Nursing Fundamental Part 3

A nurse is reinforcing teaching about crutch use with a client who has had knee surgery. Which of the following instructions should the nurse include?

"Hold both crutches with a hand when you sit down in a chair." Rationale: The client should stand in front of the chair with the back of her nonoperative leg touching the chair. Then, she should transfer a crutch to the other hand on the operative side and hold both while transferring her weight to the crutches and the nonoperative leg. Finally, she should grab the arm of the chair and lower herself down into the chair.

A nurse is reinforcing teaching with a client who has a new colostomy. Which of the following statements should the nurse identify as an indication that the client understands the instructions?

"I will make sure to replace my pouch around 4 hours after I eat." Rationale: It is best for the client to replace the pouch at a time when the bowel is least active, either after arising in the morning or at least 2 to 4 hours after a meal. Otherwise, the client risks releasing stool while there is no pouch in place.

A nurse is caring for a client who has a terminal illness. The family wants to care for the client at home. Which of the following statements indicates that the nurse understands family-centered care?

"Let's set up a meeting time with the doctor to discuss your options for home care." Rationale: With family-centered care, the nurse considers the health of the family as a unit; therefore, the client and family help determine outcomes and goals. Setting up a meeting to discuss this option with the provider will give the family a sense of autonomy and foster the family-centered nursing environment.

A nurse is caring for a client who has type 1 diabetes mellitus and is resistant to learning self-injection insulin methods. Which of the following statements should the nurse provide?

"Tell me what I can do to help you overcome your fear of giving yourself injections." Rationale: This response illustrates the therapeutic communication technique of clarifying and offering of self. The nurse should allow the client to express feelings and fears and support the client in learning how to give the injections.

A nurse is collecting data about a client's spiritual wellbeing. Which of the following questions should the nurse ask?

"What is your source of strength and hope?" Rationale: This is a broad, open-ended question that encourages the client to express feelings without any assumptions on the nurse's part. It focuses on a global view of spirituality as a complex concept that encompasses the client's life experiences and beliefs about strength, love, and hope.

A nurse is caring for an older adult client who becomes agitated when the nurse requests that the client's dentures be removed prior to surgery. Which of the following responses should the nurse offer?

"What worries you about being without your teeth?" Rationale: This response by the nurse is therapeutic because it validates the client's feelings of agitation and seeks a reason for it.

A nurse is calculating the protein needs of a young adult client who weighs 132 lb. The RDA for protein for an adult who has no health medical conditions is 0.8 g/kg. How many grams of protein per day should the nurse recommend for this client?

132/2.2 = 60 kg 60 kg x 0.8 g = 48 g

A nurse is reinforcing teaching with the parent of a child who is to take 30 mL of a liquid medication. The parent has a hollow medication spoon that has marks to indicate teaspoons and tablespoons. How many tablespoons of medication should the nurse instruct the parent to give the child?

2 Rationale: 15 mL/1 tbsp = 30 mL/X tbsp15X = 30X = 2

A nurse is assessing the pH of a client's gastric fluid to confirm the placement of an NG tube in the stomach. Which of the following pH values should the nurse expect?

2 Rationale: A pH of 2 is within the expected reference range of 0 to 4 for gastric secretions.

A nurse is preparing to administer sotalol to a client with a prescription for sotalol 320 mg/day divided equally every 12 hours. The medication is available in 80 mg tablets. How many tablets should the nurse administer per dose?

2 Rationale: Have/Quantity = Desired/X80 mg/1 tablet = 320 mg/X tabletX = 4

A nurse is collecting data for the health history of a client who is postoperative and has paralytic ileus. Which of the following findings should the nurse expect?

Absent bowel sounds with distention Rationale: Paralytic ileus is an immobile bowel. In this disorder, bowel sounds are absent, and the abdomen is distended.

By asking a client to explain the statement, "A bird in the hand is worth 2 in the bush," the nurse is evaluating the client's ability in which of the following intellectual functions?

Abstract reasoning Rationale: This exercise evaluates higher-level thinking and the ability to understand and interpret abstract thoughts.

A nurse is evaluating a client for conductive hearing loss. Using the Rinne test, which of the following results should the nurse identify as an indication that the client has conductive hearing loss of the left ear?

Air conduction is less than bone conduction in the left ear. Rationale: This finding indicates conductive hearing loss of the left ear.

A nurse is admitting a client who has measles. Which of the following types of transmission precautions should the nurse initiate?

Airborne Rationale: Airborne precautions are required for clients who have infections that spread via droplet nuclei that are smaller than 5 microns in diameter, including varicella, tuberculosis, and measles.

A nurse on a medical unit is caring for a client who has difficulty sleeping. Which of the following actions should the nurse take to promote the client's ability to fall asleep?

Allow the client to maintain the same bedtime routine as at home Ratioanale: For many clients in an acute care facility, disrupting the usual sleep routine is the primary reason for a client's inability to sleep.

A nurse is collecting data from a client who has mixed aphasia. Which of the following strategies should the nurse use to help facilitate communication with this client?

Ask simple, short questions Rationale: Keeping language simple and brief can help the client understand its content. Facial and hand gestures can also help.

A nurse is supervising a newly licensed nurse who is caring for a client with streptococcal pharyngitis on transmission-based precautions. Which of the following actions by the newly licensed nurse indicates an understanding of droplet precautions?

Assigning another client with the same infection to share the room with the client Rationale: The nurse can place clients who are infected with the same pathogen in a shared room if a private room is not available.

A nurse is caring for a client who is having difficulty breathing. The client is lying in bed with a nasal cannula delivering oxygen. Which of the following interventions is the nurse's priority?

Assist the client to an upright position Rationale: The priority action the nurse should take when using the airway, breathing, and circulation (ABC) approach to care is to improve the client's respiratory status by seeking to relieve dyspnea. High Fowler's positioning permits full chest and lung expansion and makes breathing easier.

A nurse is beginning a therapeutic relationship with a client. Which of the following actions should the nurse perform to convey empathy when using the therapeutic communication technique of active listening?

Assume an open position Rationale: The nurse should sit with arms and legs uncrossed. Crossing them suggests a defensive posture.

A nurse is caring for a client who is receiving mechanical ventilation via a tracheostomy tube and has a gastrostomy tube for enteral feedings. Which pieces of information are critical to communicate to the next nurse caring for this client? (Select all that apply.)

B. New prescriptions D. Arterial blood gas results E. Tracheal secretion characteristics Rationale: The nurse should report any changes to the client's treatment in the nursing handoff report. For a client who is receiving mechanical ventilation, the latest arterial blood gas results and tracheal secretion characteristics reflect the client's current respiratory and ventilatory status and are an essential part of the nursing handoff report.

A nurse is caring for a semiconscious client who had a small-bore NG tube placed yesterday for the administration of enteral feeding. Which of the following methods should the nurse use to verify correct tube placement? (Select all that apply.)

B. Verify initial X-ray examination C. Measure the length of the exposed tube D. Determine the pH of the aspirated fluid Rationale: The nurse should confirm the NG tube placement by checking the X-ray results following the insertion of the NG tube. Also, the nurse should check the length of the NG tube that is exposed by comparing the markings on the tube to the client's nose to verify tube placement. Finally, the nurse should check the pH of the aspirated fluid to verify the tube placement.

A nurse is assisting with the care of a client who requires ventilatory assistance with breathing following a motor vehicle crash. The nurse should suspect that the client has an injury to which of the following parts of the brain?

Brainstem Rationale: The nurse should identify an injury to the medulla and pons of the brainstem for a client who is experiencing difficulty with breathing. The brainstem serves as the respiratory control center, and a neurological injury can impair this center and inhibit respiratory effort.

While drawing blood for laboratory testing from a client, a nurse observes a blood spill on her gloved hand. The client has no documented bloodstream infection. Which of the following actions should the nurse take?

Carefully remove the gloves and follow with hand hygiene Rationale: Standard precautions require the use of gloves and hand hygiene in the care of all clients.

A nurse is caring for a middle adult client. The nurse should evaluate the client for progress toward which of the following developmental tasks?

Ceasing to compare personal identity with those of others Rationale: Middle adults usually feel more comfortable with themselves and cease to make comparisons with others.

A nurse enters a client's room and finds the client sitting on the floor and leaning against the side of the bed. The client states she slipped while getting out of bed. Which of the following actions should the nurse take first?

Check the client for injuries Rationale: The first action the nurse should take using the nursing process is to evaluate the client for any injuries or physiological changes. The nurse should also notify the provider to determine the need for any further examination or intervention.

A nurse is caring for a client who was transferred to the surgical unit by stretcher from the PACU. Which of the following actions should the nurse perform first after the transfer?

Check the client's vital signs Rationale: The greatest risk to this client is an injury from vital signs becoming unstable such as with hypotension and respiratory depression, after having received anesthesia and medication. Therefore, the nurse should first check the client's vital signs and compare them with the readings during the PACU stay.

A nurse is caring for a client who had a mastectomy and has a self-suction drainage evacuator in place. Which of the following actions should the nurse take to ensure proper operation of the device?

Collapse air from the device after emptying Rationale: The nurse should collapse air from the device after emptying the contents and periodically to create enough suction to pull fluid exudate into the collection area of the device.

A nurse is reviewing the laboratory results for a client who has a non-healing wound. Wound cultures have identified vancomycin-resistant enterococci (VRE). Which of the following types of precautions should the nurse initiate?

Contact Rationale: Contact precautions are a type of transmission-based precaution for clients who have an infection with an organism such as VRE, which spreads either by direct or indirect contact.

A nurse is collecting data from a client who has a total calcium level of 12.7 mg/dL. Which of the following findings should the nurse expect?

Depressed deep-tendon reflexes Rationale: A total calcium level of 12.7 mg/dL is above the expected reference range. Manifestations of hypercalcemia include depressed deep-tendon reflexes, nausea, vomiting, bone pain, lethargy, and weakness.

A nurse is performing an otoscopic examination of a client's right ear. The light reflex is visible in the right lower quadrant of the tympanic membrane. Which of the following actions should the nurse take in response to this finding?

Document this as an expected finding Rationale: The light the otoscope reflects off the tympanic membrane is cone-shaped or triangular. In the right ear, it is visible in the right lower quadrant of the eardrum. In the left ear, it is visible in the left lower quadrant.

A nurse is caring for a client who has a methicillin-resistant Staphylococcus aureus (MRSA) infection. A dietary assistant asks the nurse what precautions are necessary for entering the client's room with the lunch tray. Which of the following instructions should the nurse give the dietary assistant?

Don gloves when entering the room and use hand sanitizer when exiting Rationale: Clients who have a MRSA infection require contact precautions. In addition to the use of standard precautions and meticulous hand hygiene, contact precautions require any staff member who will have contact with the client's environment to don gloves prior to entering the room. Additional precautions such as a gown are required for contact with the client, and a mask and goggles are needed if secretions from the infected area could spray into the worker's face. Since delivering the tray will require contact with the environment, the dietary assistant must wear gloves.

A nurse is changing the dressings for a client recovering from an appendectomy following a ruptured appendix. The client's surgical wound is healing by secondary intention. Which of the following observations should the nurse report to the provider?

Halo of erythema on the surrounding skin Rationale: The nurse should report to the provider when the client has a ring of erythema (redness) on the surrounding skin, which might indicate an underlying infection. This and any other manifestation of infection such as purulent drainage, swelling, warmth, or a strong odor should be reported to the provider.

A nurse is collecting data about a client's pulses of the lower extremities. The nurse should identify which of the following as the location of the most distal pulse?

Dorsalis pedis Rationale: The dorsalis pedis pulse is located on the top of the foot, following the groove between the tendons of the great toe. It is best felt by putting the fingertip between the first and second toe and slowly moving up the dorsum of the foot. However, this pulse is congenitally absent in some clients.

A nurse is preparing to administer eye drops to a client following surgery. Which of the following actions should the nurse take when instilling the eye drops?

Drop the eye medication into the lower conjunctival sac. Rationale: The nurse should drop the eye medication in the lower conjunctival sac to avoid placing the drops on the cornea and causing damage.

A nurse is contributing to the plan of care for a client who had a stroke and is scheduled to receive feeding via a gastrostomy tube. Which of the following actions should the nurse recommend prior to initiating each feeding?

Elevate the head of the bed Rationale: Clients who have a brain injury are typically unable to swallow effectively and thus cannot protect their airway from aspiration. Even though this route bypasses the nasopharynx, it is still possible for the client to cough or vomit enteral formula into the oral cavity. Consequently, the nurse should take actions to prevent aspiration such as elevating the head of the bed prior to initiating the feeding.

A nurse is caring for an adult client who has an NG tube in place and a prescription for continuous enteral feedings. Which of the following actions should the nurse take to reduce the client's risk for aspiration?

Elevate the head of the bed by 30° to 45° Rationale: Elevating the head of the bed to at least 30° and preferably 45° helps prevent the gravitational reflux of gastric contents, thereby decreasing the risk of aspiration.

A nurse is caring for a client who has cancer and is experiencing pain. The nurse should implement which of the following interventions to assist the client with pain relief?

Encourage the client to listen to soft music Rationale: The nurse should encourage the client to use music therapy to reduce anxiety, provide a distraction, and relieve pain.

A nurse is preparing to insert an NG tube for a client who has a bowel obstruction. Which of the following actions should the nurse take first?

Explain the procedure to the client :

A nurse is collecting data as part of a comprehensive physical examination of a client. The nurse should use inspection to evaluate which of the following?

Gait Rationale: Inspection is the technique of looking or observing. Gait inspection involves watching the client's walking movements and observing for any unusual findings.

A nurse is collecting data from a client who is postoperative. Which of the following findings should the nurse identify as an indication that the client is experiencing pain?

Grimacing

At a well-child visit, a nurse is collecting data from a 6-month-old infant. Which of the following findings should the nurse report to the provider?

Head lagging when the parent pulls the infant up to sit Rationale: Between 4 and 6 months, there should be no head lag when the parent pulls the infant to a sitting position. Between the ages of 6 months and 8 months, the infant should be able to sit without support.

A nurse is collecting data from a client who is experiencing stress over a near fall out of bed. Which of the following physiological responses should the nurse expect to observe due to the client's fight-or-flight response?

Increased blood pressure Rationale: The nurse should expect a client who is experiencing the fight-or-flight response to manifest increased arterial blood pressure, heart rate, and cardiac output due to the arousal of the central nervous system.

A nurse is reinforcing teaching with a group of young adults. Which of the following should the nurse identify as an expected developmental task for this age group?

Independent moral development

A nurse manager is providing teaching to a group of newly licensed nurses about ways that clients acquire health care-associated infections (HAIs). Which of the following routes of infection should the manager identify as an iatrogenic HAI?

Infection acquired from a diagnostic procedure

A nurse in an acute-care facility is assisting with planning care for a client who is alert but is temporarily immobile due to a total hip arthroplasty. Which of the following interventions should the nurse suggest to prevent a complication of immobility?

Instruct the client to perform foot and leg exercises every 1 to 2 hours while awake to help prevent thrombophlebitis

A nurse in the emergency department is caring for an inmate who has a laceration and is bleeding. The client was brought to the facility by a guard who asks the nurse about the client's HIV infection status. Which of the following actions should the nurse take?

Instruct the guard to ask the inmate Rationale: The nurse is not able to supply this information to the guard. In order for the guard to obtain this information, the client must offer the information freely. Therefore, the nurse should instruct the guard to ask the client for this information.

A nurse is obtaining the blood pressure in a client's lower extremity. Which of the following actions should the nurse take?

Place the bladder of the cuff over the posterior aspect of the thigh Rationale: This is the correct position for the nurse to place the bladder of the cuff when measuring a lower-extremity blood pressure.

A nurse is reinforcing teaching with a client regarding protein intake. Which of the following foods should the nurse include as an example of an incomplete protein?

Lentils Rationale: Incomplete proteins are missing 1 or more of the essential amino acids necessary for the synthesis of protein in the body. Examples of incomplete proteins include lentils, vegetables, grains, nuts, and seeds.

A nurse is performing a physical examination of a client. The nurse should use percussion to evaluate which of the following parts of the client's body?

Lungs Rationale:Percussion creates a vibration that helps the examiner determine the density of the underlying tissue. The lungs are hollow organs that can produce sounds such as resonance (hollow sound over alveoli) or dullness (dull sound over consolidated areas of the lungs or diaphragm). The nurse also uses auscultation and palpation when evaluating the lungs.

A nurse is initiating the use of a sequential compression device for a client who is postoperative following knee surgery. Which of the following actions should the nurse take?

Make sure 2 fingers can fit under the sleeves Rationale: If 2 fingers cannot fit between the sleeves and the legs, the device could impair the client's circulation when the nurse inflates the sleeves.

A nurse is preparing to administer medication to a client who has gout. The nurse discovers that an error was made during the previous shift in which the client received atenolol instead of allopurinol. Which of the following interventions is the nurse's priority?

Measure the client's apical pulse Rationale: The first action the nurse should take using the nursing process is to assess the client by measuring the client's apical pulse. Atenolol is a beta blocker and can decrease the client's heart rate.

A nurse is measuring a client's vital signs. The clients resting radial pulse rate is 55/min. Which of the following actions should the nurse take next?

Measure the client's apical pulse rate Rationale: First, the nurse should assess or collect data from the client. This pulse rate is below the expected reference range for an adult. The nurse and a coworker should measure the apical and radial pulse rates simultaneously to determine if there is a pulse deficit. If the client's radial pulse rate is lower than the apical rate, the client might have a cardiovascular disorder.

A nurse on a medical-surgical unit is caring for a client who develops deep, rapid respirations. Arterial blood gas analysis includes the following values: pH 7.25, PaCO2 40, and HCO3- 18. Which of the following acid-base imbalances should the nurse identify and report to the provider?

Metabolic acidosis Rationale: A pH of 7.25 indicates acidosis. If the cause is respiratory, the pH and PaCO2 values deviate in opposite directions. Since the PaCO2 is within the expected range, despite the low pH, the cause must be metabolic. Therefore, the nurse should report to the provider that the client has metabolic acidosis.

A nurse is caring for a client who had a stroke and is at risk of falling. Which of the following actions should the nurse take?

Monitor the client at least once every hour Rationale: The nurse should monitor the client frequently as a means of reducing the client's fall risk. Other measures can include keeping the client's bed in a low position, creating elimination schedules, and using a gait belt when the client is ambulating.

A nurse is caring for an older adult client who has dysphagia following a cerebrovascular accident. Which of the following actions should the nurse take when assisting the client at mealtime?

Offer the client tart or sour foods first Rationale: This client who has impaired pharyngeal swallowing should consume tart and sour foods at the beginning of the meal to stimulate saliva production, which aid chewing and swallowing.

A nurse is preparing to administer a tap water enema to a client. Which of the following actions should the nurse take?

Place the client in a left Sims' position Rationale: The nurse should place the client into a left Sims' position for the insertion of an enema. This left lateral position facilitates the flow of the enema solution into the sigmoid and descending colon. The anus is exposed by flexing the right leg.

A nurse is planning to collect a stool specimen for ova and parasites from a client who has diarrhea. Which of the following actions should the nurse take when collecting the specimen?

Place the stool specimen collection container in a biohazard bag Rationale: The nurse should place the specimen collection container in a biohazard bag with the client label placed on the container and the bag for easy identification and to prevent contamination with microorganisms.

A home health nurse enters a client's home and finds a used insulin syringe, without a cap, on the table. Which of the following actions should the nurse take?

Place the syringe in a puncture-proof disposal container Rationale: The nurse should place the uncapped syringe in a puncture-proof sharps disposal container or rigid plastic container to prevent a needlestick injury. The nurse should keep the syringe uncapped while placing the cap on the needle and reinforce client education on safety and proper disposal of syringes.

A nurse on a rehabilitation unit is preparing to transfer a client who is unable to walk from a bed to a wheelchair. Which of the following techniques should the nurse use?

Place the wheelchair at a 45° angle to the bed Rationale: Positioning the wheelchair at a 45° angle allows the client to pivot, lessening the amount of rotation required.

A nurse is removing a dressing over the surgical incision of a client who is postoperative following abdominal surgery. Today, the client reported that "something opened up." The nurse finds that the incision has separated and intestinal tissue is protruding. After calling for help, which of the following actions should the nurse take?

Position the client supine with the knees in flexion Rationale: This position reduces any strain that could cause further opening of the incision and worsening of the evisceration.

A nurse is monitoring a client's laboratory results. Which of the following results should the nurse report to the provider?

Potassium 3.0 mEq/L Rationale: This potassium level is below the expected reference range, indicating hypokalemia. The nurse should report this finding to the provider for instructions about preventing muscle weakness that could affect respiration.

A nurse is assisting with planning a community presentation for parents. When suggesting a discussion of controlling impulses and cooperating with others, the nurse should plan to relate it to Erikson's developmental task for which of the following age groups?

Preschoolers Rationale: Helping children control impulses and cooperate with others relates to Erikson's developmental task for preschoolers, which is initiative vs guilt. Altered development during this stage can result from harsh punishment and excessive limits on behavior, leading to guilt and frustration.

A nurse is auscultating breath sounds for a client who has fine crackles. At which of the following areas on the lung field should the nurse place the stethoscope?

Rationale: The nurse should place the stethoscope at the lower lobes of the lung field to auscultate for fine crackles that arise from the small airways of the lungs. Crackles are interrupted sounds that are heard at the end of inspiration. Fine crackles are caused by atelectasis, pneumonia, and chronic pulmonary disease.

A nurse is caring for a client in a long-term care facility. Which of the following findings should alert the nurse to the possibility that the client has developed delirium?

Reduced level of consciousness Rationale: When a client has delirium, the nurse should expect a reduced level of consciousness, sudden memory impairment, illogical thinking, and sleep disturbances.

A nurse is caring for a client who requires wrist restraints. Which of the following actions should the nurse take?

Remove the restraints at least every 2 hr Rationale: The nurse should remove the restraints at least every 2 hours to reposition the client, provide fluids and nutrients, assist with range-of-motion exercises, and evaluate the client's overall wellbeing.

A nurse is helping a client change his hospital gown. The client has an IV infusion on an infusion pump. Which of the following actions should the nurse take first?

Remove the sleeve of the gown from the arm without the IV line Rationale: the nurse should first remove the gown from the client's arm without the IV line. Beginning the process in this way will enable the nurse to move the gown fully off the client and then stop the system to remove the gown from the line, resulting in minimal interruption of the IV flow.

A nurse is reviewing a client's laboratory report. The client's ABG levels are pH 7.5, PaCO2 32 mmHg, and HCO3- 24 mEq/L. The nurse should determine that the client has which of the following acid-base imbalances?

Respiratory alkalosis Rationale: ABGs are drawn to determine the acid-base balance in the arterial blood. This client's pH is elevated above the expected reference range of 7.35 to 7.45, indicating alkalosis. The client's PaCO2 is below the expected reference range of 35 to 45 mmHg, which indicates a respiratory origin. The nurse should conclude that the client's elevated pH and decreased PaCO2 indicate respiratory alkalosis.

A home health nurse is visiting the home of a caregiver who says he is "exhausted" from working part-time in addition to caring for his mother, who is an older adult and has severe dementia. Which of the following options should the nurse suggest to the caregiver?

Respite care Rationale: Respite care is a service for caregivers who need free time to rest, away from multiple responsibilities related to the care of a family member who needs assistance.

A nurse is collecting baseline data about a client's respirations as part of a comprehensive physical examination. Which of the following types of breath sounds should the nurse report to the provider?

Rhonchi Rationale: A nurse is assessing the pH of a client's gastric fluid to confirm the placement of an NG tube in the stomach. Which of the following pH values should the nurse expect?

A nurse is collecting data from a 5-year old client during a routine examination. Which of the following activities should the nurse expect the child to perform?

Ride a bicycle with training wheels Rationale: By the age of 5 years, preschoolers should be able to ride a bicycle with training wheels, skip and jump rope, and print letters and numbers. They should also be able to demonstrate creativity and imagination.

A nurse is collecting data from a client as part of a neurological examination. To promote safety during the examination, the nurse stands nearby as the client follows the instructions for which of the following tests?

Romberg Rationale: A Romberg test evaluates standing balance, first with the client's eyes open and then with them closed. The nurse should remain close by because the client could fall during this test.

A nurse is collecting data about a client's incision and observes the drainage to be blood-tinged. Which of the following terms should the nurse use to document this finding?

Sanguineous Rationale: The nurse should document blood-tinged drainage as sanguineous. This type of drainage contains large amounts of red blood cells, indicating that damaged capillaries are allowing the escape of red blood cells from the plasma.

A nurse at a screening clinic is collecting data for a client who reports a history of a heart murmur related to aortic valve stenosis. At which of the following anatomical areas should the nurse place the stethoscope to auscultate the aortic valve?

Second intercostal space to the right of the sternum Rationale: The aortic valve is located in the second intercostal space to the right of the sternum. Aortic stenosis produces a midsystolic ejection murmur that can be heard clearly at the aortic area with the client leaning forward.

A nurse is planning an instructional session about walking with a cane for a client who has a moderate sensorineural hearing loss. Which of the following actions should the nurse take?

Sit at the same level as the client Rationale: The nurse should sit face-to-face with the client, at the same level, to offer an optimal opportunity for speech reading (i.e. lip reading). It is also important to avoid blocking the client's direct view of the nurse's mouth such as by touching her face or mouth.

A nurse is examining a client for signs of costovertebral angle tenderness. The nurse should place the client in which of the following positions for evaluation?

Sitting Rationale: The costovertebral angle is the area where the spine and the twelfth rib intersect. A sitting position promotes relaxation and allows access to the back for percussion of that region.

A nurse is caring for a client who is dehydrated. An insensible fluid loss of approximately 500 to 600 mL occurs each day through which of the following organ?

Skin Rationale: The nurse should identify that the skin can excrete approximately 500 to 600 mL of insensible fluid. This type of fluid loss is continuous and can increase if the client is experiencing a fever or has had a recent burn to the skin.

A nurse on a medical unit is caring for a client who has been coughing intermittently during meals, attempting to clear her throat repeatedly, and eating only a small portion of her meals. The nurse should recommend a referral to which of the following members of the interprofessional team to evaluate the client for dysphagia?

Speech-language pathologist A speech-language pathologist can perform a thorough evaluation of the client for dysphagia and help the client learn to eat safely. For example, the client can learn the supraglottic swallow (take a breath, hold the breath while swallowing, cough after swallowing, and swallow again to clear the mouth).

A nurse is preparing to administer a medication to a client. Which of the following administration schedules indicates that the nurse should administer the medication once and as soon as possible?

Stat prescription Rationale: The nurse should identify that a stat medication prescription is carried out immediately and one time only.

As part of a neurological examination, a nurse instructs a client to keep his eyes closed, places an object in his hand, and asks him to identify the object. Which of the following abilities is the nurse evaluating with this technique?

Stereognosis Rationale: Stereognosis is the ability to identify an object's size, shape, and texture via tactile sensation.

A nurse is reinforcing teaching about nutrition with a middle adult client who has a sedentary job. Which of the following factors should the nurse consider?

The basal metabolic rate could decrease. Rationale: The basal metabolic rate decreases as adipose tissue replaces skeletal muscle mass. This places the client at risk for weight gain if he does not maintain a healthy diet.

A nurse is evaluating a client's use of crutches. The nurse should identify that which of the following actions by the client indicates safe usage of this equipment?

The client has slightly flexed elbows when ambulating with the crutches Rationale: The client should have slightly flexed elbows when ambulating with crutches. This allows the client to bear weight on the hands and not on the axillae.

A nurse is reinforcing teaching about range-of-motion exercises with a client who has osteoarthritis. Which of the following positions indicates the client's correct understanding of supination of the hand?

The client holds the hand with the palm up. Rationale: Holding the hand with the palm up demonstrates an understanding of supination of the hand.

A nurse is helping a client perform range-of-motion exercises of the neck. For evaluating neck flexion, which of the following motions should the nurse instruct the client to perform?

Touching his chin to his chest Rationale: Flexion of the neck is moving the chin down so that it rests on the chest.

A nurse is reinforcing teaching about bladder retraining for a client who has urinary incontinence. Which of the following instructions should the nurse include?

Try to block the urge to urinate until the next scheduled time Rationale: When the client is following a schedule of voiding intervals and feels the urge to urinate before the next scheduled time, the client should try to practice slow, deep breathing to help reduce the urge. The client can also try 5 or 6 strong and quick pelvic muscle exercises.

A nurse is inserting an indwelling urinary catheter into the penis of a client. Which of the following actions should the nurse take?

Use the nondominant hand to grasp the penile shaft Rationale: To position the penis for insertion of the catheter, the nurse should use the nondominant hand to grasp the shaft just below the glans and hold it at up at a right angle to the client's body. This helps straighten the urethra to facilitate insertion of the catheter.

A nurse is caring for a client who reports using several herbal supplements. Which of the following actions should the nurse take?

Verify that the herbal supplements do not interact with medications the provider has prescribed Rationale: Many herbal products interact with other prescription and nonprescription medications. Valerian, for example, interacts with antihistamines as well as barbiturates and other sleep-promoting medications. The nurse should report any potential interactions to the provider.

A nurse is reviewing the laboratory results of a client who is preoperative. Which of the following results should the nurse report to the surgeon?

WBC count 18,000/mm^3 Rationale: This WBC count is above the expected reference range, indicating infection. The nurse should report this finding to the surgeon immediately, as it might result in postponement of the surgical procedure.

A nurse is collecting data from a client who is postoperative following abdominal surgery. Which of the following findings is the nurse's priority to report to the surgeon immediately?

Warm, tender area on the right calf Rationale: The greatest risk to this client is an injury from thrombus formation; therefore, this is the priority finding that the nurse should report to the surgeon immediately. This is a life-threatening postoperative complication because the thrombus could dislodge and become a pulmonary embolism.

A nurse is contributing to the plan of care for a client who has fluid volume excess. Which of the following interventions should the nurse plan to include to monitor the client's weight?

Weigh the client on arising in the morning Rationale: The nurse should weigh the client on arising each day, after voiding and before breakfast. An accurate weight requires the client to be weighed wearing the same type of garments and on the same carefully calibrated scale (balanced to 0 before each use). Accurate daily weights provide the easiest measurement of volume status. An increase of 1 kg (2.2 lb) is equal to 1,000 mL (1 L) of retained fluid.

A nurse is caring for a client who has a deficiency in vitamin D. Which of the following foods should the nurse recommend the client include in his diet?

Whole milk Rationale: The fat-soluble vitamins, A, D, E, and K require fatty substances or tissues to be dissolved as well as the presence of bile in the small intestine for absorption. Whole milk contains vitamins A and K and is often fortified with vitamin D.

A nurse is evaluating the development of a group of clients. The nurse should understand that, according to Erikson, the developmental task of intimacy vs. isolation occurs during which of the following stages of development?

Young adulthood Rationale: The developmental task of young adulthood is intimacy vs. isolation.