HESI Practice Test - NUR 134

In evaluating client care, which action should the nurse take first? A) Determine if the expected outcomes of care were achieved. B) Review the rationales used as the basis of nursing actions. C) Document the care plan goals that were successfully met. D) Prioritize interventions to be added to the client's plan of care.

A) Determine if the expected outcomes of care were achieved. Rationale In evaluating care, the nurse should first determine if the expected outcomes of the plan of care were achieved.

While the nurse is administering a bolus feeding to a client via a nasogastric tube, the client begins to vomit. Which action should the nurse implement first? A) Discontinue the administration of the bolus feeding. B) Auscultate the client's breath sounds bilaterally. C) Elevate the head of the bed to a high Fowler's position. D) Administer a PRN dose of a prescribed antiemetic.

A) Discontinue the administration of the bolus feeding. Rationale When a client receiving a tube feeding begins to vomit, the nurse should first stop the feeding to prevent further vomiting.

When teaching a female client to perform intermittent self-catheterization, the nurse should ensure the client's ability to perform which action? A) Locate the perineum. B) Transfer to a commode. C) Attach the catheter to a drainage bag. D) Manipulate a syringe to inflate the balloon.

A) Locate the perineum. Rationale Adequate visualization or palpation of the perineum is essential to ensure the correct placement of the catheter. During a self-catheterization, the client typically allows the urine to drain into an open collection device, rather than a drainage bag and uses a straight catheter without a balloon.

After a client has been premedicated for surgery with an opioid analgesic, the nurse discovers that the operative permit has not been signed. Which action should the nurse implement? A) Notify the surgeon that the consent form has not been signed. B) Read the consent form to the client before witnessing the client's signature. C) Determine if the client's spouse is willing to sign the consent form. D)Administer an opioid antagonist prior to obtaining the client's signature.

A) Notify the surgeon that the consent form has not been signed. Rationale Once a client has been premedicated for surgery with any type of sedative, legal informed consent is not possible, so the nurse must notify the surgeon.

Which action is most important for the nurse to implement when placing a client in the lateral recumbent position? A) Raise the bed to a waist-high working level. B) Elevate the head of the bed 45 degrees. C) Place a pillow behind the client's back. D) Bring the client to one edge of the bed.

A) Raise the bed to a waist-high working level. Rationale A waist-high bed height is a comfortable and safe working height to maintain the nurse's proper body mechanics and prevent back injury.

The nurse is completing the plan of care for a client who is admitted for benign prostatic hypertrophy. Which data should the nurse document as a subjective finding? A) Reports inability to empty bladder. B) Temperature of 99.8 °F (37.7 °C) and pulse of 108. C) Postvoided residual volume of 750 mL. D) Specimen collection for culture and sensitivity.

A) Reports inability to empty bladder. Rationale The nurse should document the client's complaints of inability to empty bladder as subjective data - symptoms only the client can describe.

While caring for a child and mother from an Asian culture, which action should the nurse implement to accommodate the clients' cultural needs? A) Speak initially with the oldest family member to show respect. B) Realize that Southeast Asians may not take Western medications. C) Ask the husband to step out during the mother's pelvic examination. D) Tell the family that planning health care is provided in private with the client.

A) Speak initially with the oldest family member to show respect. Rationale Members of the Asian culture have high respect for others, especially those in positions of authority. Extended family members need to be included in the nursing care plan. Southeast Asians do not necessarily refuse Western medications. Asians also believe that touching strangers is not acceptable, particularly health professionals whom they have not previously known.

A client is admitted to the hospital with intractable pain. Which instruction should the nurse provide the unlicensed assistive personnel (UAP) who is preparing to assist this client with a bed bath? A) Take measures to promote as much comfort as possible. B) Report any signs of drug addiction to the nurse immediately. C) Wait until the client's pain is gone before assisting with personal care. D) This client's pain will be difficult to manage since the cause is unknown.

A) Take measures to promote as much comfort as possible. Rationale Intractable pain is highly resistant to pain relief measures, so it is important to promote comfort during all activities.

Which statement best describes durable power of attorney for health care? A) The client signs a document that designates another person to make legally binding healthcare decisions if the client is unable to do so. B) The healthcare decisions made by another person designated by the client are not legally binding. C) Instructions about actions to be taken in the event of a client's terminal or irreversible condition are not legally binding. D) Directions regarding care in the event of a terminal or irreversible condition must be documented to ensure that they are legally binding.

A) The client signs a document that designates another person to make legally binding healthcare decisions if the client is unable to do so. Rationale The durable power of attorney is a legal document or a form of advance directive that designates another person to voice healthcare decisions when the client is unable to do so. A durable power of attorney for health directives is legally binding.

The nurse is preparing a male client who has an indwelling catheter and an IV infusion to ambulate from the bed to a chair for the first time following abdominal surgery. Which action(s) should the nurse implement prior to assisting the client to the chair? (Select all that apply.)Select all that apply A) Premedicate the client with an analgesic. B) Inform the client of the plan for moving to the chair. C) Obtain and place a portable commode by the bed. D) Ask the client to push the IV pole to the chair. E) Clamp the indwelling catheter. F) Assess the client's blood pressure.

A,B,D,F Rationale Premedicating the client with an analgesic reduces the client's pain during mobilization and maximizes compliance. To ensure the client's cooperation and promote independence, the nurse should inform the client about the plan for moving to the chair and encourage the client to participate by pushing the IV pole when walking to the chair. The nurse should assess the client's blood pressure prior to mobilization, which can cause orthostatic hypotension.

The nurse is performing a breast assessment. Which statement made by the client indicates a risk of breast cancer? Select all that apply. One, some, or all responses may be correct. A) "I had a late onset of menarche." B) "My first child was born when I was 32." C) "I noticed a slight discharge from a nipple." D) "I perform breast self-examinations frequently." E) "I consume two to four glasses of alcohol a day." F) "My provider prescribed hormone replacement therapy (HRT)" G) "I am go

B) "My first child was born when I was 32." C) "I noticed a slight discharge from a nipple." E) "I consume two to four glasses of alcohol a day." F) "My provider prescribed hormone replacement therapy (HRT)" H) "My new diet is not helping me with my obesity very much." Rationale: Clients who gave birth to a first child after the age of 30 are at a risk of breast cancer. Discharge from the nipple may indicate an early symptom of breast cancer. Consuming two to four glasses of alcohol daily may also increase the risk of breast cancer. The use of HRT containing estrogen and progestin increases the risk of breast cancer. Another risk factor is obesity. An early, not late, onset of menarche is a risk factor for breast cancer. Performing breast self-examinations frequently may help identify the early stages of breast cancer. The risk of breast cancer progressively increases after an individual turns 65 years old.

The nurse is caring for a client who is weak from inactivity because of a 2-week hospitalization. In planning care for the client, the nurse should include which range of motion (ROM) exercises? A) Passive ROM exercises to all joints on all extremities four times a day. B) Active ROM exercises to both arms and legs two or three times a day. C) Active ROM exercises with weights twice a day with 20 repetitions each. D) Passive ROM exercises to the point of resistance and slightly beyond.

B) Active ROM exercises to both arms and legs two or three times a day. Rationale Active, rather than passive, ROM is best to restore strength, and doing it two to three times a day is an effective schedule. ROM is not performed beyond the point of resistance or pain because of the risk of damage to underlying structures.

A client is demonstrating a positive Chvostek's sign. Which action should the nurse take? A) Observe the client's pupil size and response to light. B) Ask the client about numbness or tingling in the hands. C) Assess the client's serum potassium level. D) Restrict dietary intake of calcium-rich foods.

B) Ask the client about numbness or tingling in the hands. Rationale A positive Chvostek's sign is an indication of hypocalcemia, so the client should be assessed for the subjective symptoms of hypocalcemia, such as numbness or tingling of the hands or feet.

A male client with acquired immunodeficiency syndrome (AIDS) develops cryptococcal meningitis and tells the nurse he does not want to be resuscitated if his breathing stops. Which action should the nurse implement? A) Document the client's request in the medical record. B) Ask the client if this decision has been discussed with his healthcare provider. C) Inform the client that a written, notarized advance directive, is required to withhold resuscitation efforts. D) Advise the client to designate a person to make healthcare decisions when the client is unable to do so.

B) Ask the client if this decision has been discussed with his healthcare provider. Rationale Advance directives are written statements of a person's wishes regarding medical care, and verbal directives may be given to a healthcare provider with specific instructions in the presence of two witnesses. To obtain this prescription, the client should discuss his choice with the healthcare provider.

A male client with an infected wound tells the nurse that he follows a macrobiotic diet. Which type of foods should the nurse recommend that the client select from the hospital menu? A) Low fat and low sodium foods. B) Combination of plant proteins to provide essential amino acids. C) Limited complex carbohydrates and fiber. D) Increased amount of vitamin C and beta carotene-rich foods.

B) Combination of plant proteins to provide essential amino acids. Rationale A macrobiotic diet is high in whole-grain cereals, vegetables, sea vegetables, beans, and vegetarian soups, and the client needs essential amino acids to provide complete proteins to heal the infected wound. Although a macrobiotic diet contains no source of animal protein, essential amino acids should be obtained by combining plant (incomplete) proteins to provide complete (all essential amino acids) proteins for anabolic processes.

Which action should the nurse implement when adding sterile liquids to a sterile field? A) Use an outdated sterile liquid if the bottle is sealed and has not been opened. B) Consider the sterile field contaminated if it becomes wet during the procedure. C) Remove the container cap and lay it with the inside facing down on the sterile field. D) Hold the container high and pour the solution into a receptacle at the back of the sterile field.

B) Consider the sterile field contaminated if it becomes wet during the procedure. Rationale Wet or damp areas on a sterile field allow organisms to wick from the table surface and permeate into the sterile area, so the field is considered contaminated if it becomes wet. Outdated liquids may be contaminated and should be discarded. The container's cap should be removed, placed facing up, and off the sterile field. To prevent contamination of the sterile field, liquids should be held close (6 inches) to the receptacle when pouring to prevent splashing, and the receptacle should be placed near the front edge to avoid reaching over or across the sterile field.

The nurse is preparing to irrigate a client's indwelling urinary catheter using an open technique. Which action should the nurse take after applying gloves? A) Empty the client's urinary drainage bag. B) Draw up the irrigating solution into the syringe. C) Secure the client's catheter to the drainage tubing. D) Use aseptic technique to instill the irrigating solution.

B) Draw up the irrigating solution into the syringe. Rationale To irrigate an indwelling urinary catheter, the nurse should first apply gloves, then draw up the irrigating solution into the syringe. The syringe is then attached to the catheter and the fluid is instilled, using aseptic technique. Once the irrigating solution is instilled, the client's catheter should be secured to the drainage tubing. The urinary drainage bag can be emptied whenever intake and output measurement is indicated, and the instilled irrigating fluid can be subtracted from the output at that time.

The nurse is preparing to give a dehydrated client IV fluid delivered at a continuous rate of 175 mL/hour. Which infusion device should the nurse use? A) Portable syringe pump. B) Electronic infusion device/smart pump. C) Volumetric controller. D) Nonvolumetric controller.

B) Electronic infusion device/smart pump. Rationale An electronic infusion device/smart pump should be used to accurately deliver large volumes of fluid over longer periods of time with extreme precision, such as mL/hour. A syringe pump is accurate for low-dose continuous infusion of low-dose medication at a basal rate, but not large fluid volume replacement. Volumetric and nonvolumetric controllers count drops/minute to administer fluid volume and are inherently inaccurate because of variations in drop size.

When caring for an immobile client, what nursing problem has the highest priority? A) Risk for fluid volume deficit. B) Impaired gas exchange. C) Risk for impaired skin integrity. D) Altered tissue perfusion.

B) Impaired gas exchange. Rationale The ABCs of caring for clients are airway, breathing, and circulation. Impaired gas exchange implies that the client is having trouble breathing, which has the highest priority of the nursing problems listed.

A male client with venous incompetence stands up and his blood pressure subsequently drops. Which finding should the nurse identify as a compensatory response? A) Bradycardia. B) Increase in pulse rate C) .Peripheral vasodilation. D) Increase in cardiac output.

B) Increase in pulse rate Rationale When postural hypotension occurs, the body attempts to restore arterial pressure by stimulating the baroreceptors to increase the heart rate, not decrease it. Peripheral vasoconstriction of the veins and arterioles occurs with venous incompetence through the baroreceptor reflex. A decrease in cardiac output occurs when orthostatic hypotension occurs.

Which action should the nurse implement to mitigate the formation of a hip pressure injury for a client who is immobile? A) Maintain in a lateral position using protective wrist and vest devices. B) Partial side lying with hip elevated to 30 degrees (30-degree lateral position). C) Raise the head and knee gatch when lying in a supine position. D) Transfer into a wheelchair close to the nurse's station for observation.

B) Partial side lying with hip elevated to 30 degrees (30-degree lateral position). Rationale The partial side-lying position with hip elevation maintains alignment and provides the best pressure relief over the hip bony prominence. Raising the head and bed gatch may reduce shearing forces due to sliding down in bed, but it interferes with venous return from the legs and places pressure on the sacrum, predisposing to pressure injury formation. Sitting in a wheelchair places the body weight over the ischial tuberosities and predisposes it to a potential pressure point.

On the third postoperative day following thoracic surgery, a client reports feeling constipated. Which intervention should the nurse implement to promote bowel elimination? A) Remind the client to turn every two hours while lying in bed. B) Provide warm prune juice before the client goes to bed at night. C) Teach the client to splint the incision while walking to the bathroom. D) Administer an analgesic before the client attempts to defecate.

B) Provide warm prune juice before the client goes to bed at night. Rationale Prune juice is a natural laxative that stimulates peristalsis, and warming the prune juice facilitates peristalsis.

The nurse is digitally removing a fecal impaction for a client. The nurse should stop the procedure and take corrective action if which client reaction is noted? A) Temperature increases. B) Pulse rate decreases from 78 to 52 beats/min. C) Respiratory rate increases from 16 to 24 breaths/min. D) Blood pressure increases from 110/84 to 118/88 mm/Hg.

B) Pulse rate decreases from 78 to 52 beats/min. Rationale Parasympathetic reaction can occur as a result of digital stimulation of the anal sphincter, which should be stopped if the client experiences a vagal response, such as bradycardia.

A male client arrives at the outpatient surgery center for a scheduled needle aspiration of the knee. He tells the nurse that he has already given verbal consent for the procedure to the healthcare provider. Which action should the nurse pursue next? A) Witness the client's signature on the consent form. B) Verify the client's consent with the healthcare provider. C) Notify the healthcare provider that the client is ready for the procedure. D) Document that the client has given consent for the needle aspiration.

B) Verify the client's consent with the healthcare provider. Rationale Written informed consent is required prior to any invasive procedure. The healthcare provider must explain the procedure to the client, but the nurse can witness the client's signature on a consent form. If the nurse was not present when the HCP explained the procedure/surgery, then the first action before witnessing the client's signature on the consent should be to verify that the HCP indeed, received verbal consent from the client.

A single mother of two teenagers, ages 16 and 18, was just told that she has advanced cancer. She is devastated by the news and expresses her concern about who will care for her children. Which statement by the nurse is likely to be most helpful at this time? A) "Your children are old enough to help you make decisions about their futures." B) "The social worker can tell you about placement alternatives for your children." C) "Tell me what you would like to see happen with your children in the future." D) "You have just received bad news, and you need some time to adjust to it."

C) "Tell me what you would like to see happen with your children in the future." Rationale The nurse should first assess what the client desires. Though a referral to the social worker may be indicated, the nurse should first offer support. Time is likely to help the client cope with this news, but the nurse should first provide support and assess what the client wants to see happen with her children.

Which technique is most important for the nurse to implement when performing a physical assessment? A) A head-to-toe approach. B) The medical systems model. C) A consistent, systematic approach. D) An approach related to a nursing model.

C) A consistent, systematic approach. Rationale The most important factor in performing a physical assessment is following a consistent and systematic technique each time an assessment is performed to minimize variation in the sequence which may increase the likelihood of omitting a step or exam of an isolated area. The method of completing a physical assessment may be at the discretion of the examiner, but a consistent sequence by the examiner provides a reliable method to ensure a thorough review of the clients' history, complaints, or body systems.

What is the rationale for using the nursing process in planning care for clients? A) As a scientific process to identify nursing problems based on a clients' healthcare diagnoses. B) To establish a nursing theory that incorporates the biopsychosocial nature of humans. C) As a tool to organize thinking and clinical decision-making about clients' healthcare needs. D) To promote the management of client care in collaboration with other healthcare professionals.

C) As a tool to organize thinking and clinical decision-making about clients' healthcare needs. Rationale The nursing process is a problem-solving approach that provides an organized, systematic, decision-making process to effectively address the client's needs and problems. The nursing process includes an organized framework using knowledge, judgments, and actions by the nurse as the client's plan of care is determined and encompasses recognizing cues, analyzing cues, prioritizing hypotheses, generating solutions, taking actions, and evaluating outcomes.

As the nurse prepares the equipment to be used to start an IV on a 4-year-old boy in the treatment room, he cries continuously. Which intervention should the nurse implement? A) Take the child back to his room. B) Recruit others to restrain the child. C) Ask the mother to be present to soothe the child. D) Show the child how to manipulate the equipment.

C) Ask the mother to be present to soothe the child. Rationale A 4-year-old typically has a vivid imagination and lacks concrete thinking abilities. The mother's assistance can provide a stabilizing presence to help soothe the child, who may perceive the invasive procedure as mutilating. To preserve the child's sense of security associated with the hospital room, it is best to perform difficult or painful procedures in another area.

Before administering a client's medication, the nurse assesses a change in the client's condition and decides to withhold the medication until consulting with the healthcare provider. After consultation with the healthcare provider, the dose of the medication is changed and the nurse administers the newly prescribed dose an hour later than the originally scheduled time. Which action should the nurse implement in response to this situation? A) Notify the charge nurse that a medication error occurred. B) Submit a medication variance report to the supervisor. C) Document the events that occurred in the nurses' notes. D) Discard the original medication administration record.

C) Document the events that occurred in the nurses' notes. Rationale The nurse took the correct action and should document the events that occurred in the nurses' notes.

The nurse expects a client with an elevated temperature to exhibit which indicators of pyrexia? Select all that apply. One, some, or all responses may be correct. A) Dyspnea B) Increased appetite C) Flushed face D) Precordial pain E) Increased pulse rate F) Increased blood pressure G) General lethargy H) Chills

C) Flushed face E) Increased pulse rate G) General lethargy H) Chills Rationale: Increased body heat dilates blood vessels, causing a flushed face. The pulse rate increases to meet increased tissue demands for oxygen in the febrile state. The client with a fever may demonstrate general lethargy or report chills. Fever may not cause difficulty breathing. Appetite will be decreased, not increased in the presence of a fever. Precordial pain is not related to fever. Blood pressure is not expected to increase with fever.

A client is admitted with a stage four pressure injury that has a black, hardened surface (eschar) that is stable. Which dressing is best for the nurse to use first? A) Hydrogel. B) Exudate absorber. C) No dressing. D) Transparent adhesive film

C) No dressing. Rationale If eschar is dry and intact and debridement is not part of the plan of care, no dressing is used, allowing eschar to act as physiological cover.

In providing care for a terminally ill resident of a long-term care facility, the nurse determines that the resident is exhibiting signs of impending death and has a do not resuscitate or DNR status. Which intervention should the nurse implement first? A) Request hospice care for the client. B) Report the client's acuity level to the nursing supervisor. C) Notify family members of the client's condition. D) Inform the chaplain that the client's death is imminent.

C) Notify family members of the client's condition. Rationale The nurse's first priority is to notify the family of the resident's impending death.

The nurse removes the dressing on a client's heel that is covering a pressure injury one inch in diameter and finds that there is straw-colored drainage seeping from the wound. Which description of this finding should the nurse include in the client's record? A) Stage 1 pressure injury draining serosanguineous drainage. B) Pressure injury at bony prominence with exudate noted. C) One-inch pressure injury draining serous fluid. D) Pressure injury on the heel with a small amount of purulent drainage.

C) One-inch pressure injury draining serous fluid. Rationale Serous drainage is clear watery plasma and provides accurate documentation based on the information provided. Information to stage this pressure injury is not provided, and serosanguineous drainage is pale and watery with a combination of plasma and red cells and may be blood-streaked. Exudate is a fluid such as pus and serum. Purulent drainage is thick, yellow, green, or brown indicating the presence of dead or living organisms and white blood cells.

How should the nurse handle linens that are soiled with incontinent feces? A) Put the soiled linens in an isolation bag, then place it in the dirty linen hamper. B) Place an isolation hamper in the client's room and discard the linens in it. C) Place the soiled linens in the designated fluid-resistant dirty linen bag and deposit them in the dirty linen hamper. D) Ask the housekeeping staff to pick up the soiled linen from the dirty utility room.

C) Place the soiled linens in the designated fluid-resistant dirty linen bag and deposit them in the dirty linen hamper. Rationale The nurse should be careful to keep the soiled linens from contaminating the fresh linens and should handle the soiled linens like any other dirty linens as outlined in the facility guidelines/protocols.

A 50-year-old client is diagnosed with chronic obstructive pulmonary disease (COPD). Which vital signs obtained by the nurse indicate an improvement in condition? Select the 3 findings that indicate client improvement. A) Radial pulse: 88 beats/min B) Temp: 98.6 C) R: 14 beats/min D) BP: 110/70 Hg E) O2 Sat: 92% F) Pain 2/10

C) Respiratory rate: 14 breaths/min D) Blood pressure: 110/70 mm Hg E) Oxygen saturation: 92% Rationale: The respiratory rate in older adults ranges from 12 to 20 breaths/min, and this range may be elevated in clients with chronic obstructive pulmonary disease (COPD). Thus, a rate decrease to 14 breaths/min indicates a positive outcome, as it is within normal range. COPD may also cause high blood pressure. Thus, a blood pressure of 110/70 mm Hg obtained during therapy indicates a positive outcome. The normal oxygen saturation rate should be 95% to 100%. An oxygen saturation increase from 88% to 92% indicates a positive outcome of the therapy. The radial pulse is slightly elevated but relatively unchanged, which does not demonstrate an improvement in condition. A body temperature reading of 98.6°F (37°C), is considered normal and not a sign of COPD. A pain score of 2 out of 10 does not indicate a positive or negative outcome and is not a sign of COPD.

The nurse notes that a client consistently coughs while eating and drinking. Which nursing problem is most important for the nurse to include in this client's plan of care? A) Ineffective breathing pattern. B) Impaired gas exchange. C) Risk for aspiration. D) Ineffective airway clearance.

C) Risk for aspiration. Rationale Coughing during or after meals is a manifestation of dysphagia, or difficulty swallowing, which places the client at risk for aspiration. Dysphagia can lead to aspiration pneumonia, but the client is not currently exhibiting any symptoms of breathing difficulty or impaired gas exchange.

A client with chronic renal disease is admitted to the hospital for evaluation prior to a surgical procedure. Which laboratory test indicates the client's protein status for the longest length of time? A) Transferrin. B) Prealbumin. C) Serum albumin. D) Urine urea nitrogen.

C) Serum albumin. Rationale Serum albumin has a long half-life and is the best long-term indicator of the body's entry into a catabolic state following protein depletion from malnutrition or stress of chronic illness.

The home health nurse visits an older female client who had a stroke three months ago and is now able to ambulate with the assistance of a quad cane. Which assessment finding has the greatest implications for this client's care? A) The husband, who is the caregiver, begins to weep when the nurse asks how he is doing. B) The client tells the nurse that she does not have much of an appetite today. C) The nurse notes that there are numerous scatter rugs throughout the house. D) The client's pulse rate is 10 beats higher than it was at the last visit one week ago.

C) The nurse notes that there are numerous scatter rugs throughout the house. Rationale Scatter rugs pose a safety hazard because the client can trip on them when ambulating, so this finding has the greatest significance in planning this client's care. Psychological support of the caregiver is a less acute need than that of client safety. The other options are not safety priorities.

Which statement correctly identifies a written learning objective for a client with peripheral vascular disease? A) The nurse will provide client instruction for daily foot care. B) The client will demonstrate proper trimming toenail technique. C) Upon discharge, the client will list three ways to protect the feet from injury. D) After instruction, the nurse will ensure the client understands the foot care rationale.

C) Upon discharge, the client will list three ways to protect the feet from injury. Rationale An objective should contain four elements: who will perform the activity or acquire the desired behavior, the actual behavior that the learner will exhibit, the condition under which the behavior is to be demonstrated, and the specific criteria to be used to measure success. "Upon discharge, the client will list three ways to protect the feet from injury" is a concise statement that is a learning objective that defines exactly how the client will demonstrate mastery of the content.

A nurse is preparing to insert a rectal suppository and observes a small amount of rectal bleeding. Which action should the nurse implement? A) Administer the medication as scheduled after assessing the client's vital signs. B) Ask the pharmacist to send an alternate form of the prescribed medication to the unit. C) Withhold the administration of the suppository until contacting the healthcare provider. D) Insert the suppository very gently being careful not to further injure the rectal mucosa.

C) Withhold the administration of the suppository until contacting the healthcare provider. Rationale The presence of rectal bleeding is generally a contraindication for the insertion of a rectal suppository, so the nurse should withhold the medication and notify the healthcare provider.

According to Erikson's stages of life, which is the stage of development when a child begins walking, feeding, and using the toilet? A) Trust vs. mistrust B) Initiative vs guilt C) Identity vs role confusion D) Autonomy vs sense of shame and doubt

D) Autonomy vs sense of shame and doubt At 1 to 3 years of age, a child starts walking, feeding, and using the toilet on their own. This stage is one of autonomy vs sense of shame and doubt. The stage from birth to 1 year when the infant develops trust toward the parent or the caregiver is known as the trust vs mistrust stage. The initiative vs guilt stage is marked by the child's fantasies and imaginations motivating the child to explore their environment. The identity vs role confusion stage begins after adolescence. During this stage, the adolescent aims to find their identity.

The charge nurse observes an unlicensed assistive personnel (UAP) bending at the waist to lift a 20-pound box of medical supplies off the treatment room floor. Which instruction should the charge nurse provide to the UAP? A) Ask another staff member for assistance. B) Request that supplies are delivered in smaller containers. C) Push the box against the wall to provide support while lifting. D) Bend at the knees when lifting heavy objects.

D) Bend at the knees when lifting heavy objects. Rationale A 20-pound box is safely lifted by bending the knees, holding the box close to the center of gravity, and extending the legs using the quadriceps muscles.

A client with Raynaud's phenomenon asks the nurse about using biofeedback for self-management of symptoms. Which response is best for the nurse to provide? A) The responses to biofeedback have not been well established and may be a waste of time and money. B) Biofeedback requires extensive training to retrain voluntary muscles, not involuntary responses. C) Although biofeedback is easily learned, it is most often used to manage the exacerbation of symptoms. D) Biofeedback allows the client to control involuntary responses to promote peripheral vasodilation.

D) Biofeedback allows the client to control involuntary responses to promote peripheral vasodilation. Rationale Biofeedback involves the use of various monitoring devices that help people become more aware and able to control their own physiologic responses, such as heart rate, body temperature, muscle tension, and brain waves. Biofeedback allows the client to control involuntary responses to promote peripheral vasodilation, which is an accurate statement concerning its use for clients with Raynaud's phenomenon.

The nurse is providing passive range of motion (ROM) exercises to the hip and knee for a client who is unconscious. After supporting the client's knee with one hand, which action should the nurse take next? A) Raise the bed to a comfortable working level. B) Bend the client's knee. C) Move the knee toward the chest as far as it will go. D) Cradle the client's heel.

D) Cradle the client's heel. Rationale Passive ROM exercise for the hip and knee is provided by supporting the joints of the knee and ankle and gently moving the limb in a slow, smooth, firm but gentle manner. Raising the bed should be done before the exercises are begun to prevent injury to the nurse and client. Bending the knee is carried out after both joints are supported. After the knee is bent, the knee is moved toward the chest to the point of resistance two or three times.

A 75-year-old client who has a history of end-stage renal failure and advanced lung cancer recently had a stroke. Two days ago the healthcare provider discontinued the client's dialysis treatments, stating that death is inevitable, but the client is disoriented and will not sign a DNR directive. Which is the priority nursing intervention? A) Review the client's most recent laboratory reports. B) Refer the client and family members for hospice care. C) Notify the hospital ethics committee of the client's situation. D) Determine who is legally empowered to make decisions.

D) Determine who is legally empowered to make decisions. Rationale When death is impending, it is essential for the nurse to determine who is legally empowered to make decisions regarding the use of life-saving measures for the client.

An older female client with rheumatoid arthritis is reporting severe joint pain that is caused by the weight of the linen on her legs. Which action should the nurse implement first? A) Apply flannel pajamas to provide warmth. B) Administer a PRN dose of ibuprofen. C) Perform range of motion exercises in a warm tub. D) Drape the sheets over the footboard of the bed.

D) Drape the sheets over the footboard of the bed. Rationale The nurse should first provide an immediate comfort measure to address the client's complaint about the linens and drape the linens over the footboard of the bed instead of tucking them under the mattress, which can add pressure perceived by the client as the source of her pain.

When making the bed of a client who needs a bed cradle, which action should the nurse include? A) Teach the client to call for help before getting out of bed. B) Keep both the upper and lower side rails in a raised position. C) Keep the bed in the lowest position while changing the sheets. D) Drape the top sheet and covers loosely over the bed cradle.

D) Drape the top sheet and covers loosely over the bed cradle. Rationale A bed cradle is used to keep the top bedclothes off the client, so the nurse should drape the top sheet and covers loosely over the cradle. A client using a bed cradle may still be able to ambulate independently and does not require raised side rails.

The nurse formulates the nursing problem of, "Ineffective health maintenance related to lack of motivation" for a client with Type 2 diabetes. Which finding supports this nursing problem? A) Does not check capillary blood glucose as directed. B) Occasionally forgets to take daily prescribed medication. C) Cannot identify signs or symptoms of high and low blood glucose. D) Eats anything and does not think diet makes a difference in health.

D) Eats anything and does not think diet makes a difference in health. Rationale The nursing problem of ineffective health maintenance refers to an inability to identify, manage, and/or seek out help to maintain health, and is best exemplified in the client's belief or understanding about diet and health maintenance.

A client provides the nurse with information about the reason for seeking care. The nurse realizes that some information about past hospitalizations is missing. How should the nurse obtain this information? A) Solicit information on hospitalization from the insurance company. B) Look up previous medical records from archived hospital documents. C) Ask the client to discuss previous hospitalizations in the last 5 years. D) Elicit specific facts about past hospitalizations with direct questions.

D) Elicit specific facts about past hospitalizations with direct questions. Rationale Direct questions should be used after the client's opening narrative to fill in any details that have been left out or during the review of systems to elicit specific facts about past health problems.

Which client care activity requires the nurse to wear barrier gloves as required by the protocol for standard precautions? A) Removing the empty food tray from a client with a urinary catheter. B) Washing and combing the hair of a client with a fractured leg in traction. C) Administering oral medications to a cooperative client with a wound infection. D) Emptying the urinary catheter drainage bag for a client with Alzheimer's disease.

D) Emptying the urinary catheter drainage bag for a client with Alzheimer's disease. Rationale Possible contact with body secretions, excretions, or broken skin is an indication of wearing barrier (nonsterile) gloves. Emptying a urine drainage bag requires the use of gloves.

A 35-year-old female client with cancer refuses to allow the nurse to insert an IV for a scheduled chemotherapy treatment and states that she is ready to go home to die. Which intervention should the nurse initiate? A) Review the client's medical record for an advance directive. B) Determine if a do-not-resuscitate prescription has been obtained. C) Document that the client is being discharged against medical advice. D) Evaluate the client's mental status for competence to refuse treatment.

D) Evaluate the client's mental status for competence to refuse treatment. Rationale Competent clients have the right to refuse treatment, so the nurse should first ensure that the client is competent.

Which activity should the nurse use in the evaluation phase of the nursing process? A) Ask a client to evaluate the nursing care provided. B) Document the nursing care plan in the progress notes. C) Determine whether a client's health problems have been alleviated. D) Examine the effectiveness of nursing interventions toward meeting client outcomes.

D) Examine the effectiveness of nursing interventions toward meeting client outcomes. Rationale In the nursing process, the evaluation component examines the effectiveness of nursing interventions in achieving client outcomes.

A nurse observes a student nurse taking a copy of a client's medication administration record. When questioned, the student states, "Another student is scheduled to administer medications for this client tomorrow, so I am going to make a copy to help my friend prepare for tomorrow's clinical." Which response should the nurse provide first? A) Ask the nursing supervisor to meet with the students. B) Notify the student's clinical instructor of the situation. C) Ask the student if permission was obtained from the client. D) Explain that the records are hospital property and may not be removed.

D) Explain that the records are hospital property and may not be removed. Rationale The nurse should deal with the issue immediately and explain that a client's records are the property of the hospital and cannot be removed, even with the client's permission. Next, the clinical instructor should be notified so that all students can be educated regarding copying and removing clinical records from the healthcare agency. The nursing supervisor should also be alerted to ensure appropriate supervision of students as well as the protection of client information.

A healthcare provider is performing a sterile procedure at a client's bedside. Near the end of the procedure, the nurse observes the healthcare provider contaminating a sterile glove and the sterile field. Which is the best action for the nurse to implement? A) Report the healthcare provider for the violation in aseptic technique. B) Allow the completion of the procedure. C) Ask if the glove and sterile field are contaminated. D) Identify the break in surgical asepsis and provide another set of sterile supplies.

D) Identify the break in surgical asepsis and provide another set of sterile supplies. Rationale Any possible break in surgical asepsis that is identified when others are unaware should be considered contaminated and new sterile supplies added to maintain the sterile field. When sterility is suspected during aseptic technique, it should not be questioned but all members of the team should move forward with reestablishing a sterile field. Allowing the procedure to progress under unsterile conditions places the client at risk for infection and is an act of omission (negligence) by the nurse and other healthcare team members.

Which statement is an example of a correctly written nursing problem statement? A) Altered tissue perfusion related to heart failure. B) Altered urinary elimination related to urinary tract infection. C) Risk for impaired tissue integrity related to the client's refusal to turn. D) Ineffective coping related to an inadequate level of perception of control.

D) Ineffective coping related to an inadequate level of perception of control. Rationale The first part of the nursing problem statement is the diagnostic label. This is followed by the cause of the problem which was identified. The etiology is the "related to" which directs the nurse to the appropriate interventions.

The charge nurse assigns a nursing procedure to a new staff nurse who has not previously performed the procedure. Which action is most important for the new staff nurse to take? A) Review the steps in the procedure manual. B) Ask another nurse to assist while implementing the procedure. C) Follow the agency's policy and procedure. D) Inform the charge nurse that they have never done this procedure.

D) Inform the charge nurse that they have never done this procedure. Rationale According to states' nurse practice acts, it is the responsibility of the nurse to function within safe nursing practice, and in this case, safe nursing practice constitutes informing the charge nurse that they have never done the procedure. Although state mandates, agency policies, and continued education and experience identify tasks that are within the scope of nursing practice, nurses should first inform those in leadership when asked to perform tasks that are beyond their proficiency, and then pursue opportunities to enhance their competency.

A client in hospice care develops audible gurgling sounds on inspiration. Which nursing action has the highest priority? A) Ensure cultural customs are observed. B) Increase oxygen flow to 4L/minute. C) Auscultate bilateral lung fields. D) Inform the family that death is imminent.

D) Inform the family that death is imminent. Rationale An audible gurgling sound produced by a dying client is characteristic of an ineffective clearance of secretions from the lungs or upper airways, causing a rattling sound as air moves through the accumulated fluid. The nursing priority in this situation is to convey to the family that the client's death is imminent.

An older client who is able to stand but not ambulate receives a prescription to be mobilized into a chair as tolerated during each day. Which is the best action for the nurse to implement when assisting the client from the bed to the chair? A) Use a mechanical lift to transfer from the bed to a chair. B) Place a roller board under the client who is sitting on the side of the bed and slide the client to the chair. C) Lift the client out of bed to the chair with another staff member using a coordinated effort on the count of three. D) Place a transfer belt around the client, assist them to stand, and pivot to a chair that is placed at a right angle to the bed.

D) Place a transfer belt around the client, assist them to stand, and pivot to a chair that is placed at a right angle to the bed. Rationale A client who can stand can safely be assisted to pivot and transfer with the use of a transfer belt. A mechanical lift is usually used for a client who is obese, unable to be weight-bearing, and who is unable to assist. Roller boards placed under a sheet are used to facilitate the transfer of a recumbent client who is being transferred to and from a stretcher. Lifting a client out of bed places the client and nurses at risk for injury and should only be implemented by skilled lift teams.

A client with a history of cardiac dysrhythmias is admitted to the hospital due to a fluid volume deficit caused by a pulmonary infection. Which physiologic change would the nurse expect with this client? Select the 3 findings that the nurse would expect. A) Respiratory rate of 12 breaths/minute B) Blood pressure of 135/80 mm Hg C) Oxygen saturation of 100% D) Temporal temperature of 101.2°F (38.4°C) E) Radial pulse rate of 72 and irregular F) Pain of 6 of 10 with coughing

D) Temporal temperature of 101.2°F (38.4°C) E) Radial pulse rate of 72 and irregular F) Pain of 6 of 10 with coughing Rationale: The normal temperature range is 96.8°F (36°C) to 100.4°F (38°C); temperature is often elevated with any type of infection. Cardiac dysrhythmias are associated with a pulse deficit in which the radial pulse would be irregular; reassessment would not be required. Pleural pain associated with cough is expected with a pulmonary infection. In pulmonary infections, the respiratory rate would more likely be elevated than at the low end of normal. In fluid volume deficit, the blood pressure may be decreased. If oxygen saturation was changed with this client, it would be decreased, whereas 100% is at the high end of normal. A respiratory rate of 12 breaths/minute, a blood pressure of 135/80 mm Hg, and an oxygen saturation of 100% would not be considered physiologic changes expected with this client.

A male client has a nursing problem of "spiritual distress." Which intervention is best for the nurse to implement when caring for this client? A) Use distraction techniques during times of spiritual stress and crisis. B) Reassure the client that his faith will be regained with time and support. C) Consult with the staff chaplain and ask that the chaplain visits with the client. D) Use reflective listening techniques when the client expresses spiritual doubts.

D) Use reflective listening techniques when the client expresses spiritual doubts. Rationale The most beneficial nursing intervention is to use nonjudgmental reflective listening techniques, to allow the client to feel comfortable expressing his concerns.

To obtain the most complete assessment data for a client with chronic pain, which information should the nurse obtain? A) Can you describe where your pain is the most severe? B) What is your pain intensity on a scale of 1 to 10? C) Is your pain best described as aching, throbbing, or sharp? D) Which activities during a routine day are impacted by your pain?

D) Which activities during a routine day are impacted by your pain? Rationale A client with chronic pain is more likely to have adapted physiologically to vital sign changes, localization, or intensity, so pain assessment should focus on any interference with daily activities, such as sleep, relationships with others, physical activity, and emotional well-being. Exacerbation of acute symptoms, such as pain distribution, patterns, intensity, and descriptors elicit specific assessment findings.

The home health nurse visits an older client who lives at home with her husband. The client is experiencing frequent episodes of diarrhea and bowel incontinence. Which problem, for which the client is at risk, has the greatest priority when planning the client's care? A) Disturbed sleep pattern. B) Caregiver role strain. C) Impaired skin integrity. D)Fluid volume imbalance.

D)Fluid volume imbalance. Rationale Diarrhea can lead to fluid volume loss, which is potentially life-threatening, so the highest priority is to prevent a fluid volume imbalance.

Choose the most likely options for the information missing from the statement by selecting from the lists of options provided. The nurse performs the ________________by _____________________________.

Tinel sign, tapping the client's wrist with index finger Rationale: The nurse would perform the Tinel sign by tapping the client's wrist with index finger. A positive Tinel sign (tingling sensation from wrist to hand) is indicative of median nerve compression or carpal tunnel syndrome. The repetitive work of being a secretary and the history of hypothyroidism make this client prone to carpal tunnel syndrome. While the Phalen test can also be used for assessment of median nerve compression, the correct technique is placing both client's wrists in a fully palmar-flexed position with the dorsal surfaces pressed together for 1 minute, not pulling the tibia anteriorly while stabilizing the femur. Pulling the tibia anteriorly while stabilizing the femur is the Lachman test, which assesses the anterior cruciate ligament for injury or tear, not the median nerve. The Neer test assesses for a rotator cuff tear or injury, not for median nerve compression, and is performed by depressing th

A medication is prescribed to be given QID. Which schedule should the nurse use to administer this prescription? A) 0800, 1200, 1600, 2000. B) 0800. C) Every other day at 0800. D) 0800, 1200, 1600, 2000, 0000, 0400.

A) 0800, 1200, 1600, 2000. Rationale QID means four times per day.

A female nurse who sometimes tries to save time by putting medications in her uniform pocket to deliver to clients confides that after arriving home she found a hydrocodone (Vicodin) tablet in her pocket. Which possible outcome of this situation should be the nurse's greatest concern? A) Accused of diversion. B) Reported for stealing. C) Reported for a HIPAA violation. D) Accused of unprofessional conduct.

A) Accused of diversion. Rationale Even if this is only one incident, the nurse may be suspected of taking medications on a regular basis and the incident could be interpreted as diversion, or diverting narcotics for her own use, which should be reported to the peer review committee and to the State Board of Nursing.

Which action by the nurse demonstrates culturally sensitive care? A) Asks permission before touching a client. B) Avoids questions about male-female relationships. C) Explains the differences between Western medical care and cultural folk remedies. D) Applies knowledge of a cultural group unless a client embraces Western customs.

A) Asks permission before touching a client. Rationale Physical contact, such as touching the head, in some cultures, is a sign of respect, whereas, in others, it is strictly forbidden. So asking permission before touching a client demonstrates culturally sensitive care.

Health & Physical Assessment HESI Which action would the nurse implement when a client is receiving total parenteral nutrition (TPN)? Select all that apply. One, some, or all responses may be correct. A) Assess hydration B) Ensure rapid delivery of each infusion C) Monitor weight daily D) Infuse using an electric pump E) Reassess vital signs every 4 hours F) Discard any solution after 24 hours G) Check the expiration date before administration H) Utilize peripheral IV for administration

A) Assess hydration, C) Monitor weight daily D) Infuse using an electric pump E) Reassess vital signs every 4 hours F) Discard any solution after 24 hours G) Check the expiration date before administration Rationale: It is important for the nurse to monitor hydration and weight to ensure that the client is receiving the correct amount of nutrition and fluids. An electric or smart pump is always used to infuse TPN to avoid too rapid of an infusion or a delay in administration. Vital signs would be monitored every 4 hours, as this may be an indicator of TPN complications. TPN would not be administered if it was expired, and any solution left after 24 hours would be discarded. TPN is usually administered continuously over 24 hours, or sometimes it is administered over 12-14 hours while the client sleeps. A rapid infusion of TPN causes blood glucose levels to go up and predisposes the client for hyperglycemic crisis. TPN should not be administered into a peripheral IV because of its hi

Which intervention should the nurse include in the plan of care for a client who is being treated with compression dressings for leg ulcers due to chronic venous insufficiency? A) Check capillary refill of toes on the lower extremity with venous compression dressings. B) Apply dressing to the wound area before applying the venous compression dressings. C) Wrap the leg from the knee down towards the foot. D) Remove the venous compression dressings every 8 hours to assess wound healing.

A) Check capillary refill of toes on the lower extremity with venous compression dressings. Rationale Venous compression dressings can be applied too tightly. Thus, it is important to check distally for adequate circulation.

A client who has moderate, persistent, chronic neuropathic pain due to diabetic neuropathy takes gabapentin and ibuprofen daily. If Step 2 of the World Health Organization (WHO) pain relief ladder is prescribed, which drug protocol should be implemented? A) Continue gabapentin. B) Discontinue ibuprofen. C) Add aspirin to the protocol. D) Add oral methadone to the protocol.

A) Continue gabapentin. Rationale Based on the WHO pain relief ladder, adjunct medications, such as gabapentin, an antiseizure medication, may be used at any step for anxiety and pain management, so continuing gabapentin should be implemented. Nonopioid analgesics, such as ibuprofen and aspirin are Step 1 drugs. Steps 2 and 3 include opioid narcotics, and to maintain freedom from pain, drugs should be given around the clock rather than by the client's PRN requests.

When preparing to administer an intravenous medication through a central venous catheter, the nurse aspirates a blood return in one of the lumens of the triple lumen catheter. Which action should the nurse implement? A) Flush the lumen with the saline solution and administer the medication through the lumen. B) Determine if a PRN prescription for a thrombolytic agent is listed on the medication record. C) Clamp the lumen and obtain a syringe of a dilute heparin solution to flush through the tubing. D) Withdraw the aspirated blood into the syringe and use a new syringe to administer the medication.

A) Flush the lumen with the saline solution and administer the medication through the lumen. Rationale Aspiration of a blood return in the lumen of a central venous catheter indicates that the catheter is in place and the medication can be administered. The nurse should flush the tubing with the saline solution, administer the medication, then flush the lumen with saline again. The aspirated blood can be flushed back through the closed system into the client's bloodstream and does not need to be withdrawn.

A middle-aged woman who enjoys being a teacher and mentor feels that she should pass down her legacy of knowledge and skills to the younger generation. According to Erickson's psychosocial developmental theory, she is involved in which developmental stage? A) Generativity. B) Ego integrity. C) Identification. D) Valuing wisdom.

A) Generativity. Rationale Healthy middle-aged adults focus on establishing the next generation by nurturing and guiding, which is described by Erikson as the developmental stage of generativity, and is characteristic of middle adulthood.

The nurse overhears the healthcare provider explaining to the client that the tumor removed was nonmalignant and that the client will be fine. However, the nurse has read in the pathology report that the tumor was malignant and that there is extensive metastasis. Who should the nurse consult with first regarding the situation? A) Healthcare provider B) .Client's family. C) Case manager. D) Chief of staff.

A) Healthcare provider Rationale The nurse should address the healthcare provider with the written report and discuss why he/she did not tell the client the truth - this may be at the family's request.

Which client assessment data is most important for the nurse to consider before ambulating a postoperative client? A) Respiratory rate. B) Wound location. C) Pedal pulses. D) Pain rating.

A) Respiratory rate. Rationale Mobilization and ambulation increase oxygen use, so it is most important to assess the client's respiratory rate before ambulation to determine tolerance for activity.

A female client who has breast cancer with metastasis to the liver and spine is admitted with constant, severe pain despite around-the-clock use of oxycodone and amitriptyline for pain control at home. During the admission assessment, which information is most important for the nurse to obtain? A) Sensory pattern, area, intensity, and nature of the pain. B) Trigger points identified by palpation and manual pressure of painful areas. C) Schedule and total dosages of drugs currently used for breakthrough pain. D) Sympathetic responses consistent with the onset of acute pain.

A) Sensory pattern, area, intensity, and nature of the pain. Rationale The components of every pain assessment should include sensory patterns, area, intensity, and nature (PAIN) of the pain and are essential in identifying appropriate therapy for the client's specific type and severity of pain, which may indicate the onset of disease progression or complications.

A low-sodium, low-protein diet is prescribed for a 45-year-old client with renal insufficiency and hypertension, who gained 3 pounds in the last month. The nurse determines that the client has been noncompliant with the diet, based on which report from the 24-hour dietary recall? (Select all that apply.)Select all that apply A) Snack of potato chips and diet soda. B) Lunch of tuna fish sandwich, carrot sticks, fresh fruit, and coffee. C) Breakfast of eggs, bacon, toast, and coffee. D) Dinner of vegetable lasagna, tossed salad, sherbet, and iced tea. E) Bedtime snack of crackers and milk.

A,B,C,E Rationale Potato chips are high in sodium. Tuna is high in protein. Bacon and crackers are high in sodium.

Which client statement indicates to the nurse that the client requires assistance with bathing? A) "I wasn't able to pack a bag before I left for the hospital." B) "I don't understand why I'm so weak and tired." C) "I only bathe every other day." D) "I left my eyeglasses at home."

B) "I don't understand why I'm so weak and tired." Rationale Bathing often makes a client feel weak, and if a client is already feeling weak, assistance is required during the bathing process to ensure the client's safety.

A male nurse is assigned to care for a female Muslim client. When the nurse offers to bathe the client, the client requests that a female nurse perform this task. How should the male nurse respond? A) "May I ask your daughter to help you with your personal hygiene?" B) "I will ask one of the female nursing techs to bathe you." C) "A staff member on the next shift will help you." D) "I will keep you draped and hand you the supplies as you need them."

B) "I will ask one of the female nursing techs to bathe you." Rationale Many female Muslim clients are very modest and prefer to receive personal care from another female because of their religious and cultural beliefs. The most culturally sensitive response is for the male nurse to ask a female colleague to perform this task.

The daughter of an older woman who became depressed following the death of her husband asks, "My mother was always well-adjusted until my father died. Will she tend to be sick from now on?" Which response is best for the nurse to provide? A) "She is almost sure to be less able to adapt than before." B) "It's highly likely that she will recover and return to her pre-illness state." C) "If you can interest her in something besides religion, it will help her stay well." D) "Cultural strains contribute to each woman's tendencies for recurrences of depression."

B) "It's highly likely that she will recover and return to her pre-illness state." Rationale Analysis of behavior patterns using Erikson's framework can identify age-appropriate or arrested development of normal interpersonal skills. Erikson describes the successful resolution of a developmental crisis in the later years (older than 65 years) to include the achievement of a sense of integrity and fulfillment, wisdom, and a willingness to face one's own mortality and accept the death of others.

Prior to administering a newly prescribed medication to a client, the nurse reviews the adverse effects of the medication listed in a drug reference guide and determines the priority risks to the client. While performing this action, the nurse is engaged in which step of the nursing process? A) Assessment. B) Analysis. C) Implementation. D) Evaluation.

B) Analysis. Rationale The nurse is analyzing data to establish an individualized nursing problem, such as, "Risk for injury related to side effects of drugs." This analysis is based on assessment and guides the planning and implementation of care, such as the decision to monitor the client frequently. Evaluation provides the nurse with information about the effectiveness of the plan of care.

A client has a nursing problem of, "Spiritual distress related to a loss of hope, secondary to impending death." Which intervention is best for the nurse to implement when caring for this client? A) Help the client to accept the final stage of life. B) Assist and support the client in establishing short-term goals. C) Encourage the client to make future plans, even if they are unrealistic. D) Instruct the client's family to focus on positive aspects of the client's life.

B) Assist and support the client in establishing short-term goals. Rationale Hopefulness is necessary to sustain a meaningful existence, even close to death. The nurse should help the client set short-term goals, and recognize the achievement of immediate goals, such as seeing a family member or listening to music.

In assessing a client's femoral pulse, the nurse must use deep palpation to feel the pulsation while the client is in a supine position. Which action should the nurse implement? A) Elevate the head of the bed and attempt to palpate the site again. B) Document the presence and volume of the pulse palpated. C) Use a thigh cuff to measure the blood pressure in the leg. D) Record the presence of pitting edema in the inguinal area.

B) Document the presence and volume of the pulse palpated. Rationale Deep palpation may be required to palpate the femoral pulse, and, when palpated, the nurse should document the presence and volume of the pulse.

A nurse is becoming increasingly frustrated by the family members' efforts to participate in the care of a hospitalized client. Which action should the nurse implement to cope with these feelings of frustration? A) Suggest that other cultural practices be substituted by the family members. B) Examine one's own culturally based values, beliefs, attitudes, and practices. C) Explain to the family that multiple visitors are exhausting to the client. D) Allow the situation to continue until a family member's action may harm the client.

B) Examine one's own culturally based values, beliefs, attitudes, and practices. Rationale Acknowledging a client's beliefs and customs related to sickness and health care are valuable components in the plan of care that prevents conflict between the goals of nursing and the client's cultural practices. Cultural sensitivity begins with examining one's own cultural values to compare, recognize, and acknowledge cultural bias.

A 73-year-old Hispanic client is seen at the community health clinic with a history of protein malnutrition. Which information should the nurse obtain first? A) Amount of liquid protein supplements consumed daily. B) Foods and liquids consumed during the past 24 hours. C) Usual weekly intake of milk products and red meats. D)Grains and legume combinations used by the client.

B) Foods and liquids consumed during the past 24 hours. Rationale A client's dietary habits should be determined first by the client's dietary recall before suggesting protein sources or supplements as options in the client's diet. The client's cultural preferences should be elicited after confirming the client's dietary history.

The nurse is administering an intermittent infusion of an antibiotic to a client whose intravenous (IV) access is an antecubital saline lock. After the nurse opens the roller clamp on the IV tubing, the alarm on the infusion pump indicates an obstruction. Which action should the nurse take first? A) Check for a blood return. B) Reposition the client's arm. C) Remove the IV site dressing. D) Flush the lock with saline.

B) Reposition the client's arm. Rationale If the client's elbow is bent, the IV may be unable to infuse, resulting in an obstruction alarm, so the nurse should first attempt to reposition the client's arm to alleviate any obstruction. After other sources of occlusion are eliminated, the nurse may need to check for a blood return, remove the dressing, or flush the saline lock and then resume the intermittent infusion.

The nurse determines a client's IV solution is infusing at 250 mL/hr. The prescribed rate is 125 mL/hr. Which action should the nurse take first? A) Determine when the IV solution was started. B) Slow the IV infusion to keep vein open rate. C) Assess the IV insertion site for swelling. D) Report the finding to the healthcare provider.

B) Slow the IV infusion to keep vein open rate. Rationale The nurse should first slow the IV flow rate to keep vein open (KVO) rate to prevent further risk of fluid volume overload, then gather additional assessment data, such as when the IV solution was started and the appearance of the IV insertion site before contacting the healthcare provider for further instructions.

When assessing a client with an indwelling urinary catheter, which observation requires immediate intervention by the nurse? A) The drainage tubing is secured over the side rail. B) The clamp on the urinary drainage bag is open. C) There are no dependent loops in the drainage tubing. D) The urinary drainage bag is attached to the bed frame.

B) The clamp on the urinary drainage bag is open. Rationale Maintaining a closed urinary drainage system is important to prevent infection, so the most immediate priority is to close the clamp to reduce the risk of ascending microorganisms.

When the nurse enters a client's room to do an initial assessment, the client shouts, "Get out of my room! I'm tired of being bothered!" How should the nurse respond? A) "There is no reason to be so angry." B) "Why do I need to leave your room?" C) "What is concerning you this morning?" D) "Let me call the client advocate for you."

C) "What is concerning you this morning?" Rationale An open-ended question that encourages the client to discuss personal feelings. Acting defensively and asking "why" questions are likely to elicit more anger and block communication. By deferring to the client advocate, the nurse fails to even address the client's feelings of anger and exasperation.

A signed consent form indicated a client should have an electromyogram, but a myelogram was performed instead. Though the myelogram revealed the cause of the client's back pain, which was subsequently treated, the client filed a lawsuit against the nurse and healthcare provider for performing the incorrect procedure. The court is likely to rule in favor of the plaintiff because these events represent which infraction? A) A quasi-intentional tort because a similar mistake can happen to anyone. B) Failure to respect client autonomy to choose based on intentional tort law. C) Assault and battery with deliberate intent to deviate from the consent form. D) An unintentional tort because the client benefited from having the myelogram.

C) Assault and battery with deliberate intent to deviate from the consent form. Rationale The client was not properly informed of the procedure, and failure to obtain informed consent constitutes assault and battery.

When assessing a client with a nursing problem of fluid volume deficit, the nurse notes that the client's skin over the sternum tents when gently pinched. Which action should the nurse implement? A) Confirm the finding by further assessing the client for jugular vein distention. B) Offer the client high-protein snacks between regularly scheduled mealtimes. C) Continue the planned nursing interventions to restore the client's fluid volume. D) Change the plan of care to include a nursing diagnosis of impaired skin integrity.

C) Continue the planned nursing interventions to restore the client's fluid volume. Rationale Skin turgor is assessed by pinching the skin and observing for tenting. This finding confirms the diagnosis of fluid volume deficit, so the nurse should continue interventions to restore the client's fluid volume.

According to Piaget, during which developmental stage is the pediatric client egocentric? A) Infancy B) Adolescence C) Early childhood D) Middle childhood

C) Early childhood According to Piaget, the early childhood (toddle) and preschool-aged child are both egocentric. Infancy, adolescence, and middle childhood are not characterized as being egocentric, according to Piaget.

A female client informs the nurse that she uses herbal therapies to supplement her diet and manage common ailments. Which information should the nurse offer the client about the general use of herbal supplements? A) Most herbs are toxic or carcinogenic and should be used only when proven effective. B) There is no evidence that herbs are safe or effective as compared to conventional supplements in maintaining health. C) Herbs should be obtained from manufacturers with a history of quality control of their supplements. D) Herbal therapies may mask the symptoms of serious diseases, so frequent medical evaluation is required during use.

C) Herbs should be obtained from manufacturers with a history of quality control of their supplements. Rationale The current availability of many herbal supplements lacks federal regulation, research, control, and standardization in the manufacture of their purity and dose. Manufacturers that provide evidence of quality control, such as labeling that contains scientific generic name, name and address of the manufacturer, batch or lot number, date of manufacture, and expiration date, is the best information to provide.

A 4-year-old boy who is scheduled for a tonsillectomy and adenoidectomy asks the nurse, "Will it hurt to have my tonsils and adenoids taken out?" Which response is best for the nurse to provide? A) "It may hurt a little because of the incision made in your throat." B) "It won't hurt because you're such a big boy." C) "It won't hurt because we put you to sleep." D) "It may hurt but we'll give you medicine to help you feel better."

D) "It may hurt but we'll give you medicine to help you feel better." Rationale Answering questions simply and directly provides comfort for the preschool-age child and builds confidence in the healthcare team.

The nurse working in the emergency department is assessing four clients' ability to tolerate pain. Which client is likely to tolerate a higher level of pain? A) A 10-year-old who was burned by a camp fire earlier today. B) A 70-year-old who has a postoperative infection from a surgery one week ago. C) A 23-year-old woman who sprained her knee while bicycling. D) A 55-year-old woman who has had moderate low back pain for three months.

D) A 55-year-old woman who has had moderate low back pain for three months. Rationale Experiences with the same type of pain that has successfully been relieved makes it easier for a client to interpret the pain sensation, and as a result, the client is better prepared to take steps to relieve the pain.

A client who has been on bed rest for several days now has a prescription to progress activity as tolerated. When the nurse assists the client out of bed for the first time, the client becomes dizzy. Which action should the nurse implement? A) Encourage the client to take several slow, deep breaths while ambulating. B) Help the client to remain standing by the bedside until the dizziness is relieved. C) Instruct the client to remain on bedrest until the healthcare provider is contacted. D) Advise the client to sit on the side of the bed for a few minutes before standing again.

D) Advise the client to sit on the side of the bed for a few minutes before standing again. Rationale The nurse should implement sitting on the side of the bed because orthostatic hypotension is a common result of immobilization, causing the client to feel dizzy when first getting out of bed following a period of bed rest.

The nurse encounters a slight resistance when inserting the tubing into a client's rectum for a tap water enema. Which action should the nurse implement? A) Withdraw the tube and apply additional lubricant to the tip of the tube. B) Encourage the client to bear down and continue to insert the tube. C) Remove the tube and re-position the client to reinsert the tube. D) Ask the client to relax and twist the tube gently through the sphincter.

D) Ask the client to relax and twist the tube gently through the sphincter. Rationale If a slight resistance is encountered during the initial insertion of an enema tube, the nurse should instruct the client to breathe through the mouth which relaxes the anal sphincter and allows the tube to pass through.

The nurse assesses an immobile, older male client and determines that his blood pressure is 138/60 mmHg, his temperature is 95.8 °F (35.4 °C), and his output is 100 mL of concentrated urine during the last hour. He has wet-sounding lung sounds, and increased respiratory secretions. Based on these assessment findings, which nursing action is most important for the nurse to implement? A) Administer a PRN antihypertensive prescription. B) Provide the client with an additional blanket. C) Encourage additional fluid intake. D) Encourage the client to cough and deep breathe every 2 hours.

D) Encourage the client to cough and deep breathe every 2 hours. Rationale Coughing and deep breathing every 2 hours will help to move and drain respiratory secretions and prevent pneumonia from occurring, so this intervention has the highest priority. Older adults often have an increased BP, and a PRN antihypertensive medication is usually prescribed for a BP over 140 systolic and 90 diastolic.

While preparing to insert a rectal suppository in a male adult client, the nurse observes that the client is holding his breath while bearing down. Which action should the nurse implement? A) Advise the client to continue to bear down without holding his breath. B) Gently insert the lubricated suppository four inches into the rectum C) Perform a digital exam to determine if a fecal impaction is present. D) Instruct the client to take slow deep breaths and stop bearing down.

D) Instruct the client to take slow deep breaths and stop bearing down. Rationale During the administration of a rectal suppository, the client is asked to take slow deep breaths through the mouth to relax the anal sphincter. Bearing down will push the suppository out of the rectum, so the suppository should not be inserted while the client is bearing down.

Which nursing intervention is most beneficial in reducing the risk of urosepsis in a hospitalized client with an indwelling urinary catheter? A) Ensure that the client's perineal area is cleansed twice a day. B) Maintain accurate documentation of the fluid intake and output. C) Encourage frequent ambulation if allowed or regular turning if on bedrest. D) Obtain a prescription for removal of the catheter as soon as possible.

D) Obtain a prescription for removal of the catheter as soon as possible. Rationale The best intervention to reduce the risk of urosepsis (the spread of an infectious agent from the urinary tract to systemic circulation) is the removal of the urinary catheter as quickly as possible.

The nurse is discussing dietary preferences with a client who adheres to a vegan diet. Which dietary supplement should the nurse encourage the client to include in the dietary plan? A) Fiber. B) Folate. C) Ascorbic acid. D) Vitamin B12.

D) Vitamin B12. Rationale Vitamin B12 is normally found in liver, kidney, meat, fish, and dairy products. A vegan who consumes only vegetables without careful dietary planning and supplementation may develop peripheral neuropathy due to a deficiency in vitamin B12.

Choose the most likely options for the information missing from the statement by selecting from the lists of options provided. The nurse assesses the abdomen using the following sequence: the nurse will first_____________________ , then ________________________, followed by ________________________, and ending with __________________________.

First: inspect venous return patterns Then: auscultate bowel sounds Followed by: percussing liver borders Ending with: palpating liver border in right costal margin Rationale: The correct sequence for an abdominal assessment is inspection, auscultation, percussion, and palpation. Thus, the nurse would first inspect venous return patterns, auscultate bowel sounds, followed by percussing liver borders, and ending with palpating liver border in right costal margin. The abdomen is auscultated before percussion or palpation to obtain correct findings for bowel sounds. Manipulation of the abdomen can alter bowel sounds. The nurse incorporates liver assessments because the client is exhibiting signs of liver disease from alcohol drinking.