NP1 Exam 4 Critical Thinking

Which parenteral potassium order is safe for the nurse to implement? 1. Add 20 mEq of KCL to 1,000 mL of IV fluid 2. 10 mEq KCL IV over 1-2 minutes 3. Dilute 20 mEq KCL in 3 mL of NS and give IV push 4. 10 mEq KCL Subcut

1. Add 20 mEq of KCL to 1,000 mL of IV fluid

The client has been placed on a 1,200 mL oral fluid restriction. How should the nurse plan for this restriction? 1. Allow 600 mL from 7-3, 400 mL from 3-11, and 200 mL from 11-7. 2. Instruct the client that the 1,200 mL of fluid placed in the bedside pitcher must last until tomorrow. 3. Offer the client softer, cold foods such as sherbet and custard. 4. Remove fluids from diet trays and offer them only between meals.

1. Allow 600 mL from 7-3, 400 mL from 3-11, and 200 mL from 11-7.

An older client receiving intravenous fluids at 175 ml/hr is demonstrating crackles, shortness of breath, and distended neck veins. The nurse recognizes these findings as being which complication of intravenous fluid therapy? 1. An allergic reaction to the antibiotics in the fluid 2. Fluid volume excess 3. Pulmonary embolism 4. Speed shock

2. Fluid volume excess

The nurse should place highest priority on which nursing intervention for a patient with renal failure who has a potassium level of 6.8mEq/L? 1. Evaluate level of consciousness 2. Obtain an electrocardiogram (ECG) 3. Measure urinary output 4. . Draw arterial blood gases

2. Obtain an electrocardiogram (ECG)

Which statement provides evidence that an older adult who is prone to constipation is in need of further teaching? 1."I need to drink one and a half to two quarts of liquids each day." 2."I need to take a laxative such as Milk of Magnesia if I don't have a BM every day." 3."If my bowel pattern changes on its own, I should call you." 4."Eating my meals at regular times is likely to result in regular bowel movements."

2."I need to take a laxative such as Milk of Magnesia if I don't have a BM every day."

The nurse is caring for an 80-year-old client with the medical diagnosis of heart failure. The client has edema, orthopnea, and confusion. Which nursing diagnosis is most appropriate for this client? 1. Heart Failure related to edema, as evidenced by confusion 2. Fluid Volume Deficit related to loss of fluids as evidenced by edema 3. Excess Fluid Volume related to retention of fluids as evidenced by edema and orthopnea 4. Excess Fluid Volume related to congestive heart failure as evidenced by edema and confusion

3. Excess Fluid Volume related to retention of fluids as evidenced by edema and orthopnea

The nurse suspects that a client's body is attempting to correct an acid-base imbalance. How will this imbalance be corrected? 1. Slow but efficient respiratory regulation. 2. Primary regulation is through GI system losses. 3. Kidney regulation is powerfully effective. 4. The cardiovascular system is the major buffer.

3. Kidney regulation is powerfully effective.

The nurse is providing discharge instructions to a client who has been started on a diuretic: furosemide (Lasix) once daily. What information is essential to include in this information? 1. Take the medication at bedtime. 2. Avoid high-potassium foods. 3. Stand up slowly from a sitting position. 4. Do not take this medication on the days you take digitalis (Lanoxin).

3. Stand up slowly from a sitting position

After obtaining a unit of packed red blood cells for a client, the nurse learns the client needed to leave the care area for an emergency x-ray. What action should the nurse take? 1. Set up the blood with the IV fluid and y-tubing and place it on the IV standard in the client's room to initiate immediately after the client returns. 2. Place the blood in the unit refrigerator until the client returns. 3. Return the blood to the laboratory blood bank until the client returns. 4. Set up the blood with the IV fluid and y-tubing and place it in the unit medication room to initiate immediately after the client returns.

3: Blood should not be held at room temperature for more than 30 minutes before the transfusion is initiated. The unit must be returned to the laboratory blood bank until the client has returned from the CT.

The nurse considers the use of wrist restraints for a client with a medically necessary foley catheter based on which rationale? 1.The client is confused 2.The client is at risk for self-injury 3.There is no family member able to monitor client 4.The client is attempting to pull out F/C

4. The client is attempting to pull out F/C

Which physiologic change that commonly occurs in elderly males may affect insertion of the catheter? 1.Urethral stricture 2.Diminished bladder capacity 3.Weakened detrusor muscle 4.Prostate gland enlargement

4.Prostate gland enlargement

To encourage voiding, the nurse instructs the UAP to perform what intervention? 1.Apply firm pressure to the bladder for 2-3 minutes 2.Place the client's hand in a basin of cold water 3.Place the client in left lateral Sims' position 4.Turn on the tap water so water is running when the client attempts to void.

4.Turn on the tap water so water is running when the client attempts to void.

A senior student nurse delegates the task of intake and output to a new nursing assistant. The student will verify that the nursing assistant understands the task of I&O when the nursing assistant states: A. "I will record the amount of all voided urine." B. "I will not count liquid stools as output." C. "I will not record a café mocha as intake." D. "I will notate perspiration and record it as a small or large amount."

A. "I will record the amount of all voided urine."

The most common fluid imbalance associated with Congestive Heart Failure (CHF) is which of the following: A. Hypervolemia B. Hypovolemia C. Hyperkalemia D. Hypokalemia

A. Hypervolemia

Assessment findings by the nurse reveal the patient has an enlarged liver, distended neck veins, and pitting edema of the lower extremities. The patient is exhibiting signs and symptoms of which condition? A. Right-sided heart failure B. Left-sided heart failure C. Pulmonary hypertension D. Hypovolemia

A. Right-sides heart failure

Which skills does the nurse teach a patient with a new colostomy before discharge from the hospital? (Select all that apply.) 1. How to change the pouch 2. How to empty the pouch 3. How to open and close the pouch 4. How to irrigate the colostomy 5. How to determine whether the ostomy is healing appropriately

Answer: 1, 2, 3, 5. 1. How to change the pouch 2. How to empty the pouch 3. How to open and close the pouch 5. How to determine whether the ostomy is healing appropriately The patient must be able to do these tasks to successfully manage his or her colostomy when going home. Irrigation is not done routinely for a colostomy

An intravenous (IV) fluid is infusing slower than ordered. The infusion pump is set correctly. Which factors could cause this slowing? (Select all that apply.) 1. Infiltration at vascular access device (VAD) site 2. Patient lying on tubing 3. Roller clamp wide open 4. Tubing kinked in bedrails 5. Circulatory overload

Answer: 1, 2, 4. Factors that could slow an IV infusion even if the infusion pump is set correctly include increased pressure at the outflow site (e.g., infiltration) and compression of the tubing lumen (e.g., patient lying on the tubing or tubing kinked in bedrails).

Which symptoms are warning signs of possible colorectal cancer according to the American Cancer Society guidelines? (Select all that apply.) 1. Change in bowel habits 2. Blood in the stool 3. A larger-than-normal bowel movement 4. Fecal impaction 5. Muscle aches 6. Incomplete emptying of the colon 7. Food particles in the stool 8. Unexplained abdominal or back pain

Answer: 1, 2, 6, 8. 1. Change in bowel habits 2. Blood in the stool 6. Incomplete emptying of the colon 8. Unexplained abdominal or back pain According to the American Cancer Society current guidelines, persons with these symptoms should seek medical evaluation because they may have colon cancer. Other conditions may also cause these symptoms, but if colon cancer is present, early diagnosis is important.

The nurse is working in an agency that has recently implemented an electronic health record. Which of the following are acceptable practices for maintaining the security and confidentiality of electronic health record information? (Select all that apply.) 1. Using a strong password and changing your password frequently according to agency policy 2. Allowing a temporary staff member to use your computer user name and password to access the electronic record 3. Ensuring that work lists (and any other data that must be printed from the electronic health record) are protected throughout the shift and disposed of in a locked receptacle designated for documents that are to be shredded when no longer needed 4. Ensuring that the patient information that is displayed on the computer monitor that you are using is not visible to visitors and other health care providers who are not involved in that patient's care 5. Remaining logged in to a computer to save time if you only need to step away to administer a medication

Answer: 1, 3, 4. Mechanisms to protect the privacy and confidentiality of protected health information in the electronic health record include: not sharing passwords, not leaving computers with open electronic health records unattended, and preventing those not involved with a patient's care from seeing information displayed on a monitor.

What should the nurse teach a young woman with a history of urinary tract infections (UTIs) about UTI prevention? (Select all that apply.) 1. Maintain regular bowel elimination. 2. Limit water intake to 1 to 2 glasses a day. 3. Wear cotton underwear. 4. Cleanse the perineum from front to back. 5. Practice pelvic muscle exercise (Kegel) daily

Answer: 1, 3, 4. 1. Maintain regular bowel elimination. 3. Wear cotton underwear. 4. Cleanse the perineum from front to back. Maintaining regular bowel elimination prevents the rectum from filling with stool, which can irritate the bladder. Adequate hydration will ensure that the bladder is regularly flushed and will help prevent a UTI. Cotton undergarments are recommended. Pelvic muscle exercises promote pelvic health but do not necessarily prevent UTIs.

A patient is scheduled to have an intravenous pyelogram (IVP) the next morning. Which nursing measures should be implemented before the test? (Select all that apply.) 1. Ask the patient about any allergies and reactions. 2. Instruct the patient that a full bladder is required for the test. 3. Instruct the patient to save all urine in a special container. 4. Ensure that informed consent has been obtained. 5. Instruct the patient that facial flushing can occur when the contrast media is given.

Answer: 1, 4, 5 1. Ask the patient about any allergies and reactions. 4. Ensure that informed consent has been obtained. 5. Instruct the patient that facial flushing can occur when the contrast media is given. An IVP involves intravenous injection of an iodine-based contrast media. Patients who have had a previous hypersensitivity reaction to contrast media are at high risk for another reaction. Informed consent is required. The patient may experience facial flushing during injection of the contrast media. There is no need for a full bladder such as with a pelvic ultrasound or to save any urine for testing. There is no instrumentation of the urinary tract such as with a cystoscopy

A patient has hypokalemia with stable cardiac function. What are the priority nursing interventions? (Select all that apply.) 1. Fall prevention interventions 2. Teaching regarding sodium restriction 3. Encouraging increased fluid intake 4. Monitoring for constipation 5. Explaining how to take daily weights

Answer: 1, 4. Hypokalemia causes bilateral skeletal muscle weakness, especially in the quadriceps, which creates a risk for falling. Hypokalemia also causes gastrointestinal smooth muscle weakness, which produces constipation.

What assessments does a nurse make before hanging an intravenous (IV) fluid that contains potassium? (Select all that apply.) 1. Urine output 2. Arterial blood gases 3. Fullness of neck veins 4. Serum potassium laboratory value in EHR 5. Level of consciousness

Answer: 1, 4. Increased potassium intake when potassium output is decreased or during hyperkalemia are major risks for hyperkalemia. Before increasing IV potassium intake, check to see that urine output is normal and that the serum potassium level in the health record is not above normal.

Which instructions do you include when educating a person with chronic constipation? (Select all that apply.) 1. Increase fiber and fluids in the diet. 2. Use a low-volume enema daily. 3. Avoid gluten in the diet. 4. Take laxatives twice a day. 5. Exercise for 30 minutes every day. 6. Schedule time to use the toilet at the same time every day. 7. Take probiotics 5 times a week.

Answer: 1, 5, 6. 1. Increase fiber and fluids in the diet. 5. Exercise for 30 minutes every day. 6. Schedule time to use the toilet at the same time every day. These are the steps a patient needs to take to resolve chronic problems with constipation before considering regular laxative or enema use

During a nursing assessment a patient displayed several behaviors. Which behavior suggests the patient may have a health literacy problem? 1. Patient has difficulty completing a registration form at a medical office 2. Patient asks for written information about a health topic 3. Patient speaks Spanish as primary language 4. Patient states unfamiliarity with a newly ordered medicine

Answer: 1. Behaviors that might reflect a health literacy deficit include having difficulty completing registration forms or health histories, failing to make follow-up appointments, and asking few questions during a nursing history or physical examination

The nurse is caring for a patient with a chest tube for treatment of a right pneumothorax. Which assessment finding necessitates immediate notification of the health care provider? 1. New, vigorous bubbling in the water seal chamber. 2. Scant amount of sanguineous drainage noted on the dressing. 3. Clear but slightly diminished breath sounds on the right side of the chest. 4. Pain score of 2 one hour after the administration of the prescribed analgesic

Answer: 1. New, vigorous bubbling in the water seal chamber. The bubbling in the water seal chamber can mean a new pneumothorax or tube dislodgment.

During the administration of a warm tap-water enema, a patient complains of cramping abdominal pain that he rates 6 out of 10. What nursing intervention should the nurse do first? 1. Stop the instillation. 2. Ask the patient to take deep breaths to decrease the pain. 3. Tell the patient to bear down as he would when having a bowel movement. 4. Continue the instillation; then administer a pain medication.

Answer: 1. Stop the instillation. When a patient complains of pain during an enema, you need to stop the instillation and conduct an assessment before discontinuing or resuming the procedure

A postoperative patient with a three-way indwelling urinary catheter and continuous bladder irrigation (CBI) complains of lower abdominal pain and distention. What should be the nurse's initial intervention(s)? (Select all that apply.) 1. Increase the rate of the CBI. 2. Assess the patency of the drainage system. 3. Measure urine output. 4. Assess vital signs. 5. Administer ordered pain medication.

Answer: 2, 3 2. Assess the patency of the drainage system. 3. Measure urine output. An appropriate first action would be to assess the patency of the drainage system. Urine output in the drainage bag should be more than the volume of the irritant solution infused. If the system is not draining urine and irrigant, the irrigant should be stopped immediately; the catheter may be occluded and the bladder distended. Pain medication should not be administered until after assessment is completed.

Which nursing interventions should a nurse implement when removing an indwelling urinary catheter in an adult patient? (Select all that apply.) 1. Attach a 3-mL syringe to the inflation port. 2. Allow the balloon to drain into the syringe by gravity. 3. Initiate a voiding record/bladder diary. 4. Pull the catheter quickly. 5. Clamp the catheter before removal

Answer: 2, 3. 2. Allow the balloon to drain into the syringe by gravity. 3. Initiate a voiding record/bladder diary. By allowing the balloon to drain by gravity, it is possible to avoid the development of creases or ridges in the balloon and thus minimize trauma to the urethra during withdrawal. All patients who have a catheter removed should have their voiding monitored. The best way to do this is with a voiding record or bladder diary. The size syringe used to deflate the balloon is dictated by the size of the balloon. In the adult patient balloon sizes are either 10 mL or 30 mL. Catheters should be pulled out slowly and smoothly. There is no evidence to support clamping catheters before removal.

Which nursing actions do you take when placing a bedpan under an immobilized patient? (Select all that apply.) 1. Lift the patient's hips off the bed and slide the bedpan under the patient. 2. After positioning the patient on the bedpan, elevate the head of the bed to a 45-degree angle. 3. Adjust the head of the bed so that it is lower than the feet, and use gentle but firm pressure to push the bedpan under the patient. 4. Have the patient stand beside the bed, and then have him or her sit on the bedpan on the edge of the bed. 5. Make sure the patient has a nurse call system in reach to notify the nurse when he or she is ready to have the bedpan removed.

Answer: 2, 5. 2. After positioning the patient on the bedpan, elevate the head of the bed to a 45-degree angle. 5. Make sure the patient has a nurse call system in reach to notify the nurse when he or she is ready to have the bedpan removed. Elevating the head of the bed allows the patient the most normal and comfortable position for defecation on a bedpan. Sitting on a bedpan for a prolonged time is uncomfortable and exerts pressure on the ischial bony prominences, so it is important for the patient to have privacy but to be able to let the nurse know when he or she is finished using the bedpan.

The nurse contacts a provider about a change in a patient's condition and receives several new orders for the patient over the phone. When documenting telephone orders in the electronic health record, most hospitals require a nurse to do which of the following? 1. Print out a copy of all telephone orders entered into the electronic health record in order to keep them in personal records for legal purposes. 2. "Read back" all telephone orders to the provider over the phone to verify all orders were heard, understood, and transcribed correctly before entering the orders in the electronic health record. 3. Record telephone orders in the electronic health record, but wait to implement the order(s) until they are electronically signed by the health care provider who gave them. 4. Implement telephone order(s) immediately, but insist that the health care provider come to the patient care unit to personally enter the order(s) into the electronic health record within the next 24 hours

Answer: 2. Guidelines from TJC require a "read-back" on all telephone (and verbal) orders. The nurse reads a telephone order back word for word and receives confirmation that the order is correct from the health care provider who gave the order.

The health care provider's order is 500 mL 0.9% NaCl intravenously over 4 hours. Which rate does the nurse program into the infusion pump? 1. 100 mL/hr 2. 125 mL/hr 3. 167 mL/hr 4. 200 mL/hr

Answer: 2. To infuse 500 mL in 4 hours, set the rate at 125 mL/hr. (500 divided by 4 = 125)

An older-adult patient is receiving intravenous (IV) 0.9% NaCl. The nurse detects new onset of crackles in the lung bases. What is the priority action? 1. Notify a health care provider. 2. Decrease the IV flow rate. 3. Lower the head of the bed. 4. Discontinue the IV site

Answer: 2. When an IV fluid is infusing, monitor for excess infusion. Crackles in the lung bases are an indication of ECV excess. For patient safety, the IV flow rate must be decreased immediately. Then notify the health care provider.

When delegating input and output (I&O) measurement to assistive personnel, the nurse instructs them to record what information for ice chips? 1. Two-thirds of the volume 2. One-half of the volume 3. One-quarter of the volume 4. Two times the volume

Answer: 2. When ice chips melt, their water volume is one-half the volume of the ice chips. The water volume should be recorded as intake.

The nurse is performing discharge teaching for a patient with chronic obstructive pulmonary disease (COPD). What statement, made by the patient, indicates the need for further teaching? 1. "Pursed-lip breathing is like exercise for my lungs and will help me strengthen my breathing muscles." 2. "When I am sick, I should limit the amount of fluids I drink so that I don't produce excess mucus." 3. "I will ensure that I receive an influenza vaccine every year, preferably in the fall." 4. "I will look for a smoking-cessation support group in my neighborhood."

Answer: 2. "When I am sick, I should limit the amount of fluids I drink so that I don't produce excess mucus." Patients need to make sure that they are adequately hydrated in order to liquefy secretions, making it easier to expectorate. Fluids should not be limited or else the mucus will become too thick. All the other answers indicate an understanding of the discharge plan

The nurse is caring for a patient with pneumonia. On entering the room, the nurse finds the patient lying in bed, coughing, and unable to clear secretions. What should the nurse do first? 1. Start oxygen at 2 L/min via nasal cannula. 2. Elevate the head of the bed to 45 degrees. 3. Encourage the patient to use the incentive spirometer. 4. Notify the health care provider.

Answer: 2. Elevate the head of the bed to 45 degrees. The HOB needs to be elevated to help increase lung expansion and ease work of breathing. Also this makes it easier for the patient to expectorate.

An ambulatory elderly woman with dementia is incontinent of urine. She has poor short-term memory and has not been seen toileting independently. What is the best nursing intervention for this patient? 1. Recommend that she be evaluated for an overactive bladder (OAB) medication. 2. Establish a toileting schedule. 3. Recommend that she be evaluated for an indwelling catheter. 4. Start a bladder-retraining program.

Answer: 2. Establish a toileting schedule. The first nursing intervention for any patient with incontinence who is able to toilet is to help him or her with toilet access. This patient has dementia; therefore a bladder-retraining program is inappropriate for her. There is nothing in the assessment to indicate that she may have an overactive bladder. A catheter increases risk for infection and is never the best intervention for incontinence.

Which nursing intervention decreases the risk for catheter-associated urinary tract infection (CAUTI)? 1. Cleansing the urinary meatus 3 to 4 times daily with antiseptic solution 2. Hanging the urinary drainage bag below the level of the bladder 3 Emptying the urinary drainage bag daily 4. Irrigating the urinary catheter with sterile water

Answer: 2. Hanging the urinary drainage bag below the level of the bladder Evidence-based interventions shown to decrease the risk for CAUTI include ensuring that there is a free flow of urine from the catheter to the drainage bag.

What should the nurse teach family caregivers when a patient has fecal incontinence because of cognitive impairment? 1. Cleanse the skin with antibacterial soap, and apply talcum powder to the buttocks. 2. Initiate bowel or habit training program to promote continence. 3. Help the patient to toilet once every hour. 4. Use sanitary pads in the patient's underwear

Answer: 2. Initiate bowel or habit training program to promote continence. Patients who are cognitively impaired often forget how to respond to the urge to defecate and benefit from a structured program of bowel retraining.

There is no urine when a catheter is inserted 3 inches into a female's urethra. What should the nurse do next? 1. Remove the catheter and start all over with a new kit and catheter. 2. Leave the catheter there and start over with a new catheter. 3. Pull the catheter back and reinsert at a different angle. 4. Ask the patient to bear down and insert the catheter farther

Answer: 2. Leave the catheter there and start over with a new catheter. The catheter may be in the vagina; leave the catheter in the vagina as a landmark indicating where not to insert, and insert another sterile catheter. Pulling the catheter back and reinserting is poor technique, increasing the risk for catheter-associated urinary tract infection (CAUTI).

The nurse is performing tracheostomy care on a patient. What finding would indicate that the tracheostomy tube has become dislodged? 1. Clear breath sounds 2. Patient speaking to nurse 3. SpO2 reading of 96% 4. Respiratory rate of 18 breaths/minute

Answer: 2. Patient speaking to nurse Patient phonation is a sign that the TT is not in its proper place.

The nurse is administering a dose of metoprolol to a patient and is completing the steps of bar code medication administration within the EHR. As the bar code information on the medication is scanned, an alert states "Do not administer dose if apical heart rate (HR) is <60 beats/minute or systolic blood pressure (SBP) is <90 mm Hg" appears on the computer screen. The alert that appeared on the computer screen is an example of what type of system? 1. Electronic health record (EHR) 2. Charting by exception 3. Clinical decision support system (CDSS) 4. Computerized physician order entry (CPOE)

Answer: 3. Computer decision support systems(CDSS) are computerized programs that prompt health care providers with clinical knowledge and relevant patient information that assists with clinical decision making. A nursing CDSS uses a complex system of rules to analyze data and provide alerts to support clinical decisions made by nurses

When documenting an assessment of a patient's cardiac system in an electronic health record, the nurse uses the computer mouse to select the "WNL" statement to document the following findings: "Heart sounds S1 & S2 auscultated. Heart rate between 80-100 beats per minute, and regular. Denies chest pain." This is an example of using which of the following documentation formats? 1. Focus charting incorporating "Data, Action & Response" (DAR) 2. Problem-intervention-evaluation (PIE) 3. Charting-by-exception (CBE) 4. Narrative documentation

Answer: 3. Charting-by-exception (CBE) is a unique documentation format designed with the philosophy that all standards are met unless otherwise documented. Many computerized nursing documentation systems have incorporated a CBE design. Exception-based documentation systems incorporate clearly defined criteria for nursing assessment and documentation of "normal" findings. Predefined statements used to document "normal" assessment of body systems are called "within defined limits" (WDL) or "within normal limits" (WNL) definitions. They consist of written criteria for a "normal" assessment for each body system. Automated documentation within a computerized documentation system allows nurses to select a WNL (or WDL) statement or to choose other statements from a drop-down menu

Which assessment does the nurse use as a clinical marker of vascular volume in a patient at high risk of extracellular fluid volume (ECV) deficit? 1. Dryness of mucous membranes 2. Skin turgor 3. Fullness of neck veins when supine 4. Fullness of neck veins when upright

Answer: 3. ECV deficit involves decreased vascular and interstitial volume. One way to assess vascular volume is to examine the fullness of neck veins when an individual is supine. With normal ECV, neck veins are full when the individual is supine. With ECV deficit, they are flat.

A nurse working in a large occupational health clinic knows that many of the workers at her company are marginalized and at risk for poor health outcomes. Which of the following individuals are most likely to be marginalized? 1. Wives of the employees 2. The head supervisors of the company 3. Workers who have a high school education 4. Workers employed for less than a year at the company

Answer: 3. Marginalized groups are more likely to have poor health outcomes and die earlier because of a complex interaction among their individual behaviors, environment of the communities in which they live, the policies and practices of health care and governmental systems, and the clinical care they receive. Examples of marginalized groups include people who are gay, lesbian, bisexual, or transgender; people of color; people who are physically and/ or mentally challenged; and people who are not college educated.

A patient is admitted to the hospital with severe dyspnea and wheezing. Arterial blood gas levels on admission are pH 7.26; PaCO2, 55 mm Hg; PaO2, 68 mm Hg; and HCO3 - , 24. How does the nurse interpret these laboratory values? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis

Answer: 3. The pH is abnormally low, which indicates acidosis. The PaCO2 is high, which indicates respiratory acidosis. The HCO3 - is in the normal range, which indicates an acute respiratory acidosis that has not had time for renal compensation. The low PaO2 and the severe dyspnea and wheezing are consistent with this interpretation.

What is a critical step when inserting an indwelling catheter into a male patient? 1. Slowly inflate the catheter balloon with sterile saline. 2. Secure the catheter drainage tubing to the bedsheets. 3. Advance the catheter to the bifurcation of the drainage and balloon ports. 4. Advance the catheter until urine flows, then insert ¼ inch more

Answer: 3. Advance the catheter to the bifurcation of the drainage and balloon ports. Advancing the catheter to the bifurcation avoids inflating the catheter balloon in the prostatic urethra, causing trauma and pain. Catheter balloons are never inflated with saline. Securing the catheter drainage tubing to the bedsheets increases the risk for accidental pulling or tension on the catheter. Advancing the catheter until urine flows and then inserting it ¼ inch more is not unique to the male patient.

A nurse is teaching a patient to obtain a specimen for fecal occult blood testing using fecal immunochemical testing (FIT) at home. How does the nurse instruct the patient to collect the specimen? 1. Get three fecal smears from one bowel movement. 2. Obtain one fecal smear from an early-morning bowel movement. 3. Collect one fecal smear from three separate bowel movements. 4. Get three fecal smears when you see blood in your bowel movement.

Answer: 3. Collect one fecal smear from three separate bowel movements. Samples from three separate bowel movements decrease the risk of a false-negative or a false-positive result.

Which instruction should the nurse give the assistive personnel (AP) concerning a patient who has had an indwelling urinary catheter removed that day? 1. Limit oral fluid intake to avoid possible urinary incontinence. 2. Expect patient complaints of suprapubic fullness and discomfort. 3. Report the time and amount of first voiding. 4. Instruct the patient to stay in bed and use a urinal or bedpan.

Answer: 3. Report the time and amount of first voiding. To adequately assess bladder function after a catheter is removed, voiding frequency and amount should be monitored. Unless contraindicated, fluids should be encouraged. To promote normal micturition, patients should be placed in as normal a posture for voiding as possible. Suprapubic tenderness and pain are possible indicators of urinary retention and/or a urinary tract infection.

The nurse is discussing the advantages of using computerized provider order entry (CPOE) with a nursing colleague. Which statement best describes the major advantage of a CPOE system within an electronic health record? 1. CPOE reduces the time necessary for health care providers to write orders. 2. CPOE reduces the time needed for nurses to communicate with health care providers. 3. Nurses do not need to acknowledge orders entered by CPOE in an electronic health record. 4. CPOE improves patient safety by reducing transcription errors.

Answer: 4. Although the other answers loosely describe some positive aspects of CPOE, option 4 provides the best description of the major advantage CPOE offers—the reduction of transcription errors, which reduces medical errors and creates a safer patient care environment.

The nurse is reviewing health care provider orders that were handwritten on paper when all computers were down during a system upgrade. Which of the following orders contain an inappropriate abbreviation included on The Joint Commission's "Do Not Use" list and should be clarified with the health care provider? 1. Change open midline abdominal incision daily using wet-tomoist normal saline and gauze. 2. Lorazepam 0.5 mg PO every 4 hours prn anxiety 3. Morphine sulfate 1 mg IVP every 2 hours prn severe pain 4. Insulin aspart 8u SQ every morning before breakfast

Answer: 4. In option 4, the word "unit(s)" should be written out because the letter "u" can be mistaken for "0," the number "4," or "cc." The other orders are written appropriately

The nurse assesses pain and redness at a vascular access device (VAD) site. Which action is taken first? 1. Apply a warm, moist compress. 2. Aspirate the infusing fluid from the VAD. 3. Report the situation to the health care provider. 4. Discontinue the intravenous infusion.

Answer: 4. Pain and redness at a VAD site are indicators of phlebitis. When phlebitis occurs, the infusion must be stopped and the VAD removed as the highest priority.

The nurse is changing the dressing over the midline incision of a patient who had surgery. Assessment of the incision reveals changes from what was documented by the previous nurse. After documenting the current wound assessment, the nurse contacts the surgeon (Dr. Oakman) by telephone to discuss changes in the incision that are of concern. Which of the following illustrates the most appropriate way for the nurse to document this conversation? 1. Health care provider notified about change in assessment of abdominal incision. T. Wright, RN 2. 09-3-18: Notified Dr. Oakman by phone that there is a new area of redness around the patient's incision. T. Wright, RN 3. 1015: Contacted Dr. Oakman and notified about changes in abdominal incision. T. Wright, RN 4. 09-3-18 (1015): Dr. Oakman contacted by phone. Notified about new area of bright red erythema extending approximately 1 inch around circumference of midline abdominal incision and oral temperature of 101.5 F. No orders received. T. Wright, RN

Answer: 4. This statement includes the date and time the health care provider was contacted, the specific name of the health care provider, descriptive details of the changes of concern noted in the patient assessment, whether any orders were received, and the name and credentials of the nurse who contacted the health care provider.

A nurse is taking a health history of a newly admitted patient with a diagnosis of possible fecal impaction. Which question is the priority to ask the patient or caregiver? 1. Have you eaten more high-fiber foods lately? 2. Have you taken antibiotics recently? 3. Do you have gluten intolerance? 4. Have you experienced frequent, small liquid stools recently?

Answer: 4. Have you experienced frequent, small liquid stools recently? Frequent or continuous oozing of liquid stools occurs when liquid fecal matter above the impacted stool seeps around the fecal impaction.

The patient states, "I have diarrhea and cramping every time I have ice cream. I am sure this is because the food is cold." Based on this assessment data, which health problem does the nurse suspect? 1. A food allergy 2. Irritable bowel syndrome 3. Increased peristalsis 4. Lactose intolerance

Answer: 4. Lactose intolerance These symptoms are consistent with lactose intolerance, and they occur with ingestion of dairy products.

Place the following steps for insertion of an indwelling catheter in a female patient in appropriate order. 1. Insert and advance catheter. 2. Lubricate catheter. 3. Inflate catheter balloon. 4. Cleanse urethral meatus with antiseptic solution. 5. Drape patient with the sterile square and fenestrated drapes. 6. When urine appears, advance another 2.5 to 5 cm. 7. Prepare sterile field and supplies. 8. Gently pull catheter until resistance is felt. 9. Attach drainage tubing

Answer: 5, 7, 2, 4, 1, 6, 3, 8, 9. 5. Drape patient with the sterile square and fenestrated drapes. 7. Prepare sterile field and supplies. 2. Lubricate catheter. 4. Cleanse urethral meatus with antiseptic solution. 1. Insert and advance catheter. 6. When urine appears, advance another 2.5 to 5 cm. 3. Inflate catheter balloon. 8. Gently pull catheter until resistance is felt. 9. Attach drainage tubing

Place the steps for an ileostomy pouch change in the correct order. 1. Close the end of the pouch. 2. Measure the stoma. 3. Cut the hole in the wafer to fit around the stoma and not leave skin exposed to the effluent. 4. Press the pouch in place over the stoma. 5. Remove the old pouch. 6. Trace the correct measurement onto the back of the wafer. 7. Assess the stoma and the skin around it. 8. Cleanse and dry the peristomal skin.

Answer: 5, 8, 7, 2, 6, 3, 4, 1. 5. Remove the old pouch. 8. Cleanse and dry the peristomal skin. 7. Assess the stoma and the skin around it. 2. Measure the stoma. 6. Trace the correct measurement onto the back of the wafer. 3. Cut the hole in the wafer to fit around the stoma and not leave skin exposed to the effluent. 4. Press the pouch in place over the stoma. 1. Close the end of the pouch. This order of tasks describes the correct way to change an ostomy pouch.

Place the following steps for discontinuing intravenous (IV) access in the correct order: 1. Perform hand hygiene and apply gloves. 2. Explain procedure to patient. 3. Remove IV site dressing and tape. 4. Use two identifiers to ensure correct patient. 5. Stop the infusion and clamp the tubing. 6. Carefully check the health care provider's order. 7. Clean the site, withdraw the catheter, and apply pressure

Answer: 6, 4, 2, 1, 5, 3, 7 A health care provider's order is necessary before discontinuing IV access, unless there is a complication such as infiltration or phlebitis. Identifying the patient and explaining the procedure are performed before hand hygiene and glove application in order to maintain clean gloves. Removing the site dressing before stopping the infusion and then withdrawing the catheter keeps the VAD patent without forming a clot that could embolize during catheter withdrawal.

The nurse is preparing to perform nasotracheal suctioning on a patient. Arrange the steps in order. 1. Apply suction. 2. Assist patient to semi-Fowler's or high Fowler's position, if able. 3. Advance catheter through nares and into trachea. 4. Have patient take deep breaths. 5. Lubricate catheter with water-soluble lubricant. 6. Apply sterile gloves. 7. Perform hand hygiene. 8. Withdraw catheter.

Answer: 7, 2, 6, 4, 5, 3, 1, 8 7. Perform hand hygiene. 2. Assist patient to semi-Fowler's or high Fowler's position, if able. 6. Apply sterile gloves. 4. Have patient take deep breaths. 5. Lubricate catheter with water-soluble lubricant. 3. Advance catheter through nares and into trachea. 1. Apply suction. 8. Withdraw catheter.

The nurse has just witnessed her patient go into cardiac arrest. What priority interventions should the nurse perform at this time? (Select all that apply.) 1. Perform chest compressions. 2. Ask someone to bring the defibrillator to the room for immediate defibrillation. 3. Apply oxygen via nasal cannula. 4. Place the patient in the high Fowler's position. 5. Educate the family about the need for CPR.

Answers: 1 and 2. 1. Perform chest compressions. 2. Ask someone to bring the defibrillator to the room for immediate defibrillation. Applying oxygen won't help the patient as he or she is not breathing. The patient needs to be supine for compressions to be effective. The family does need to be educated, but this is not the priority for the nurse at this time. The nurse could delegate this task to a member of the health care team who is not actively engaged in the resuscitation.

Health care organizations must provide which of the following based on federal civil rights laws? (Select all that apply.) 1. Provide language assistance services at all points of contact free of charge. 2. Provide auxiliary aids and services, such as interpreters, note takers, and computer-aided transcription services. 3. Use patients' family members to interpret difficult topics. 4. Ensure that interpreters are competent in medical terminology. 5. Provide language assistance to all patients who speak limited English or are deaf.

Answers: 1, 2, 4, 5. The CLAS standards include standards for communication and language assistance, including providing language assistance free of charge, auxiliary aids and services, interpreters competent in medical terminology, and language assistance for patients with limited English or who are deaf.

The nurse who works at the local hospital is transferring a patient to an acute rehabilitation center in another town. To complete the transfer, information from the patient's electronic health record must be printed and faxed to the acute rehabilitation center. Which of the following actions is most appropriate for the nurse to take to maintain privacy and confidentiality of the patient's information when faxing this information? (Select all that apply.) 1. Confirm that the fax number for the acute rehabilitation center is correct before sending the fax. 2. Use the encryption feature on the fax machine to encode the information and make it impossible for staff at the acute rehabilitation center to read the information unless they have the encryption key. 3. Fax the patient's information without a cover sheet so that the person receiving the information at the acute rehabilitation center can identify it more quickly. 4. After sending the fax, place the information that was printed out in a standard trash can after ripping it into several pieces. 5. After sending the fax, place the information that was printed out in a secure canister marked for shredding

Answers: 1, 2, 5. Nurses have the legal and ethical obligation to safeguard any patient information that is printed or extracted from the electronic (or paper) health record. Best practice is to use all measures to fax information securely, and to shred any printed health record material after it has been used for the purpose intended.

The nurse is caring for a patient with an artificial airway. What are reasons to suction the patient? (Select all that apply.) 1. The patient has visible secretions in the airway. 2. There is a sawtooth pattern on the patient's EtCO2 monitor. 3. The patient has clear breath sounds. 4. It has been 3 hours since the patient was last suctioned. 5. The patient has excessive coughing.

Answers: 1, 2, and 5. (Refer to Skill 41.1.) 1. The patient has visible secretions in the airway. 2. There is a sawtooth pattern on the patient's EtCO2 monitor. 5. The patient has excessive coughing. Clear breath sounds are normal and do not indicate the need for suctioning. Suctioning should be based upon assessment findings and not performed on a time-oriented basis

A 35-year-old woman has Medicaid coverage for herself and two young children. She missed an appointment at the local health clinic to get an annual mammogram because she has no transportation. She gets the annual screening because her mother had breast cancer. Which of the following are social determinants of this woman's health? (Select all that apply.) 1. Medicaid insurance 2. Annual screening 3. Mother's history of breast cancer 4. Lack of transportation 5. Woman's age

Answers: 1, 4, 5. Social determinants of health are the conditions under which persons are born, grow, live, work, and age. The social determinants of health are mostly responsible for health disparities. Examples include age, race and ethnicity, socioeconomic status (as reflected by the woman's insurance), access to nutritious food, transportation resources, religion, sexual orientation, level of education, literacy level, disability (physical and cognitive), and geographic location (e.g., access to health care)

A nurse desires to communicate with a young woman who is Serbian and who has limited experience with being in a hospital. The nurse has 10 years of experience caring for Serbian women. The patient was admitted for a serious pregnancy complication. Apply the LEARN model and match the nurse's behaviors with each step of the model. 1. L ___________ a. The nurse notes that she has learned that fathers can visit mothers at any time in both Serbia and the United States. 2. E ___________ b. The nurse shares her perception of the woman's experiences as a patient. 3. A ___________ c. The nurse asks the patient how she can maintain bed rest when she returns home. 4. R __________ d. The nurse attends to the patient and listens to her story about hospitals in Serbia. 5. N __________ e. The nurse involves the patient in a discussion of the treatment options for her condition.

Answers: 1d, 2b, 3a, 4e, 5c. Listen with empathy and understanding to patient perception of the problem; Explain your perceptions of the problem (physiological, psychological, spiritual, and/or cultural; Acknowledge and discuss cultural differences and similarities between you and your patient; Recommend treatment (involving the patient); and Negotiate agreement (incorporate selected aspects of the patient's culture into patient-centered care)

Which of the following is an example of a patient with a health disparity? (Select all that apply.) 1. A patient who has a homosexual sexual preference 2. A patient unable to access primary care services 3. A patient living with a chronic disease 4. A family who relies on public transportation 5. A patient who has had a history of smoking for 10 years

Answers: 2, 3, 5. Poor health status (chronic disease), disease risk factors (smoking history), poor health outcomes, and limited access to health care (unable to access primary care) are types of health disparities.

Which assessment findings indicate that the patient is experiencing an acute disturbance in oxygenation and requires immediate intervention? (Select all that apply.) 1. SpO2 value of 95% 2. Retractions 3. Respiratory rate of 28 breaths per minute 4. Nasal flaring 5. Clubbing of fingers

Answers: 2, 3, and 4. 2. Retractions 3. Respiratory rate of 28 breaths per minute 4. Nasal flaring SpO2 of 95% is normal and requires no intervention. Clubbed fingers are an assessment finding associated with chronic hypoxia; this does not require immediate intervention

Which skills can the nurse delegate to assistive personnel (AP)? (Select all that apply.) 1. Initiate oxygen therapy via nasal cannula. 2. Perform nasotracheal suctioning of a patient. 3. Educate the patient about the use of an incentive spirometer. 4. Assist with care of an established tracheostomy tube. 5. Reposition a patient with a chest tube

Answers: 4 and 5. 4. Assist with care of an established tracheostomy tube. 5. Reposition a patient with a chest tube Assistive personnel (AP) are not allowed to initiate oxygen therapy, provide education, or perform NT suctioning on a patient. They are allowed to assist the nurse in performing tracheostomy tube care and with repositioning patients

A patient is admitted with new onset renal failure. The nurse would observe for which of the following as the most common clinical manifestation of hypermagnesemia? A. Palpitations B. Decreased deep tendon reflexes C. Increased respirations D. Hypertension

B. Decreased deep tendon reflexes

The nurse is writing a narrative progress note. Identify each of the following statements as subjective data (S) or objective data (O): 1. April 24, 2019 (0900) 2. Repositioned patient on left side. 3. Medicated with hydrocodone-acetaminophen 5/325 mg, 2 tablets PO. 4. "The pain in my incision increases every time I try to turn on my right side." 5. S. Eastman, RN 6. Surgical incision right lower quadrant, 3 inches in length, well approximated, sutures intact, no drainage. 7. Rates pain 7/10 at location of surgical incision

Objective: 1, 2, 3, 5, 6, 7. S: 4. Statement 4 is the only example of a subjective statement. All other statements in the list are objective data. Logical order for placement of these statements includes "1, 4, 6, 7, 3, 2, and 5." The date and time of a narrative note are recorded first, followed by information from the patient that informs clinical decisions, followed by assessment data, and interventions made. A narrative note is closed with the nurse's signature (first initial, last name, credentials).

The client complains of burning along the vein in which a medicated IV is infusing. Upon assessment, the nurse finds the IV site is slightly red and swollen. What action should be taken by the nurse? 1. Slow the IV infusion and reassess the area in 15 minutes. 2. Place a cool pack over the IV site and vein. 3. Discontinue the IV. 4. Call the physician for direction

Rationale 3: This assessment likely indicates the beginning of phlebitis. The nurse should discontinue the IV and place a warm pack on the area.

The nurse has completed discharge teaching for a client who will be going home on oxygen therapy. What statement, made by the client, would indicate that this client needs further instruction? •1. "I will replace my cotton blankets with polyester ones." •2. "My son will not be able to smoke when I am around." •3. "I will have my electrical appliance checked for grounding." •4. "I will buy a fire extinguisher for my bedroom."

•1. "I will replace my cotton blankets with polyester ones."

The nurse is taking care of a client who states that he ignores the urge to defecate when he is at work. Which of the following responses by the nurse would explain why this practice should be changed? •1. "If you continue to ignore the urge to defecate, the urge is ultimately lost." •2. "It is best to suppress the urge than suffer embarrassment at work." •3. "This is a common practice, and it will strengthen the reflex later." •4. "You will get the urge later; don't worry."

•1. "If you continue to ignore the urge to defecate, the urge is ultimately lost."

A client tells the nurse about the need to get up several times throughout the night to void. The nurse suspects the client is experiencing nocturia due to: •1. Decrease in bladder tone •2. Decrease in blood supply •3. Decrease in number of nephrons •4. Decrease in cardiac output

•1. Decrease in bladder tone

The client has been admitted with complaints of shortness of breath of 2 weeks duration and has received the nursing diagnosis Impaired Gas Exchange. Which admission laboratory result would support the choice of this diagnosis? •1. Increased hematocrit •2. Decreased BUN •3. Increased blood sugar •4. Increased sedimentation rate

•1. Increased hematocrit

A client is experiencing atelectasis. The nurse anticipates that this client will have an alteration in: •1. Ventilation. •2. Alveolar gas exchange. •3. Transportation of oxygen and carbon dioxide. •4. Systemic diffusion.

•1. Ventilation.

Which assessment data would indicate compromised gastrointestinal function? •1. Bowel sounds active in all four quadrants •2. Clay color stool •3. Increased appetite •4. Semisolid and moist stool

•2. Clay color stool

A client has a bowel movement of hard, dry, but formed stool. The nurse associates these characteristics with: •1. Bowel incontinence •2. Constipation •3. Diarrhea •4. Fecal impaction

•2. Constipation

What should the nurse instruct a client to promote urinary elimination? •1. Don't interrupt your day by going to the bathroom; wait until you're at a good stopping place. •2. Drink 8 to 10 glasses of water daily. •3. Urine color changes are not important. •4. Wash with soap and water every other day.

•2. Drink 8 to 10 glasses of water daily.

After learning of a terminal illness and life expectancy, the client begins to hyperventilate and complains of being light-headed with the fingers, toes, and mouth tingling. What action should be taken by the nurse? •1. Prepare to resuscitate the client. •2. Have the client concentrate on slowing down respirations. •3. Place the client in Trendelenburg's position and ask him to cough forcefully. •4. Administer 25 mg of meperidine (Demerol) according to the prn pain order.

•2. Have the client concentrate on slowing down respirations.

The nurse should incorporate which instructions into the teaching plan for a client with a urinary diversion? •1. Change the appliance several times a day. •2. Increase fluid intake. •3. Notify the physician if the stoma is deep pink and shiny. •4. Strands of blood may appear in the urine.

•2. Increase fluid intake.

Which assessment technique will the nurse use first when examining a client with a fecal elimination problem? •1. Auscultation •2. Inspection •3. Palpation •4. Percussion

•2. Inspection

What should the nurse instruct a client prior to administering a cleansing enema? •1. Hold the solution for a short time. •2. Lie in the left lateral position. •3. Lie in the right lateral position. •4. Take fast breaths through the nose.

•2. Lie in the left lateral position.

Which nursing diagnosis would be appropriate for a client who has a retention catheter if the drainage bag is found lying on the floor? •1. Risk for Impaired Skin Integrity related to catheter placement •2. Risk for Infection related to improper handling •3. Self-Care Deficit related to presence of a retention catheter •4. Risk for Incontinence related to an obstruction

•2. Risk for Infection related to improper handling

A client asks the RN why it is more difficult to use a bedpan for defecating than sitting on the toilet. Which of the following is the best response? •1. The sitting position decreases the contractions of the muscles of the pelvic floor. •2. The sitting position increases the downward pressure on the rectum, making it easier to pass stool. •3. The sitting position increases the pressure within the abdomen. •4. The sitting position inhibits the urge to urinate, allowing one to defecate.

•2. The sitting position increases the downward pressure on the rectum, making it easier to pass stool.

The client is receiving oxygen by nonrebreather mask, but the bag is not deflating on inspiration. What action should be taken by the nurse? •1. Turn the client to the left side. •2. Continue to monitor the respirations closely. •3. Check for an airtight seal between the client's face and the mask. •4. Increase the liter flow of oxygen being delivered.

•3. Check for an airtight seal between the client's face and the mask.

The nurse is concerned that an older client with a retention catheter is developing a urinary tract infection when what is assessed? •1. Elevated blood pressure. •2. Elevated heart rate. •3. Confusion. •4. Leg pain.

•3. Confusion.

A client, diagnosed with chronic obstructive lung disease receiving oxygen at 1.5 liters per minute via nasal cannula, is complaining of shortness of breath. What action should the nurse take? •1. Increase the oxygen to 3 liters per minute via nasal cannula. •2. Lower the head of the client's bed to semi-Fowler's position. •3. Have the client breathe through pursed lips. •4. Encourage the client to breathe more rapidly.

•3. Have the client breathe through pursed lips.

Upon assessment, the nurse notes that the client is dyspneic, has bibasilar crackles, and tires easily upon exertion. Which nursing diagnosis is best supported by these assessment details? •1. Ineffective Breathing Pattern •2. Anxiety •3. Ineffective Airway Clearance •4. Impaired Gas Exchange

•3. Ineffective Airway Clearance

Which intervention would the nurse plan to help a client prevent a urinary tract infection? •1. Encourage the use of bubble baths. •2. Have the client increase sugar in the diet. •3. Instruct the client to empty the bladder completely. •4. Wipe from back to front.

•3. Instruct the client to empty the bladder completely.

A client who was a victim of a house fire is coughing. The nurse realizes that the purpose of the cough is to: •1. Improve oxygenation. •2. Remove irritants from the nasal passages. •3. Remove irritants from the trachea or bronchi. •4. Close the glottis.

•3. Remove irritants from the trachea or bronchi.

The nurse is most likely to report which of the following findings to the primary care provider for a client who has an established colostomy? •1. The stoma extends 1/2 in. above the abdomen. •2. The skin under the appliance looks red briefly after removing the appliance •3. The stoma color is a deep red-purple.

•3. The stoma color is a deep red-purple.

The nurse has placed an oropharyngeal airway in a client. What action should the nurse take at this time? •1. Tape the airway in place. •2. Suction the client. •3. Turn the client's head to the side. •4. Insert a nasal trumpet.

•3. Turn the client's head to the side.

What goal would be applicable for a client who is experiencing diarrhea? •1. Client will defecate regularly. •2. Client will increase the amount of sugar in the diet. •3. Client will limit fluid intake. •4. Client will regain normal stool consistency.

•4. Client will regain normal stool consistency.

During tracheal suctioning, the nurse notes that the client' heart rate has increased from 80 to 100 bpm. Based upon this assessment, what action should the nurse take? •1. Immediately discontinue suctioning. •2. Prepare to resuscitate the client. •3. Continue to suction until the airway is clear. •4. Complete the suction episode as quickly as possible.

•4. Complete the suction episode as quickly as possible.

The nurse is determining tasks to delegate to UAP. Which task would not be appropriate for the nurse to delegate to this level of healthcare provider? •1. Measuring intake and output. •2. Assessing vital signs for clients who are clinically stable. •3. Performing complete morning care for a client recovering from a stroke. •4. Inserting a urinary catheter into a client.

•4. Inserting a urinary catheter into a client.

The client has a medical condition that often results in the development of metabolic acidosis. The nurse should observe this client for the development of which breathing pattern as a result of this condition? •1. Cheyne-Stokes •2. Biot's •3. Cluster •4. Kussmaul's

•4. Kussmaul's

The nurse would instruct a client with frequent bouts of diarrhea to: •1. Change the daily routine. •2. Decrease fluid consumption. •3. Increase fiber in the diet. •4. Note the precipitating event.

•4. Note the precipitating event.

The nurse is instructing a client on ostomy care. What should be included in this teaching? •1. Change the drainage pouch daily. •2. Clothing of a special style will be needed now that a pouch is worn. •3. Stick a pin into the drainage pouch to relieve any gas buildup. •4. Secure the faceplate to the drainage pouch so no skin around the stoma is exposed.

•4. Secure the faceplate to the drainage pouch so no skin around the stoma is exposed.

Which client behavior would indicate that teaching to prevent constipation was effective? •1. The client continues to ask for his pain medication. •2. The client decreases his fluid consumption. •3. The client refuses to eat the bran flakes on his tray. •4. The client walks around the unit several times a day.

•4. The client walks around the unit several times a day.