ATI Fundamentals Quiz 2 NCLEX-RN

A nurse is caring for several clients who are receiving oxygen therapy. Which client should the nurse ASSESS MOST FREQUENTLY for manifestations of OXYGEN TOXICITY? The client receiving A. 100% oxygen via a partial re-breathing mask B. 21% oxygen via mechanical ventilation C. 40% oxygen via tracheostomy collar D. 4 L/min of oxygen via nasal cannula

A. 100% oxygen via a partial re-breathing mask RATIONALE: 100% oxygen via partial re-breathing mask delivers concentrations of 60 with 90% inspired oxygen (inspired oxygen concentration with oxygen flow to the reservoir bag and with how much the bag collapses with inspiration). Oxygen toxicity is associated with oxygen concentrations about 50% for longer than 24-48 hours. 21% oxygen is room air. It cannot cause oxygen toxicity even when delivered by mechanical ventilation. 40% oxygen or less is considered non-toxic for short-term therapy and the method of delivery is irrelevant. 6 L/min of oxygen via nasal cannula delivers the equivalent of approx 30% oxygen, which is considered non-toxic for short-term therapy, regardless of the method of delivery. Inspired oxygen concentrations vary when a nasal cannula is in use because it is a low-flow system that depends in part on the client's respiratory rate and mouth or nose breathing.

A nurse is in a public building when someone cries out, "Help, I think he is having a heart attack!" The nurse responds to the scene and finds an UNCONSCIOUS ADULT lying on the floor. Another bystander has obtained an AED machine. The nurse's FIRST ACTION, after making certain someone has called for emergency medical services, should be to A. Administer cardiac compressions B. Open the airway C. Deliver two rescue breaths D. Apply the pads to the chest

A. Administer cardiac compressions RATIONALE: using airway, breathing, circulation (ABC) approach to client care, the nurse determines the priority finding is to administer chest compressions for a client who has suffered an unwitnessed, out-of-hospital cardiac arrest. It is recommended that the rescuer complete 5 cycles (or about 2 min) of CPR before attaching and using the AED. Using the head-tilt-chin lift to open the client's airway is important to prepare for rescue breathing. However, this is not the priority action. It is essential for the rescuer to give two rescue breaths, using an appropriate barrier device, but this is not the first step the nurse should take in this situation. To use the AED, the nurse will have to place the pads on the person's chest, but this is not the first step to take in this situation.

A post-op client has an INDWELLING CATHETER in place to gravity drainage. The nurse notes that the client's URINARY DRAINAGE BAG has been EMPTY for 2 HOURS. The FIRST ACTION the nurse should take is to A. Check to see if the tubing is kinked B. Request a prescription for a diuretic C. Irrigate the catheter with 0.9% sodium chloride D. Encourage the client to drink more fluids

A. Check to see if the tubing is kinked RATIONALE: a common reason a tube is not draining is that there is a kink in the tubing or that the client is lying on it. The nurse should inspect the tubing carefully, straightening out any kinks, and making certain that there are no dependent loops. Unless the client also has signs of fluid overload, requesting a diuretic would be an inappropriate choice and certainly not the nurse's first action in this situation. Irrigating the catheter is an invasive procedure that may put the client at risk for infection and may distend the bladder. This is not the first action the nurse should take in this situation. It may or may not be appropriate to encourage a post-op client to drink more fluids; the nurse would have to verify the client's post-op orders first. Nevertheless, this is not the first action the nurse should take in this situation. TEST-TAKING STRATEGY: with a priority-setting question where all the options appear correct, but various stages of the nursing process are reflected in the options, rely on the nursing process to help set priorities. Assessment comes first, followed by analysis, planning, intervention, and evaluation.

When REPLACING a client's surgical DRESSING, the nurse should A. Don clean gloves to remove the old dressing B. Loosen the dressing by pulling the tape away from the wound C. Remove the entire dressing at once D. Open sterile supplies for the new dressing after removing the old one

A. Don clean gloves to remove the old dressing RATIONALE: standard precautions require the nurse to don clean gloves whenever there is a possibility of coming into contact with secretions. Removing a soiled dressing is a procedure that requires wearing clean (not sterile) gloves. Sterile gloves are not necessary until the nurse applies the new sterile dressing. Tape should be loosened by pulling TOWARD the wound. Pulling tape away from the wound may be painful and puts increased tension on the healing wound edges. The old dressing should be removed with the same care with which it was put on, layer by layer. This allows the nurse to assess drainage and limits the possibility of disrupting the healing wound and any drains within the layers. The sterile field must be prepared before removing the old dressing; otherwise, the client's wound is unnecessarily left exposed.

Which nursing action PREVENTS INJURY to a client's EYE during the administration of EYE DROPS? A. Holding tip of the container above the conjunctival sac B. Applying gentle pressure over the opening of the nasolacrimal duct C. Depositing the drops into the conjunctival sac D. Instructing the client to close his eyes after administration

A. Holding tip of the container above the conjunctival sac RATIONALE: the tip of the container can injure the client's eye and should not come in contact with the eye. In addition, if the client has an eye infection, the nurse must be careful not to touch one eye with secretions from the other eye. Occlusion of the nasolacrimal duct prevents systemic absorption but does not PROTECT the eye from injury. Depositing the drops into the conjunctival sac is the correct technique. It helps distribute the medication throughout the eye, but it does not PROTECT the eye from injury. Having the client close his eyes after the drops have been placed in the eyes helps distribute the medication over the eyeball, but it does not PROTECT the eye from injury.

A client's provider has ordered that a SPUTUM SPECIMEN be collected for CULTURE and SENSITIVITY. The nurse plans to collect the specimen A. In the morning, on arising B. In the evening, after forcing fluids all day C. After antibiotics have been started D. After the client has taken an expectorant

A. In the morning, on arising RATIONALE: generally, the DEEPEST specimens are obtained in the early morning, and it is preferable to collect the specimen BEFORE breakfast. The nurse instructs the client to RINSE the mouth, take a DEEP BREATH, and COUGH prior to expectorating into the sterile container. Although forcing fluids (especially clear fluids) will help THIN the secretions, the evening hours are not the best time for obtaining a DEEP specimen. A specimen ordered for culture and sensitivity should be collected before the client receives antibiotic therapy to prevent interference with the test results. Expectorants can contaminate the specimen.

A nurse is teaching a client with a new COLOSTOMY about how to IRRIGATE the OSTOMY. The nurse realizes that the client NEEDS FURTHER TEACHING when the client A. Positions the irrigating solution bag 30 inches above the stoma. B. Uses lukewarm tap water for the irrigation C. Inserts a lubricated cone tip into the ostomy stoma D. Uses up to 500 mL of irrigating solution

A. Positions the irrigating solution bag 30 inches above the stoma RATIONALE: the irrigating solution bag should be positioned a maximum of 20 inches above the height of the stoma, not 30 inches. This height can cause too much pressure in the line and force the irrigating solution in too rapidly, causing abdominal cramping. Tap water is appropriate and it should feel warm to the client's wrist. Water that is too cool can cause cramping and water that is too hot may burn the mucosal lining of the colon. It is appropriate to use a lubricated cone tip. The cone-tipped irrigating device prevents backflow of the solution and also protects the client from injury. Up to 1000 mL can be used for colostomy irrigations. TEST-TAKING STRATEGY: this question asks which action indicates that the client needs FURTHER TEACHING, thus the CORRECT answer is an INCORRECT action.

CPR has been INITIATED for a client in the ER. The nurse understands that a critical concept related to effective cardiac (chest) compressions is the need to A. Push hard and deep on the chest B. Compress at a rate of 80/min C. Keep the chest from recoiling after each compression D. Interrupt chest compressions at regular intervals

A. Push hard and deep on the chest RATIONALE: compressions should be hard and deep. Shallow chest compressions may not produce adequate blood flow. While there has not been a single ideal compression rate, most studies identify that a compression rate of 100/min will produce adequate blood flow and improve survival. Complete chest recoil maximizes refilling of the heart and is necessary for effective blood flow during chest compressions. When the chest is not compressed, blood does not flow. Rescuers should not interrupt chest compressions often or for long during CPR and should try to keep interruptions to less than 10 seconds.

When AMBULATING a FRAIL, OLDER ADULT client, the nurse should A. Use a transfer belt if the client is unsteady B. Allow the client to walk unsupervised with a walker C. Encourage the client to shuffle when walking D. Walk 2 feet behind the client in case of a fall

A. Use a transfer belt if the client is unsteady RATIONALE: the use of a transfer belt helps hold the client steady while ambulating. The nurse should assess the client's abilities before allowing him to move around unsupervised. Even with the use of a walker, the client may be at risk for falling. The client should be discouraged from shuffling his feet while walking. Shuffling may cause the client to trip and fall. The client may fall forward while walking so the nurse would be unable to help if walking 2 ft behind him.

A client is hospitalized for an INFECTION of a SURGICAL WOUND following abdominal surgery. To PROMOTE HEALING and FIGHT WOUND INFECTION the nurse plans to arrange to increase the client's intake of A. Vitamin C and Zinc B. B-complex vitamins C. Vitamin K and Iron D. Calcium and Vitamin D

A. Vitamin C and Zinc RATIONALE: the body's need for both vitamin C and zinc increases when fighting a wound infection. The client should receive a multivitamin plus a mineral supplement of both. In addition, vitamin E supplements have been shown to aid in skin and wound healing. Although B-complex vitamins, vitamin K, and iron are important for the client's overall health, the client's need for them is not necessarily increased when fighting a wound infection. If the client is a female, calcium and vitamin D are important for overall health and to prevent osteoporosis. However, the client's need for them does not necessarily increase when fighting infection.

A client RETURNING FROM THE SURGICAL SUITE following a vaginal hysterectomy is awake and ASKING FOR SOMETHING TO DRINK. Her POST-OP DIET prescription reads: CLEAR LIQUIDS; ADVANCE DIET AS TOLERATED. Which of the following is appropriate for the nurse to tell the client? A. "Lunch trays should be here within the hour." B. "I am going to listen to your abdomen." C. "I'll get you some water to drink." D. "I would wait a bit, or you could feel sick."

B. "I am going to listen to your abdomen." RATIONALE: a common reason clients experience nausea and vomiting after surgery is delayed gastric emptying time or decreased peristalsis. The nurse must auscultate the client's abdomen to determine the presence of bowel sounds BEFORE clear liquids can be given. The response in Option A is non-therapeutic because it indicates that the client's immediate needs are not important. Option C is not appropriate because when a client is ready to resume a post-surgical diet, it is preferable to OFFER A CHOICE of clear liquids rather than water. Water provides hydration, but no other nutrients. The response in option D is a non-therapeutic communication block of offering unsolicited advice to the client.

When obtaining a URINE SPECIMEN for a CULTURE AND SENSITIVITY from an INDWELLING CATHETER, the nurse should A. Wear sterile gloves B. Cleanse the entry port prior to withdrawing urine C. Collect the specimen from the urometer port D. Drain the bad and wait for a fresh urine sample to send from the drainage bag

B. Cleanse the entry port prior to withdrawing urine RATIONALE: disinfecting the entry port removes or destroys any microbes on the surface of the catheter, thereby avoiding contamination of the specimen and the catheter. Sterile gloves are unnecessary when using the appropriate technique to collect a urine specimen from a closed drainage system. The nurse should wear clean gloves, however, as standard precautions require. The urometer port can only be used to obtain an unsterile specimen and a urine specimen for C&S must be collected using surgical asepsis. If the urine is obtained from the drainage bag, it is not considered sterile.

A client being discharged following abdominal surgery will be performing his own DRESSING CHANGES AT HOME. It is MOST IMPORTANT for the nurse to include which of the following in the DISCHARGE PLAN? A. Discussion of surgical asepsis B. Demonstration of appropriate hand hygiene C. Discussion of sterile gloving D. Demonstration of maintaining sterility of supplies

B. Demonstration of appropriate hand hygiene RATIONALE: proper hand hygiene is the most important and most basic strategy for preventing and controlling the transmission of pathogens. Very often, the home environment does not lend itself to the practice of surgical asepsis (sterile technique) and the client is usually taught to use medical asepsis (clean technique). However, the client is still at risk for the transmission of micro-organisms that may cause an infection and the nurse must help the client improvise with the resources available. The client is usually taught to use medical asepsis at home, including the use of clean, rather than sterile, gloves.

A client is recovering from gallbladder SURGERY performed under GENERAL ANESTHESIA. The nurse should encourage the client to use the INCENTIVE SPIROMETER how many times PER HOUR? A. One to two B. Four to five C. Eight to twelve D. Fifteen to twenty

B. Four to five RATIONALE: this device is designed to motivate the client to take deep breaths and should be included in the post-op plan of care. Using an incentive spirometer one to two times per hour is not enough to decrease the risks of atelectasis and pneumonia. Using it eight to twelve or fifteen to twenty times per hour is beyond the reasonable expectation for a post-op client. This number of times may tire the client and reduce adherence. Post-op breathing exercises must be balanced with the client's need for rest.

While CHANGING the LINEN on a client's bed, the nurse should A. Place the soiled linen on the chair while making the bed B. Hold the linen away from his body and clothing C. Put the linen on the floor until he can carry it to the hamper D. Shake the clean linen to unfold it

B. Hold the linen away from his body and clothing RATIONALE: this is the appropriate method for handling the linen. The nurse should hold the linen away from his clothing to prevent soiling or the transfer of micro-organisms. Since he must go from client to client, any micro-organisms present on the nurse's clothing could be transferred from one client to another. Option A is inappropriate because soiled linen is contaminated with micro-organisms and will further contaminate the surfaces of the chair. Soiled linen contaminated with micro-organisms will further contaminate the floor and attract any micro-organisms present on the floor, thus putting the nurse and client at risk for infection. Opening linens by shaking them causes movement of air. Air currents can carry dust and spread micro-organisms throughout the room, putting the nurse and client at risk for potential infection.

The mother of a TODDLER calls to the nurse, "Help! My baby is choking on his food." The nurse determines that the HEIMLICH MANEUVER is NECESSARY based on which FINDING? A. Pulse of 130 bpm and respiratory rate of 42 br/min B. Inability of the toddler to cry or speak C. Gagging without emesis D. Use of accessory muscles for respiration with rib retraction

B. Inability of the toddler to cry or speak RATIONALE: when no sound can pass through the vocal cords, a complete obstruction is evident. The Heimlich maneuver should be used to dislodge whatever is obstructing the trachea. Option A reflects typical signs of anxiety. The sympathetic nervous system is reacting to produce tachycardia and tachypnea. If breath sounds are present, the Heimlich maneuver is not indicated. Gagging can help clear the airway. The Heimlich maneuver is not indicated merely for gagging. Option D reflects the signs of respiratory difficulty but these symptoms alone are not an indication for the Heimlich maneuver.

A nurse has inserted an INDWELLING URINARY CATHETER for a MALE client. Where should the nurse TAPE THE CATHETER to PREVENT PRESSURE on the client's URETHRA at the PENOSCROTAL JUNCTION? A. Lateral thigh B. Lower abdomen C. Mid-abdominal region D. Medial thigh

B. Lower abdomen RATIONALE: the lower abdomen or inner aspect of the thigh are the recommended sites to eliminate the penoscrotal angle and prevent the formation of a urethrocutaneous fistula. Taping the catheter to the lateral thigh or outside thigh would be uncomfortable and would not eliminate the penoscrotal angle. The mid-abdominal region would not be comfortable for the client nor would it allow for the downward flow of urine via gravity into the drainage bag. Taping the catheter to the medial thigh would not eliminate the penoscrotal angle and could lead to fistula formation.

A client returns from surgery with TWO PENROSE DRAINS in place. Anticipating FREQUENT DRESSING CHANGES, what should the nurse use around the incision area? A. Silicone spray B. Montgomery straps C. Hypoallergenic tape D. Large absorbent pads

B. Montgomery straps RATIONALE: Montgomery straps are adhesive strips applied to the skin on either side of the surgical wound. The strips have holes for using gauze to tie the dressing securely. When the dressing is changed, the ties are released, the dressing is replaced, and the ties secured again without removing the adhesive strips. This taping technique minimizes irritation to the skin around the wound edges. Silicone spray is appropriate, but its purpose is not to reduce skin irritation. It is used OVER the adhesive to hold the dressing in place. The silicone WATERPROOFS the dressing so that the client can bathe. It also isolates the area from contamination. Hypoallergenic tape is used when a client is sensitive to adhesive material, but it sill has to be removed with each dressing change which could increase the risk of skin irritation. Large absorbent pads absorb more wound drainage but does not prevent skin irritation around the incisional area.

A nurse takes an OLDER ADULT client who has DYSPHAGIA following a CVA to the dining room for dinner. When assisting the client at MEALTIME, the nurse should A. Encourage the client to drink plenty of fluids B. Offer the client tart or sour foods C. Have the client tilt her head backward when swallowing D. Turn on the TV

B. Offer the client tart or sour foods RATIONALE: tart or sour foods stimulate saliva production, which helps with chewing and swallowing. When pharyngeal swallowing is impaired, liquids (especially THIN liquids) can make the client choke. It is preferable to suggest "dry swallows" to clear the mouth between bites of food. Tilting the head FORWARD helps promote swallowing. Distractions at mealtimes keep the client from concentrating on chewing thoroughly and swallowing. The nurse should promote an environment that increases the client's ability to concentrate.

A nurse is caring for a client who is receiving zan IV INFUSION that has INFILTRATED. Which of the following would be an UNEXPECTED FINDING when the nurse ASSESSES the client's INFUSION LINE and INSERTION SITE? A. The infusion slows or stops while the tubing is not kinked B. The area around the insertion site feels warm when touched C. Swelling, hardness, or pain located around the needle site D. Blood fails to return in the tubing when the bottle is lowered

B. The area around the insertion site feels warm when touched RATIONALE: the area around the insertion site would NOT feel WARM when the IV is INFILTRATED. If the area around the site feels warm, it may indicate INFECTION or PHLEBITIS. A sign of infiltration is that the infusion slows or stops despite the fact that the tubing is not kinked. Another sign of infiltration is swelling, hardness, or pain located around the needle site. In addition, blood that fails to return in the tubing when the bottle is lowered indicates infiltration. TEST-TAKING STRATEGY: since this is a negative-format stem question, an INAPPROPRIATE finding is CORRECT.

A nurse is ASSESSING a client admitted with a SUDDEN ONSET OF SEVERE BACK PAIN of unknown origin. Which statement would be MOST EFFECTIVE for the nurse to use to ELICIT FURTHER INFORMATION from the client about his pain? A. "Does the medication you're taking relieve the pain?" B. "Can you point to where the pain is worst?" C. "Tell me how you're feeling right now." D. "Changing positions makes your pain worse, right?"

C. "Tell me how you're feeling right now." RATIONALE: this is an OPEN-ENDED statement that allows the client to respond to the nurse with the widest range of information. Option A, B, and D are CLOSE-ENDED questions and are not the best INITIAL questions to ask the client. Also, his pain had a SUDDEN ONSET, so he might not have been taking medication long enough to answer this question. In option B, the client may not be able to point to where the pain is. It would be better for the nurse to have the client identify this location on an illustration of the body. Option D is a leading question that suggests to the client that changes in position SHOULD increase the pain.

A nurse is assisting a client with a meal. The client suddenly GRABS AT HER NECK WITH BOTH HANDS and appears frightened. The appropriate nursing action is to A. Place an oxygen mask on the client B. Begin rescue breathing C. Ask the client if she is choking D. Go to the nurse's station to get some help

C. Ask the client if she is choking RATIONALE: the client may be demonstrating the universal choking gesture. If she nods and cannot talk, severe airway obstruction is present. If there is good air exchange and she can cough and breathe spontaneously, then the nurse should stay with the client and monitor her condition. If the client's airway is obstructed, then oxygen is of no value. Initiating rescue breaths is an inappropriate nursing action because the client might not have a PATENT airway and is conscious. Leaving a client who is in distress is EXTREMELY INAPPROPRIATE. The nurse can summon help by calling out or by using the emergency call system.

A nurse is preparing to insert a NG TUBE for a client admitted with bowel obstruction. Which of the following should the nurse do FIRST? A. Give the client a cup of water B. Assist the client to a sitting position C. Explain the procedure to the client D. Have a stethoscope available to listen for proper placement

C. Explain the procedure to the client RATIONALE: informing the client about the procedure reduces fear and it helps gain the client's cooperation, which is important for the NG tube insertion and is the first action the nurse should take. Water facilitates swallowing during tube insertion, but giving a cup of water to the client is not the first action. Assisting the client to a sitting position is appropriate for insertion of a NG tube, but it is not the first action. A stethoscope will help the nurse evaluate the NG tube placement, but making one available is not the first action.

A nurse is caring for a client who has a new prescription for tube feeding. The nurse understands that the provider prescribed TUBE FEEDING because the client A. Refuses to eat solid foods in the hospital because he does not like them B. Prefers this feeding method because it is easier C. Is unable to swallow foods by mouth D. Has family who requests this method because it is more efficient for their older relative

C. Is unable to swallow foods by mouth RATIONALE: tube feeding is commonly prescribed for clients who are unable to eat by mouth. The client or family's preference is not a valid reason for prescribing tube feedings. After consultation with a dietician, the dietary department may be able to provide more foods the client likes while also meeting their dietary needs. Consultation with a dietician is important to help the family meet their older relative's nutritional needs.

A client who is post-operative following a LAPAROTOMY is REPORTING PAIN and a dry mouth. The client has morphine sulfate ordered to control the pain. BEFORE ADMINISTERING the morphine prescribed for the client, the nurse should FIRST A. Provide mouth care B. Discuss the side effects with the client C. Measure the client's vital signs D. Have the client turn, cough, and deep breathe

C. Measure the client's vital signs RATIONALE: the nurse should measure the client's vital signs before administering morphine to provide a baseline for measuring respiratory depression, an adverse effect of opioid analgesics. Mouth care should be provided to relieve the client's dry mouth, but it is not a priority. Clients do need to be informed of possible adverse effects, but it is not a priority in this situation. Option D is an important intervention for post-op clients, but it is not a priority in this situation.

When a nurse makes an INITIAL ASSESSMENT of a client who is post-operative following a GASTRIC RESECTION, the client's NASOGASTRIC TUBE is NOT DRAINING. The nurse's ATTEMPT TO IRRIGATE the tube with 10 mL of 0.9% sodium chloride is UNSUCCESSFUL, so she determines that the TUBE IS OBSTRUCTED. Which of the following actions should the nurse take? A. Advance or withdraw the tube until drainage is re-established B. Reposition the client on the left side C. Notify the surgeon D. Irrigate the tube with 45 mL of 0.9% sodium chloride

C. Notify the surgeon RATIONALE: it is the surgeon's responsibility to manage the tube obstruction. Nurses should not insert, reposition, or withdraw a NG tube after a client has had a gastric resection because the suture line could easily be interrupted and hemorrhage could result. Repositioning the client on the left side will not help if the tube is obstructed. NG tubes are typically irrigated with 10-30 mL of 0.9% sodium chloride, especially following gastric surgery. Irrigating with 45 mL could rupture the suture line because it lies so close to the tip of the NG tube.

A client develops a FECAL IMPACTION. Before DIGITAL REMOVAL of the mass, which TYPE OF ENEMA should the nurse give to LOOSEN THE FECES? A. Soapsuds enema B. Fleet's enema C. Oil retention enema D. Tap water enema

C. Oil retention enema RATIONALE: before digital removal of the fecal mass, an oil retention enema is given to soften the stool. This makes the de-impaction less painful for the client. A soapsuds enema acts as an irritant to increase peristalsis, thus facilitating the removal of the stool. It is usually given to CLEANSE the bowel completely AFTER digital removal of an impaction. A Fleet's enema, a commercial product that contains hypertonic fluid solution, is given to CLEANSE the bowel AFTER digital impaction. Tap water enemas were previously used to cleanse the bowel but are now contraindicated because of the risk of fluid and electrolyte imbalances. Tap water, which is hypotonic, can be drawn into the cells, causing fluid overload (hypervolemic state).

A nurse is planning to collect a LIQUID STOOL SPECIMEN from a client for OVA and PARASITES. INACCURATE TEST RESULTS may result if the nurse A. Instructs the client to defecate into a bedpan B. Transfers the specimen to a sterile container C. Refrigerates the collected specimen D. Collects only bloody and mucous portions of the stool

C. Refrigerates the collected specimen RATIONALE: a liquid stool specimen for ova and parasites must be sent IMMEDIATELY to the lab and examined within 30 minutes to preserve the life of any ova. If it cannot be examined within 30 min, then some of the specimen should be placed in a preservative, NOT the refrigerator. Defecation into a bedpan would not affect the test results; however, the stool must remain free from urine contamination. Placing stool to be tested for ova and parasites in a sterile container would have no effect on the test results. If the entire stool sample cannot be sent to the lab, the test results would not be affected by sending only the bloody and mucoid portions. TEST-TAKING STRATEGY: this question asks which action could FALSELY alter the test results, thus the CORRECT answer in an INCORRECT action.

A nurse is performing an EYE IRRIGATION for a client who has been exposed to smoke and ash. Which of the following nursing actions should receive the HIGHEST PRIORITY during the irrigation? A. Cleansing the eyelids prior to the irrigation B. Placing the client in an upright position with head tilted backwards C. Wearing gloves during the procedure D. Ensuring the irrigant is not warmed to more than 110 degrees Fahrenheit

C. Wearing gloves during the procedure RATIONALE: the nurse must wear gloves during an eye irrigation to maintain standard precautions. They protect the nurse from direct contact with body secretions. Wearing gloves also helps protect the client's eyes from introduction of a foreign body or micro-organisms from the nurse's hands. It is helpful to remove dust, secretions, and crusts prior to irrigation, but it is not the highest priority action. The nurse should ask the client to take a position of comfort, such as lying supine or sitting with her head tilted back or inclined slightly toward the side. However, this is not the highest priority action. Having the client look upward during irrigation or instillation of eye medications helps reduce blinking. It is a helpful intervention, but it is not the nurse's highest priority action.

The nurse is caring for an ADULT client who has FLUID VOLUME EXCESS. When WEIGHING this client, the nurse should A. Balance the scale daily B. Wait at least 2 hr after a meal C. Weigh the client on arising D. Weigh the client without clothing

C. Weigh the client on arising RATIONALE: accurate daily weights provide the easiest measurement of volume status. An increase of 1 kg (2.2 lb) is equal to 1000 mL (1 L) of retained fluid. An accurate weight requires the client to be weighed at the same time every day (preferably on arising), wearing the same garments, and on the same carefully calibrated scale (balanced to zero before each use). The scale should be balanced at zero every time the client is weighed, not just on a daily basis. Weighing the client after a meal does not provide an accurate reflection of the client's fluid status. It is best to weigh a client at the same time on the same scale, and ideally with the same clothing on. Weighing the client without clothing violates the client's privacy.

A client recovering from an appendectomy for a ruptured appendix has a surgical WOUND healing by SECONDARY INTENTION. When changing the client's dressing, which observation should the nurse REPORT to the client's SURGEON? A. Tenderness when touched B. Pink, shiny tissue with a granular appearance C. Serosanguineous drainage D. A halo of erythema on the surrounding skin

D. A halo of erythema on the surrounding skin RATIONALE: a ring of erythema (redness) on the surrounding skin may indicate underlying infection. This and any other signs of infection, such as purulent drainage, swelling, warmth, or strong odor, should be reported Tenderness when touched is an expected finding in a post-op wound healing by secondary intention. Severe pain may indicate infection or underlying tissue destruction and SHOULD be reported. Pink, shiny tissue with a grainy appearance is granulation tissue and indicates the PROLIFERATIVE STAGE of wound healing. This is a normal finding in a post-op wound healing by secondary intention. Serosanguineous drainage, made up of RBCs and plasma, is an expected finding in a post-op wound healing by secondary intention. PURULENT DRAINAGE would suggest an infection and WOULD need to be reported. TEST-TAKING STRATEGY: this question requires sorting out post-op wound observations that are EXPECTED versus UNEXPECTED.

In planning care for a client with a SURGICAL WOUND healing by SECONDARY INTENTION, the nurse can ANTICIPATE that the client will A. Have well-approximated wound edges B. Have the wound sutured closed at a later date C. Require skin grafting for the wound to heal D. Be at an increased susceptibility for infection

D. Be at an increased susceptibility for infection RATIONALE: the wound edges are left open and are poorly approximated in a wound healing by secondary intention. Most wounds left to heal by secondary intention heal within 5-21 days by forming granulation tissue that fills in the wound edges and is associated with increased scar formation. Open wounds place the client at an increased risk for wound infection. Sutured wounds have well approximated edges and heal by PRIMARY INTENTION. Wounds left open to drain and heal, then later are sutured, heal by TERTIARY INTENTION. Skin grafting is required for deeper wounds, such as full-thickness burns, and is only rarely required for surgical wounds that do not heal.

A nurse is caring for a client who is INCONTINENT OF LOOSE STOOL and is reporting a PAINFUL PERINEUM. Which of the following is the PRIORITY nursing action? A. Increase the client's fluid intake to prevent dehydration B. Contact the primary care provider to obtain an order for loose stools C. Turn the client every 2 hours D. Check the client's perineum

D. Check the client's perineum RATIONALE: the first step of the nursing process is assessment. In this situation, the nurse should collect more data before taking any other action. Preventing dehydration is important for a client with loose stools, but this is not the priority action. Contacting the primary care provider may be necessary, but it is not the priority intervention. Turning the client at least every 2 hours is important for preventing skin breakdown, but it is not the priority intervention. TEST-TAKING STRATEGY: "call the provider" is RARELY the correct option. There is almost always an INDEPENDENT NURSING ACTION (either an important appropriate assessment or immediate intervention) that the nurse should take PRIOR to "calling the provider."

A nurse is caring for a client who has just had a mastectomy and has a CLOSED WOUND SUCTION DEVICE (Hemovac) in place. Which nursing action will ensure PROPER OPERATION of the DEVICE? A. Irrigating the tubing with sterile normal saline once each shift B. Emptying the device when it is full C. Keeping the tubing above the level of the surgical incision D. Collapsing the device whenever it is one half to two thirds full of air

D. Collapsing the device whenever it is one half to two thirds full of air RATIONALE: a closed wound self-suction device has a drainage catheter connected to a spring-loaded drum. It must be collapsed periodically to create enough suction to pull fluid into the collection area of the device. As drainage or air accumulates, it is emptied and the device is re-compressed. The Hemovac, a self-suction device, has a drainage catheter connected to a spring-loaded drum. It is not possible to irrigate the tubing. Option B will not ensure proper operation of a closed wound suction device. Option C would defeat the purpose of a portable, closed wound suction device. The drainage tubing should always be BELOW the level of the incision to enhance drainage.

A client is admitted for evaluation and control of HYPERTENSION. Several hours after the client's admission, the nurse discovers the client supine on the floor, UNRESPONSIVE to verbal or painful stimuli. The nurse's FIRST ACTION at this time should be to A. Elevate the client's head to 45 degrees B. Perform a neurological assessment C. Administer oxygen D. Establish an airway

D. Establish an airway RATIONALE: this is an emergency situation. For an unresponsive client, the nurse's IMMEDIATE PRIORITY is to establish and maintain an airway. Option A does not address the client's immediate need related to unresponsiveness. Option B is not appropriate because the client is unresponsive. A neurological assessment at this time is time-consuming and is not an immediate priority. In option C, the client may need oxygen therapy, but this action not the IMMEDIATE PRIORITY. TEST-TAKING STRATEGY: when answering a priority-setting question where all four options appear plausible, think of the ABCs (airway, breathing, circulation). Nursing actions should follow that order, so if there is a respiratory action listed that is appropriate for the client, then it is likely to be the correct answer.

An OLDER ADULT client has been hospitalized on BED REST for 1 week. The client reports ELBOW PAIN. Which of the following is an appropriate INITIAL ACTION for the nurse caring for this client to take? A. Reposition the client to increase comfort B. Place elbow pads on the client C. Ask the primary care provider for a pain medication order D. Examine the elbow

D. Examine the elbow RATIONALE: assessing the elbow is appropriate because the nurse does not know enough about the client's elbow pain or its probable cause. The nurse should assess the elbow for redness, swelling, and joint pain. Then, after assessing the problem, the nurse can analyze the situation and develop a plan of care and implement the appropriate nursing interventions. Repositioning the client can help provide for the client's comfort. However, it is not a priority action in this case. The nurse cannot assume that the client's pain is related to pressure or skin breakdown. Elbow pads would be helpful if pressure is the cause of the client's pain. The nurse does not know enough about the client's elbow pain or what is causing it; therefore, asking for a pain medication order is not the priority action to take at this time. TEST-TAKING STRATEGY: with a priority-setting question where all the options appear correct, but various stages of the nursing process are reflected in the options, rely on the nursing process to help set priorities. Assessment comes first, followed by analysis, planning, intervention, and evaluation.

When COMMUNICATING with a client who is HEARING IMPAIRED the nurse should A. Speak directly into the impaired ear B. Exaggerate lip movements C. Talk very loudly to the client D. Face the client and speak slowly

D. Face the client and speak slowly RATIONALE: nurses should always face clients who are hearing impaired and accentuate their words. Many clients who are hearing impaired combine lip reading with their residual hearing when communicating. Speaking directly into the impaired ear is contraindicated. Moving closer to the better ear facilitates communication. While it is appropriate to accentuate the words, exaggerated lip movements are contraindicated because they can inhibit lip reading. Speaking very loudly or shouting over-employs normal speaking movements, which may cause distortion. It also may be too loud for the client.

A nurse is caring for a client who is 3 DAYS POST OP following a cholecystectomy. The nurse suspects a wound infection because the DRAINAGE on the dressing is YELLOW and THICK. The nurse identifies this type of DRAINAGE as A. Sanguineous B. Serous C. Serosanguineous D. Purulent

D. Purulent RATIONALE: purulent describes thick, yellow, green, or brown drainage. Purulent drainage is often associated with wound sloughing or infection. Sanguineous drainage indicates fresh bleeding and is bright red. Serous drainage is clear to light yellow, watery plasma. Serosanguineous indicates plasma mixed with light bloody discharge. It is typically pale yellow to blood-tinged and watery discharge.

A nurse is collecting a URINE SPECIMEN for a client to check for the urine's SPECIFIC GRAVITY via urine DIPSTICK. The nurse knows the result will indicate the AMOUNT of A. Leukocytes in the urine B. Uric acid crystals in the urine C. Proteins in the urine D. Solutes in the urine

D. Solutes in the urine RATIONALE: the specific gravity of any liquid reflects the quantity of solutes dissolved in it. The specific gravity of urine is a measurement of the ability of the kidneys to concentrate and excrete urine and will vary with the client's hydration status and renal function. Leukocytes (WBCs) are one of the components that may be present in urine, but they are not measured by specific gravity. While a few leukocytes may be found in the urine of healthy clients, the presence of WBCs in the urine is most often associated with UTIs. Uric acid crystals are components that may be present in urine, but they are not measured by specific gravity. While uric acid may be found in the urine of healthy clients, the presence of uric acid crystals in the urine is most often associated with urolithiasis (kidney stones) or gout. Proteins are components that may be present in urine, but they are not measured by specific gravity. While minute amounts of protein may be found in the urine of healthy clients, the presence of protein in the urine is most often associated with renal failure.

A nurse is caring for a client who is post-operative following a partial COLECTOMY. The client has a NG TUBE set to low continuous suction. The client tells the nurse that his throat is sore and asks the nurse when the NG tube will be TAKEN OUT. Which of the following responses by the nurse is APPROPRIATE at this time? A. "You'll have to ask your doctor about that." B. "The tube will be probably be removed tomorrow, but cannot eat for 3-5 more days" C. "The doctor will have the tube removed." D. "When your GI tract is working again, in about 3-5 days, the tube can be removed."

D. When your GI tract is working again, in about 3-5 days, the tube can be removed." RATIONALE: bowel sounds and the passing of flatus through the rectum indicates the return of peristalsis. It is then safe to remove the NG tube and begin the client's progression from sips of clear liquids to a regular diet. The response of option A represents the non-therapeutic communication block of placing the client's issue "on hold" and gives no information. In option B,, the client will continue to need the NG tube because gastric and intestinal juices are still being produced and can accumulate, leading to nausea, vomiting, and discomfort. In option C, after the tube is removed, the client must be able to ingest nutrients. This cannot be determined if the tube is removed immediately prior to discharge.