binding, and the drug's therapeutic index are not affected by the change in route from PO to IV. In addition, an increased therapeutic index reduces the risk of drug toxicity.

When turning an immobile bedridden client without assistance, which action by the nurse best ensures client safety? A. Securely grasp the client's arm and leg. B. Put bed rails up on the side of bed opposite from the nurse. C. Correctly position and use a turn sheet. D. Lower the head of the client's bed slowly.

Answer: B Rationale: Because the nurse can only stand on one side of the bed, bed rails should be up on the opposite side to ensure that the client does not fall out of bed. Option A can cause client injury to the skin or joint. Options C and D are useful techniques while turning a client but have less priority in terms of safety than use of the bed rails.

The nurse identifies a potential for infection in a client with partial-thickness (second-degree) and full-thickness (third-degree) burns. What action has the highest priority in decreasing the client's risk of infection? A. Administration of plasma expanders. B. Use of careful handwashing technique. C. Application of a topical antibacterial cream. D. Limiting visitors to the client with burns.

Answer: B Rationale: Careful handwashing technique is the single most effective intervention for the prevention of contamination to all clients. Option A reverses the hypovolemia that initially accompanies burn trauma but is not related to decreasing the proliferation of infective organisms. Options C and D are recommended by various burn centers as possible ways to reduce the chance of infection. Option B is a proven technique to prevent infection.

A nurse is assigned to care for a close friend in the hospital setting. Which action should the nurse take first when given the assignment? A. Notify the friend that all medical information will be kept confidential. B. Explain the relationship to the charge nurse and ask for reassignment. C. Approach the client and ask if the assignment is uncomfortable. D. Accept the assignment but protect the client's confidentiality.

Answer: B Rationale: Caring for a close friend can violate boundaries for nurses and should be avoided when possible (B). If the assignment is unavoidable (there are no other nurses to care for the client) then C, A, and D should be addressed.

The nurse is instructing a client with cholecystitis regarding diet choices. Which meal best meets the dietary needs of this client? A. Steak, baked beans, and a salad. B. Broiled fish, green beans, and an apple. C. Pork chops, macaroni and cheese, and grapes. D. Avocado salad, milk, and angel food cake.

Answer: B Rationale: Clients with cholecystitis (inflammation of the gallbladder) should follow a low-fat diet, such as option B. Option A is a high-protein diet, and options C and D contain high-fat foods, which are contraindicated for this client.

During evacuation of a group of clients from a medical unit because of a fire, the nurse observes an ambulatory client walking alone toward the stairway at the end of the hall. Which action should the nurse take? A. Assign unlicensed assistive personnel to transport the client via a wheelchair. B. Remind the client to walk carefully down the stairs until reaching a lower floor. C. Ask the client to help by assisting a wheelchair-bound client to a nearby elevator. D. Open the closest fire doors so that ambulatory clients can evacuate more rapidly.

Answer: B Rationale: During evacuation of a unit because of fire, ambulatory clients should be evacuated via the stairway if at all possible and reminded to walk carefully. Ambulatory clients do not require the assistance of a wheelchair to be evacuated. Elevators should not be used during a fire, and fire doors should be kept closed to help contain the fire.

Which fluid will the nurse select to administer with the prescribed blood transfusion? A. 5% Dextrose and water. B. Normal saline. C. Lactated Ringers solution. D. 5% Dextrose and lactated ringers.

Answer: B Rationale: Normal saline solution is the only solution that is compatible with blood.

When assisting a client from the bed to a chair, which procedure is best for the nurse to follow? A. Place the chair parallel to the bed, with its back toward the head of the bed and assist the client in moving to the chair. B. With the nurse's feet spread apart and knees aligned with the client's knees, stand and pivot the client into the chair. C. Assist the client to a standing position by gently lifting upward, underneath the axillae. D. Stand beside the client, place the client's arms around the nurse's neck, and gently move the client to the chair.

Answer: B Rationale: Option B describes the correct positioning of the nurse and affords the nurse a wide base of support while stabilizing the client's knees when assisting to a standing position. The chair should be placed at a 45-degree angle to the bed, with the back of the chair toward the head of the bed. Clients should never be lifted under the axillae; this could damage nerves and strain the nurse's back. The client should be instructed to use the arms of the chair and should never place his or her arms around the nurse's neck; this places undue stress on the nurse's neck and back and increases the risk for a fall.

The nurse is drawing a blood sample from the client's basilic vein. Multiple attempts were made prior to obtaining the sample with the tourniquet in place for nearly 5 minutes. Which laboratory finding would the nurse suspect is inaccurate related to the prolonged tourniquet placement? A. Na 148 mEq/L B. K 5.3 mEq/L C. Cl 102 mEq/L D. Ca 9.3 mg/dL

Answer: B Rationale: Prolonged tourniquet placement can cause accumulation of potassium, skewing the result upward. The sodium level is also high, but that is not related to the blood draw. The chloride and calcium levels are normal.

The nurse selects the best site for insertion of an IV catheter in the client's right arm. Which documentation should the nurse use to identify placement of the IV access? A. Left brachial vein. B. Right cephalic vein. C. Dorsal side of the right wrist. D. Right upper extremity.

Answer: B Rationale: The cephalic vein is large and superficial and identifies the anatomic name of the vein that is accessed, which should be included in the documentation. The basilic vein of the arm is used for IV access, not the brachial vein, which is too deep to be accessed for IV infusion. Although veins on the dorsal side of the right wrist are visible, they are fragile and using them would be painful, so they are not recommended for IV access. Option D is not specific enough for documenting the location of the IV access.

The nurse is instructing a client in the proper use of a metered-dose inhaler. Which instruction should the nurse provide the client to ensure the optimal benefits from the drug? A. "Fill your lungs with air through your mouth and then compress the inhaler." B. "Compress the inhaler while slowly breathing in through your mouth." C. "Compress the inhaler while inhaling quickly through your nose." D. "Exhale completely after compressing the inhaler and then inhale."

Answer: B Rationale: The medication should be inhaled through the mouth simultaneously with compression of the inhaler. This will facilitate the desired destination of the aerosol medication deep in the lungs for an optimal bronchodilation effect. Options A, C, and D do not allow for deep lung penetration.

The nurse is counting a client's respiratory rate. During a 30-second interval, the nurse counts six respirations and the client coughs three times. In repeating the count for a second 30-second interval, the nurse counts eight respirations. Which respiratory rate will the nurse document? A. 14 B. 16 C. 17 D. 28

Answer: B Rationale: The most accurate respiratory rate is the second count obtained by the nurse, which was not interrupted by coughing. Because it was counted for 30 seconds, the rate should be doubled. Options A, C, and D are inaccurate recordings.

A 65-year-old client who attends an adult daycare program and is wheelchair mobile has redness in the sacral area. Which instruction is most important for the nurse to provide? A. "Take a vitamin supplement tablet once a day." B. "Change positions in the chair frequently." C. "Increase daily intake of water or other oral fluids." D. "Purchase a newer model wheelchair."

Answer: B Rationale: The most important teaching is to change positions frequently because pressure is the most significant factor related to the development of pressure ulcers. Increased vitamin and fluid intake may also be beneficial and promote healing and reduce further risk. Option D is an intervention of last resort because this will be very expensive for the client.

A terminally ill client tells the nurse, "I am so tired and in so much pain! Please help me to die." Which is the best response for the nurse to provide? A. Administer the prescribed maximum dose of pain medication. B. Talk with the client about thoughts and feelings about death. C. Collaborate with the healthcare provider about initiating antidepressant therapy. D. Refer the client to the ethics committee of her local healthcare facility.

Answer: B Rationale: The nurse should first assess the client's feelings about death and determine the extent to which this statement expresses the client's true feelings. The client may need additional pain management, but further assessment is needed before implementing option A. Options C and D are both premature interventions and should not be implemented until further assessment is obtained.

The nurse assesses a 2-year-old who is admitted for dehydration and finds that the peripheral IV rate by gravity has slowed, even though the venous access site is healthy. What should the nurse do next? A. Apply a warm compress proximal to the site. B. Check for kinks in the tubing and raise the IV pole. C. Adjust the tape that stabilizes the needle. D. Flush with normal saline and recount the drop rate.

Answer: B Rationale: The nurse should first check the tubing and height of the bag on the IV pole, which are common factors that may slow the rate. Gravity infusion rates are influenced by the height of the bag, tubing clamp closure or kinks, needle size or position, fluid viscosity, client blood pressure (crying in the pediatric client), and infiltration. Venospasm can slow the rate and often responds to warmth over the vessel, but the nurse should first adjust the IV pole height. The nurse may need to adjust the stabilizing tape on a positional needle or flush the venous access with normal saline, but less invasive actions should be implemented first.

The nurse is preparing the room for a client after a laparotomy with a 5 inch midline abdominal incision. The nurse plans on teaching the client how to splint the wound when coughing or deep breathing. What extra item will the nurse place in the client's room? A. Pillow case. B. Pillow. C. Sheet. D. Blue absorbent pad.

Answer: B Rationale: The purpose of splinting an incision is to offer additional support to the wound. The client can hold a pillow or rolled up blanket against the abdominal incision. The remaining items do not offer the level of support necessary to splint the wound.

The nurse teaches the use of a gait belt to a caregiver whose spouse has right-sided weakness and needs assistance with ambulation. The caregiver performs a return demonstration of the skill. Which observation indicates that the caregiver has learned how to use the belt? A. Standing on the spouse's strong side, the caregiver is ready to hold the gait belt if any evidence of weakness is observed. B. Standing on the spouse's weak side, the caregiver provides security by holding the gait belt from the back. C. Standing behind the spouse, the caregiver provides balance by holding both sides of the gait belt. D. Standing slightly in front and to the right of the spouse, the caregiver guides the client forward by gently pulling on the gait belt.

Answer: B Rationale: The spouse is most likely to lean toward the weak side and needs extra support on that side and from the back to prevent falling. Options A, C, and D provide less security.

Ten minutes after signing an operative permit for a fractured hip, an older client states, "The aliens will be coming to get me soon!" and falls asleep. Which action should the nurse take next? A. Make the client comfortable and allow the client to sleep. B. Assess the client's neurological status. C. Notify the surgeon about the comment. D. Ask the client's family to co-sign the operative permit.

Answer: B Rationale: This statement may indicate that the client is confused. Informed consent must be provided by a mentally competent individual, so the nurse should further assess the client's neurologic status to be sure that the client understands and can legally provide consent for surgery. Option A does not provide sufficient follow-up. If the nurse determines that the client is confused, the surgeon must be notified and permission obtained from the next of kin.

The nurse observes a UAP taking a client's blood pressure in the lower extremity. Which observation of this procedure requires the nurse to intervene with the UAP's approach? A. The cuff wraps around the girth of the leg. B. The UAP auscultates the popliteal pulse with the cuff on the lower leg. C. The client is placed in a prone position. D. The systolic reading is 20 mm Hg higher than the blood pressure in the client's arm.

Answer: B Rationale: When obtaining the blood pressure in the lower extremities, the popliteal pulse is the site for auscultation when the blood pressure cuff is applied around the thigh. The nurse should intervene with the UAP who has applied the cuff on the lower leg. Option A ensures an accurate assessment, and option C provides the best access to the artery. Systolic pressure in the popliteal artery is usually 10-40 mm Hg higher than in the brachial artery.

Which action should the nurse implement when providing wound care instructions to a client who does not speak English? A. Ask an interpreter to provide wound care instructions. B. Speak directly to the client, with an interpreter translating. C. Request the accompanying family members to translate. D. Instruct a bilingual employee to read the instructions.

Answer: B Rationale: Wound care instructions should be given directly to the client by the nurse with an interpreter who is trained to provide accurate and objective translation in the client's primary language so that the client has the opportunity to ask questions during the teaching process. The interpreter usually does not have any healthcare experience, so the nurse must provide client teaching. Family members should not be used to translate instructions because the client or family member may alter the instructions during conversation or be uncomfortable with the topics discussed. The employee should be a trained interpreter to ensure that the nurse's instructions are understood accurately by the client.

The nurse administered 10 mg of diazepam to the preoperative client. What steps will the nurse take next? (Select all that apply.) A. Place the client in the bed next to the nurse's station. B. Instruct the client not to get out of bed. C. Place the call bell within the client's reach. D. Place the side rails up, according to institutional policy. E. Assist the client to the bathroom.

Answer: B, C, D Rationale: Diazepam is a common preoperative medication. Close observation by placing the client close to the nurse's station is not necessary. The medication has a sedative effect and the client should not get out of bed, even with assistance. The remaining selections are correct.

The nurse is preparing to insert an IV, and cap off the IV with an intermittent infusion devise for an 80-year-old who is prescribed IV antibiotics every 8 hours. The client is taking po fluids well. What supplies will the nurse take into the room for this procedure? (Select all that apply.) A. A 16-gauge IV catheter. B. Normal saline in a 10 mL syringe. C. Clear plastic sterile bandage. D. Skin preparation antiseptic swab. E. 1000 mL bag of normal saline.

Answer: B, C, D Rationale: Items not needed to insert an IV for intermittent antibiotic therapy for an 80-year-old are a 16 gauge intracath; the intracath is too large. Large bore intracaths are for rapid infusions. A small bag of NS, e.g. 250 mL, will be needed to flush the line. The remaining items are needed to start an IV.

The nurse is called to the waiting room of a pediatric clinic. The frantic mother states, "I think my 4-month-old baby is choking!" What steps will the nurse take? (Select all that apply.) A. Compress the chest once between the nipples with two fingers. B. Note any obstruction or absence of breathing. C. Deliver five backslaps between the shoulder blades. D. Place the infant over the nurse's arm. E. Perform a blind finger sweep.

Answer: B, C, D Rationale: The fingers are placed at the same location on an infant as chest compressions for CPR; however, the nurse must deliver five chest thrusts, after the five back slaps. Blind sweeps are not used as this action may push the object deeper into the throat. The remaining steps are correct.

The nurse is teaching a group of young adults with families about preparing their underground shelter in the event of a tornado. What instructions will the nurse include in teaching plan for these families? (Select all that apply.) A. Place two electric lights in the shelter. B. Plan for 1 gallon of water per family member for at least 3 days. C. Don't forget a can opener with the supply of canned food. D. Make sure you include a first aid kit in the shelter. E. Pack shoes with sturdy soles and they must completely cover the feet.

Answer: B, C, D, E Rationale: The lights need to be battery powered and not rely on electricity. The remaining items are necessary emergency supplies.

The client 12 hours after a laparotomy reports to the nurse a pain rating of 7-10. The nurse reviews the medication orders, and it is another hour before the client can have another dose of pain medication. What actions can the nurse take to assist the client? (Select all that apply.) A. Administer the IV pain medication an hour early. B. Assist the client into side-lying, curled position. C. Obtain a warm pack to apply to the site of the incision. D. Suggest to the client taking 10 deep breaths, in through the nose and out through the mouth. E. Help the client with sustained concentration of a personally pleasant topic.

Answer: B, C, D, E Rationale: The nurse would be not following the healthcare provider's prescription if the pain medication were delivered an hour early. The nurse could call for an additional dose of medication for break-through pain, but administering medication early is prescribing without authority. The remaining selections are all nonpharmacologic measures for pain relief.

The client states to the nurse, "This medication makes my mouth so dry." What are the nurse's suggestions to quench the client's thirst? (Select all that apply.) A. Drink two 8-ounce glasses of lemon-lime soda every day. B. Infuse your water with fresh citrus fruits to quench your thirst. C. Freeze strawberries and water together in popsicle mold. D. Add ginger ale to your daily glass of juice every day. E. Keep a few pieces of hard candy with you to suck on.

Answer: B, C, E Rationale: Sodas do not tend to be thirst quenching because of the amount of sugar in them that draws fluid into the GI system. Citrus infused water quenches thirst, as does consuming frozen liquids. Hard candy can produce moisture in the mouth.

The nurse is evaluating measures implemented for the nonresponsive client. Which findings indicate the effectiveness of the care delivered? (Select all that apply.) A. Footboard at the end of the bed. B. Heals without redness bilaterally. C. Skin intact on the back. D. Sheepskin booties in place. E. Elbow joint fully flexes and extends. F. Ankle joint rotates 360 degrees freely.

Answer: B, C, E, F Rationale: The footboard helps prevent foot drop, but does not measure the effectiveness of the treatment. The sheepskin booties are in place to protect the heal, but they do not demonstrate the effectiveness. The remaining are assessments that demonstrate the interventions are effective.

The nurse is providing care to an 86-year-old admitted for a heart catheterization. The nurse determines the client does not have an advance directive (AD) on file. What are the nurse's next steps? (Select all that apply.) A. Ask the client's cardiologist to come to the hospital and obtain the AD. B. Ask the client, "Have you considered completing the paperwork for an AD?" C. Ask the client's spouse to complete the AD. D. Tell the client, "An AD helps the staff provide care according to your wishes." E. Call the client's clergy member to make the final decisions for the client.

Answer: B, D Rationale: A living will is one type of advance directive. The living will outlines the medical treatment the client elects in the event that the client is no longer able to participate in the decision-making process. As long as the client has capacity, the client is the sole determinant for the AD. While a living will describes the wishes of the client, it does not have to be obtained from the physician. Clients may be assisted by the social work staff. The forms can be completed outside of a medical facility and it is the client's responsibility to provide a copy of the AD to all healthcare providers.

The nurse is evaluating the chart of a client scheduled for surgery in 1 hour. When viewing the consent form, the nurse notes the surgeon's signature, but not the client's signature. What steps must the nurse take? (Select all that apply.) A. Call the surgeon. B. Ask the client, "Did your surgeon explain the procedure to you?" C. Have the client's spouse sign the form. D. Ask the client, "Do you have any questions?" E. Witness the signature. F. Obtain the consent.

Answer: B, D, E Rationale: It is the surgeon's responsibility to review the procedure with the client until the client has no further questions. The nurse can verify the review by the surgeon and ask if the client has any further questions. If the client has questions, the nurse must call in the surgeon. When the nurse signs the consent form, the nurse is witnessing the signature only.

The nurse is teaching an obese client, newly diagnosed with arteriosclerosis, about reducing the risk of a heart attack or stroke. Which health promotion brochure is most important for the nurse to provide to this client? A. "Monitoring Your Blood Pressure at Home." B. "Smoking Cessation as a Lifelong Commitment." C. "Decreasing Cholesterol Levels Through Diet." D. "Stress Management for a Healthier You."

Answer: C Rationale: A health promotion brochure about decreasing cholesterol is most important to provide this client, because the most significant risk factor contributing to development of arteriosclerosis is excess dietary fat, particularly saturated fat and cholesterol. Option A does not address the underlying causes of arteriosclerosis. Options B and D are also important factors for reversing arteriosclerosis but are not as important as lowering cholesterol.

The nurse is preparing a liquid medication for a 2-year-old. The dose is 2.2 mL. What delivery devise will the nurse select to prepare the medication? A. 30 mL medication cup. B. 10 mL medication spoon. C. 3 mL needleless syringe. D. 5 mL medicine dropper.

Answer: C Rationale: Accuracy is most important when delivering small amounts of medication to a child. The most accurate dispensing devise is the 3 mL needleless syringe that is marked off in increments of tenths.

A client with frequent urinary tract infections (UTIs) asks the nurse to explain a friend's advice about drinking a glass of juice daily to prevent future UTIs. Which response is best for the nurse to provide? A. "Orange juice has vitamin C that deters bacterial growth." B. "Apple juice is the most useful in acidifying the urine." C. "Cranberry juice stops pathogens' adherence to the bladder." D. "Grapefruit juice increases absorption of most antibiotics."

Answer: C Rationale: Cranberry juice maintains urinary tract health by reducing the adherence of Escherichia coli bacteria to cells within the bladder. Options A, B, and D have not been shown to be as effective as cranberry juice in preventing UTIs.

When taking a client's blood pressure, the nurse is unable to distinguish the point at which the first sound was heard. Which is the best action for the nurse to take? A. Deflate the cuff completely and immediately reattempt the reading. B. Reinflate the cuff completely and leave it inflated for 90-110 seconds before taking the second reading. C. Deflate the cuff to zero and wait 30-60 seconds before reattempting the reading. D. Document the exact level visualized on the sphygmomanometer where the first fluctuation was seen.

Answer: C Rationale: Deflating the cuff for 30-60 seconds allows blood flow to return to the extremity so that an accurate reading can be obtained on that extremity a second time. Option A could result in a falsely high reading. Option B reduces circulation, causes pain, and could alter the reading. Option D is not an accurate method of assessing blood pressure.

The healthcare provider diagnoses metastatic cancer and recommends a gastrostomy for an elderly client in stable condition. The client's adult child is concerned and states to the nurse, "I don't think my parent 'can handle' the cancer diagnosis." What information will guide the nurse's response? A. The family can provide the consent required in this situation because the older adult is in no condition to make such decisions. B. Because the client is mentally incompetent, the adult child has the right to waive informed consent for the parent. C. The court will allow the healthcare provider to make the decision to withhold informed consent under therapeutic privilege. D. If informed consent is withheld from a client, healthcare providers could be found guilty of negligence.

Answer: C Rationale: Healthcare providers may be found guilty of negligence, specifically assault and battery, if they carry out a treatment without the client's consent. The client's condition is stable, so option A is not a valid rationale. Advanced age does not automatically authorize the son to make all decisions for his mother, and there is no evidence that the client is mentally incompetent. Although option C may have been upheld in the past, when paternalistic medical practice was common, today's courts are unlikely to accept it.

Urinary catheterization is prescribed for a postoperative female client who has been unable to void for 8 hours. The nurse inserts the catheter, but no urine is seen in the tubing. Which action will the nurse take next? A. Clamp the catheter and recheck it in 60 minutes. B. Pull the catheter back 3 inches and redirect upward. C. Leave the catheter in place and reattempt with another catheter. D. Notify the healthcare provider of a possible obstruction.

Answer: C Rationale: It is likely that the first catheter is in the vagina, rather than the bladder. Leaving the first catheter in place will help locate the meatus when attempting the second catheterization. The client should have at least 240 mL of urine after 8 hours. Option A does not resolve the problem. Option B will not change the location of the catheter unless it is completely removed, in which case a new catheter must be used. There is no evidence of a urinary tract obstruction if the catheter could be easily inserted.

In completing a client's preoperative routine, the nurse finds that the operative permit is not signed. The client begins to ask more questions about the surgical procedure. Which action should the nurse take next? A. Witness the client's signature to the permit. B. Answer the client's questions about the surgery. C. Inform the surgeon the client has questions about the surgery. D. Reassure the client that the surgeon will answer any questions before the anesthesia is administered.

Answer: C Rationale: It is the surgeon's responsibility to explain the procedure to the client and obtain the client's signature on the permit. Although the nurse can witness an operative permit, the procedure must first be explained by the healthcare provider or surgeon, including answering the client's questions. The client's questions should be addressed before the permit is signed.

One week after being told that she has terminal cancer with a life expectancy of 3 weeks, the client tells the nurse, "I think I will plan a big party for all my friends." How should the nurse respond? A. "You may not have enough energy before long to hold a big party." B. "Do you mean to say that you want to plan your funeral and wake?" C. "Planning a party and thinking about all your friends sounds like fun." D. "You should be thinking about spending your last days with your family."

Answer: C Rationale: Setting goals that bring pleasure is appropriate and should be encouraged by the nurse as long as the nurse does not perpetuate a client's denial. Option A is a negative response, implying that the client should not plan a party. Option B puts words in the client's mouth that may not be accurate. The nurse should support the client's goals rather than telling the client how to spend her time.

A community hospital is opening a mental health services department. Which document should the nurse use to develop the unit's nursing guidelines? A. Americans with Disabilities Act of 1990. B. ANA Code of Ethics with Interpretative Statements. C. ANA's Scope and Standards of Nursing Practice. D. Patient's Bill of Rights of 1990.

Answer: C Rationale: The ANA Scope of Standards of Practice for Psychiatric-Mental Health Nursing serves to direct the philosophy and standards of psychiatric nursing practice. Options A and D define the client's rights. Option B provides ethical guidelines for nursing.

A nurse stops at a motor vehicle collision site to render aid until the emergency personnel arrive and applies pressure to a groin wound that is bleeding profusely. Later the client has to have the leg amputated and sues the nurse for malpractice. Which statement reflects the likely outcome for the nurse? A. The Patient's Bill of Rights protects clients from malicious intents, so the nurse could lose the case. B. The lawsuit may be settled out of court, but the nurse's license is likely to be revoked. C. There will be no judgment against the nurse, whose actions are protected under the Good Samaritan Act. D. The client will win because the four elements of negligence (duty, breach, causation, and damages) can be proved.

Answer: C Rationale: The Good Samaritan Act protects healthcare professionals who practice in good faith and provide reasonable care from malpractice claims, regardless of the client outcome. Although the Patient's Bill of Rights protects clients, this nurse is protected by the Good Samaritan Act. The state Board of Nursing has no reason to revoke a registered nurse's license unless there was evidence that actions taken in the emergency were not done in good faith or that reasonable care was not provided. All four elements of malpractice were not shown.

The nurse comes upon an automobile accident involving many cars. Which victim should the nurse see first? A. The victim who is not breathing and does not have a pulse. B. The victim who is bleeding out of both the ears, and the nose and mouth, with a blank stare. C. The victim who is heavily bleeding bright red blood from a thigh wound. D. The victim who is crying, complaining of arm pain, and no other apparent injuries.

Answer: C Rationale: The client hemorrhaging from the leg wound is the priority as of the severely injured clients; the nurse can help the client by tying off the leg above the injury and/or applying pressure to the wound site. When there is only one healthcare provider on the scene, the nurse must provide care to those who are most likely to survive. The client without a pulse and respirations is dead. The client with bleeding from the ears, nose, and mouth, with a blank stare, likely has severe head trauma. The victim with arm pain and crying is the lowest priority.

When bathing an uncircumcised boy older than 3 years, which action should the nurse take? A. Remind the child to clean his genital area. B. Defer perineal care because of the child's age. C. Retract the foreskin gently to cleanse the penis. D. Ask the parents why the child is not circumcised.

Answer: C Rationale: The foreskin (prepuce) of the penis should be gently retracted to cleanse all areas that could harbor bacteria. The child's cognitive development may not be at the level at which option A would be effective. Perineal care needs to be provided daily regardless of the client's age. Option D is not indicated and may be perceived as intrusive.

An older adult who recently began self-administration of insulin calls the nurse daily to review the steps that should be taken when giving an injection. The nurse has assessed the client's skills during two previous office visits and knows that the client safely administered the injections. What is the nurse's best response? A. "I know you are capable of giving yourself the insulin." B. "Giving yourself the injection seems to make you nervous." C. "When I watched you give yourself the injection, you did it correctly." D. "Tell me what you want me to do to help you give yourself the injection at home."

Answer: C Rationale: The nurse needs to focus on the client's positive behaviors, so focusing on the client's demonstrated ability to self-administer the injection is likely to reinforce his level of competence without sounding punitive. Option A does not focus on the specific behaviors related to giving the injection and could be interpreted as punitive. Option B uses reflective dialogue to assess the client's feelings but telling the client that he is nervous may serve as a negative reinforcement of this behavior. Option D reinforces the client's dependence on the nurse.

The nurse who is preparing to give a 14-year-old client a prescribed antipsychotic medication notes that parental consent has not been obtained. Which action should the nurse take? A. Review the chart for a signed consent for hospitalization. B. Get the healthcare provider's permission to give the medication. C. Do not give the medication and document the reason. D. Complete an incident report and notify the parents.

Answer: C Rationale: The nurse should not give the medication and should document the reason because the client is a minor and needs a guardian's permission to receive medications. Permission to give medications is not granted by a signed hospital consent or a healthcare provider's permission unless conditions are met to justify coerced treatment. Option D is not necessary unless the medication had previously been administered.

The nurse worked with a client to alleviate pain with aroma and relaxation therapy. Twenty minutes after working with the client, the nurse returns to the room and finds the client's eyes are closed and breathing deeply. What is the best entry for the nurse to document this finding? A. Client sleeping. B. Pain medication working. C. Eyes closed, deeply breathing. D. Effective use of alternative therapy.

Answer: C Rationale: The purpose of charting is to document the client's response to care. Charting must be objective. The client could still be awake, and in a calm state. Clients can sleep through pain, especially if the client has chronic pain. There is no mention of pain medication in the questions. Chart the client's response to the care; while the method of achieving relaxation is important, it is not the most important.

A client in a long-term care facility reports to the nurse, "I have not had a bowel movement in 2 days." What is the nurse's first action? A. Instruct the caregiver to offer a glass of warm prune juice at mealtimes. B. Notify the healthcare provider and request a prescription for a large-volume enema. C. Assess the client's medical record to determine the client's normal bowel pattern. D. Instruct the caregiver to increase the client's fluids to five 8-ounce glasses per day.

Answer: C Rationale: This client may not routinely have a daily bowel movement, so the nurse should first assess this client's normal bowel habits before attempting any intervention. Options A, B, or D may then be implemented, if warranted.

Which instruction is most important for the nurse to include when teaching a client with limited mobility strategies to prevent venous thrombosis? A. Perform cough and deep breathing exercises hourly. B. Turn from side to side in bed at least every 2 hours. C. Dorsiflex and plantarflex the feet 10 times each hour. D. Drink approximately 4 ounces of water every hour.

Answer: C Rationale: To reduce the risk of venous thrombosis, the nurse should instruct the client in measures that promote venous return, such as dorsiflexion and plantar flexion. Options A, B, and D are helpful to prevent other complications of immobility but are less effective in preventing venous thrombus formation than option C.

The nurse is preparing to administer 10 mL of liquid potassium chloride through a feeding tube, followed by 10 mL of liquid acetaminophen. Which action should the nurse include in this procedure? A. Dilute each of the medications with sterile water prior to administration. B. Mix the medications in one syringe before opening the feeding tube. C. Administer water between the doses of the two liquid medications. D. Withdraw any fluid from the tube before instilling each medication.

Answer: C Rationale: Water should be instilled into the feeding tube between administering the two medications to maintain the patency of the feeding tube and ensure that the total dose of medication enters the stomach and does not remain in the tube. These liquid medications do not need to be diluted when administered via a feeding tube and should be administered separately, with water instilled between each medication.

The clinic nurse is conducting an assessment of a 2-year-old. The nurse asks the mother, "What is your child playing with now?" Which response indicates to the nurse that further teaching is needed? (Select all that apply.) A. "We color together using jumbo crayons." B. "Finger paints in the kitchen are a favorite pastime." C. "A marble run race track is set up in the playroom." D. "When outside, the wagon filled with soccer balls is the preferred toy." E. "We got a golf set because my other children play golf."

Answer: C, E Rationale: Avoid small objects that can be a choking hazard during the toddler stage. A golf set is not age appropriate. The remaining play toys are appropriate for toddlers.

The nurse is providing care to a client receiving high doses of chemotherapy. Which situation will cause the nurse to intervene for this client? A. Co-workers walk into the room with a 2' x 3' get well card. B. A neighbor stops by with a box of chocolate candy. C. A clergy member places a book of prayers at the client's bedside. D. The florist delivers an arrangement of fresh flowers.

Answer: D Rationale: A common side effect of chemotherapy is the inability to fight infection secondary to neutropenia. Fresh fruits and fresh flowers are sources of infection that must be avoided for these clients. The remaining options pose a low risk for infection.

A 20-year-old female client with a noticeable body odor has refused to shower for the last 3 days. She states, "I have been told that it is harmful to bathe during my period." Which action should the nurse take first? A. Accept and document the client's wish to refrain from bathing. B. Offer to give the client a bed bath, avoiding the perineal area. C. Obtain written brochures about menstruation to give to the client. D. Teach the importance of personal hygiene during menstruation with the client.

Answer: D Rationale: Because a shower is most beneficial for the client in terms of hygiene, the client should receive teaching first, respecting any personal beliefs such as cultural or spiritual values. After client teaching, the client may still choose option A or B. Brochures reinforce the teaching.

A client's blood pressure reading is 156/94 mm Hg. Which action should the nurse take first? A. Tell the client that the blood pressure is high and that the reading needs to be verified by another nurse. B. Contact the healthcare provider to report the reading and obtain a prescription for an antihypertensive medication. C. Replace the cuff with a larger one to ensure an ample fit for the client to increase arm comfort. D. Compare the current reading with the client's previously documented blood pressure readings.

Answer: D Rationale: Comparing this reading with previous readings will provide information about what is normal for this client; this action should be taken first. Option A might unnecessarily alarm the client. Option B is premature. Further assessment is needed to determine if the reading is abnormal for this client. Option C could falsely decrease the reading and is not the correct procedure for obtaining a blood pressure reading.

The nurse transcribes the postoperative prescriptions for a client who returns to the unit following surgery and notes that an antihypertensive medication that was prescribed preoperatively is not listed. Which action should the nurse take? A. Consult with the pharmacist about the need to continue the medication. B. Administer the antihypertensive medication as prescribed preoperatively. C. Withhold the medication until the client is fully alert and vital signs are stable. D. Contact the healthcare provider to renew the prescription for the medication.

Answer: D Rationale: Medications prescribed preoperatively must be renewed postoperatively, so the nurse should contact the healthcare provider if the antihypertensive medication is not included in the postoperative prescriptions. The pharmacist does not prescribe medications or renew prescriptions. The nurse must have a current prescription before administering any medications.

Which serum laboratory value should the nurse monitor carefully for a client who has a nasogastric (NG) tube to suction for the past week? A. White blood cell count. B. Albumin C. Calcium D. Sodium

Answer: D Rationale: Monitoring serum sodium levels for hyponatremia is indicated during prolonged NG suctioning because of loss of fluids. Changes in levels of option A, B, or C are not typically associated with prolonged NG suctioning.

The nurse is preparing an older client for discharge. Which method is best for the nurse to use when evaluating the client's ability to perform a dressing change at home? A. Determine how the client feels about changing the dressing. B. Ask the client to describe the procedure in writing. C. Seek a family member's evaluation of the client's ability to change the dressing. D. Observe the client change the dressing unassisted.

Answer: D Rationale: Observing the client directly will allow the nurse to determine if mastery of the skill has been obtained and provide an opportunity to affirm the skill. Option A may be therapeutic but will not provide an opportunity to evaluate the client's ability to perform the procedure. Option B may be threatening to an older client and will not determine his ability. Option C is not as effective as direct observation by the nurse.

The nurse is assisting a client to the bathroom. When the client is 5 feet from the bathroom door, he states, "I feel faint." Before the nurse can get the client to a chair, the client starts to fall. Which is the priority action for the nurse to take? A. Check the client's carotid pulse. B. Encourage the client to get to the toilet. C. In a loud voice, call for help. D. Gently lower the client to the floor.

Answer: D Rationale: Option D is the most prudent intervention and is the priority nursing action to prevent injury to the client and the nurse. Lowering the client to the floor should be done when the client cannot support his own weight. The client should be placed in a bed or chair only when sufficient help is available to prevent injury. Option A is important but should be done after the client is in a safe position. Because the client is not supporting himself, option B is impractical. Option C is likely to cause chaos on the unit and might alarm the other clients.

During a routine assessment, an obese 50-year-old client states, "I feel so unlovable because of my weight." Which is the best response by the nurse? A. Reassure the client that many obese people have the same concerns. B. Remind the client that relationships need not be affected by obesity. C. Determine the number of friends. D. Ask the client to talk about specific concerns.

Answer: D Rationale: Option D provides an opportunity for the client to verbalize concerns and provides the nurse with more assessment data. Options A and B may not be related to the current concern, assume that obesity is the problem, and are communication blocks. Option C may be appropriate after discussing the stated concerns.

The nurse determines that a postoperative client's respiratory rate has increased from 18 to 24 breaths/min. Based on this assessment finding, what is the priority nursing action? A. Encourage the client to increase ambulation in the room. B. Offer the client a high-carbohydrate snack for energy. C. Force fluids to thin the client's pulmonary secretions. D. Determine if pain is causing the client's tachypnea.

Answer: D Rationale: Pain, anxiety, and increasing fluid accumulation in the lungs can cause tachypnea (increased respiratory rate). Encouraging the client to increase ambulation when the respiratory rate is rising above normal limits puts the client at risk for further oxygen desaturation. Option B can increase the client's carbon metabolism, so an alternative source of energy, such as Pulmocare liquid supplement, should be offered instead. Option C could increase respiratory congestion in a client with a poorly functioning cardiopulmonary system, placing the client at risk of fluid overload.

During a clinic visit, the mother of a 7-year-old reports to the nurse that her child is often awake until midnight playing and is then very difficult to awaken in the morning for school. Which assessment data should the nurse obtain in response to the mother's concern? A. The occurrence of any episodes of sleep apnea. B. The child's blood pressure, pulse, and respirations. C. Length of rapid eye movement (REM) sleep that the child is experiencing. D. Description of the family's home environment.

Answer: D Rationale: School-age children often resist bedtime. The nurse should begin by assessing the environment of the home to determine factors that may not be conducive to the establishment of bedtime rituals that promote sleep. Option A often causes daytime fatigue rather than resistance to going to sleep. Option B is unlikely to provide useful data. The nurse cannot determine option C.

When performing sterile wound care in the acute care setting, the nurse obtains a bottle of normal saline from the bedside table that is labeled "opened" and dated 48 hours prior to the current date. Which is the best action for the nurse to take? A. Use the normal saline solution once more and then discard. B. Obtain a new sterile syringe to draw up the labeled saline solution. C. Use the saline solution and then relabel the bottle with the current date. D. Discard the saline solution and obtain a new unopened bottle.

Answer: D Rationale: Solutions labeled as opened within 24 hours may be used for clean procedures, but only newly opened solutions are considered sterile. This solution is not newly opened and is out of date, so it should be discarded. Options A, B, and C describe incorrect procedures.

In the middle of running a resuscitation for a cardiac arrest the LPN states to the nurse, "What can I do for your other patients?" The nurse says to the LPN, "Go ahead and start that blood on the client in 434B. It is primed and ready to go. You have seen me do it a million times. You can do it." What is the LPN's best response? A. "No way am I starting the blood on that client!" B. "I am going to tell the manager you asked me to start blood." C. "Sure, no problem. I can do that. I have done it before." D. "I can take over compressions so you can start the blood."

Answer: D Rationale: The LPN needs to remain professional, and stating "No way ...." is an unprofessional response. Telling the manager may be appropriate, but it does nothing to help the situation of needing to start blood and resuscitate a client. Blood administration is the responsibility of the RN. The LPN can perform compressions.

The mental health nurse plans to discuss a client's depression with the healthcare provider in the emergency department. There are two clients sitting across from the emergency department desk. Which nursing action is best? A. Only refer to the client by gender. B. Identify the client only by age. C. Avoid using the client's name. D. Discuss the client another time.

Answer: D Rationale: The best nursing action is to discuss the client another time. Confidentiality must be observed at all times, so the nurse should not discuss the client when the conversation can be overheard by others. Details of the client can be identified when referring to the client by gender or age, even when not using the client's name.

A client becomes angry while waiting for a supervised break to smoke a cigarette outside and states, "I want to go outside now and smoke. It takes forever to get anything done here!" Which nursing action is best for this client? A. Encourage the client to use a nicotine patch. B. Reassure the client that it is almost time for another break. C. Have the client leave the unit with another staff member. D. Review the schedule of outdoor breaks with the client.

Answer: D Rationale: The best nursing action is to review the schedule of outdoor breaks and provide concrete information about the schedule. Option A is contraindicated if the client wants to continue smoking. Option B is insufficient to encourage a trusting relationship with the client. Option C is preferential for this client only and is inconsistent with unit rules.

At hand-off report the off going nurse reports a new 1000 mL IV bag of D5LR was hung at 1845. The prescribed infusion rate is 75 mL/hr. The oncoming nurse assesses the client at 1915 and notes there is less than 50 mL left in the IV bag. What is the nurse's next action? A. Contact the healthcare provider on call. B. Call in the off going nurse and request an explanation. C. Tell the client that 950 mL of fluid just accidentally infused. D. Auscultate the client's lungs.

Answer: D Rationale: The client may show signs of fluid overload, such as crackles. Other respiratory signs are dyspnea and increased rate. Assess the client's reaction to the fluid bolus first and then proceed with notifying the charge nurse and the healthcare provider.

The nurse is administering the 0900 medications to a client who was admitted during the night. Which client statement indicates that the nurse should further assess the medication order? A. "At home I take my pills at 08:00 am." B. "It costs a lot of money to buy all of these pills." C. "I get so tired of taking pills every day." D. "This is a new pill I have never taken before."

Answer: D Rationale: The client's recognition of a "new" pill requires further assessment to verify that the medication is correct, if it is a new prescription or a different manufacturer, or if the client needs further instruction. The time difference may not be as significant in terms of its effect, but this should be explained. Although comments about cost should be considered when developing a discharge plan, option D is a higher priority. The client's feelings C should be acknowledged, but observation of the five rights of medication administration is most essential.

An 89-year-old client is admitted to the rehabilitation unit after a hip fracture. When reviewing the client's prefracture routine the client states, "I usually get up around 0800 and have breakfast by 0900; I say my daily prayers between 1000 and 1030. I like lunch around 1300; then a nap from 1400 to 1600. I generally eat supper around 1900." What is the nurse's best response to the client's schedule? A. "We can try our best to work around your schedule." B. "Your physical therapy is scheduled for 1500-1600." C. "You will have to get your own supper if you want to eat that late." D. "Is there any way you could say your prayers between 1230 and 1300?"

Answer: D Rationale: The elderly have a routine that generally fits around their sleep-wake cycle, or their circadian rhythm. The flexibility is around prayer time, since it is during the wake time. If the rehabilitation therapy can be scheduled in the am, that is generally the time when they have more energy. Trying the best, does not place the client's sleep-wake schedule as a priority. While supper on the rehab unit may be before 1900, arrangements can be made to deliver a tray later, or keep a tray warm.

The nurse is teaching a client how to perform progressive muscle relaxation techniques to relieve insomnia. A week later the client reports, "I am still unable to sleep, despite following the same routine every night." Which action should the nurse take next? A. Instruct the client to add regular exercise as a daily routine. B. Determine if the client has been keeping a sleep diary. C. Encourage the client to continue the routine until sleep is achieved. D. Ask the client to describe the routine he is currently following.

Answer: D Rationale: The nurse should first evaluate whether the client has been adhering to the original instructions. A verbal report of the client's routine will provide more specific information than the client's written diary. The nurse can then determine which changes need to be made. The routine practiced by the client is clearly unsuccessful, so encouragement alone is insufficient.

A client has a nasogastric tube connected to low intermittent suction. When administering medications through the nasogastric tube, which action should the nurse do first? A. Clamp the nasogastric tube. B. Confirm placement of the tube. C. Use a syringe to instill the medications. D. Turn off the intermittent suction device.

Answer: D Rationale: The nurse should first turn off the suction and then confirm placement of the tube in the stomach before instilling the medications. To prevent immediate removal of the instilled medications and allow absorption, the tube should be clamped for a period of time before reconnecting the suction.

The nurse finds a client crying behind a locked bathroom door. The client will not open the door. Which action should the nurse take first? A. Instruct unlicensed assistive personnel (UAP) to stay and keep talking to the client. B. Sit quietly in the client's room until the client leaves the bathroom. C. Allow the client to cry alone and leave the client in the bathroom. D. Talk to the client and attempt to find out why the client is crying.

Answer: D Rationale: The nurse's first concern should be for the client's safety, so an immediate assessment of the client's situation is needed. Option A is incorrect; the nurse should implement the intervention. The nurse may offer to stay nearby after first assessing the situation more fully. Although option C may be correct, the nurse should determine if the client's safety is compromised and offer assistance, even if it is refused.

Which action is most important for the nurse to include in the plan of care for a client at high risk for the development of postoperative thrombus formation? A. Instruct the use of the incentive spirometer. B. Elevate the head of the bed during all meals. C. Use aseptic technique to change the dressing. D. Encourage frequent ambulation in the hallway.

Answer: D Rationale: Thrombus (clot) formation can occur in the lower extremities of immobile clients, so the nurse should plan to encourage activities to increase mobility, such as frequent ambulation in the hallway. Option A helps promote alveolar expansion, reducing the risk for atelectasis. Option B reduces the risk for aspiration. Option C reduces the risk for postoperative infection.

After receiving written and verbal instructions from a clinic nurse about a newly prescribed medication, a client asks the nurse what to do if questions arise about the medication after getting home. How should the nurse respond? A. Provide the client with a list of internet sites that answer frequently asked questions about medications. B. Advise the client to obtain a current edition of a drug reference book from a local bookstore or library. C. Reassure the client that information about the medication is included in the written instructions. D. Encourage the client to call the clinic nurse or healthcare provider if any questions arise.

Answer: D Rationale: To ensure safe medication use, the nurse should encourage the client to call the nurse or healthcare provider if any questions arise. Options A, B, and C may all include useful information, but these sources of information cannot evaluate the nature of the client's questions and the follow-up needed.