ATI Fundemental

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

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

A nurse is teaching a client how to perform range-of-motion exercises of the wrist. To perform adduction, which of the following instructions should the nurse include?

"With your palm facing down, move your wrist sideways toward your thumb." -This motion describes adducting the wrist. The client should be able to move her wrist 30º to 50º with this motion.

A nurse is measuring the blood pressure of several clients. Which of the following results is within the expected reference range for blood pressure?

116/70 mmHg -This blood pressure is within the expected reference range, which is any value <120 mmHg systolic and <80 mmHg diastolic.

A nurse is preparing to administer sotalol to a client with a prescription for 320 mg/day divided equally every 12 hr. The medication is available in 80 mg tablets. How many tablets should the nurse administer per dose? (Fill in the blank with the numeric value only, round the answer to the nearest tenth, and use a leading zero if applicable. Do not use a trailing zero.)

2

A nurse is calculating a client's intake for a 12-hr shift. The client had dextrose 5% in 0.45% sodium chloride infusing at 125 mL/hr, gentamicin 150 mg in 100 mL at 1400, famotidine 20 mg in 50 mL at 1000 and 1600, 250 mL of blood over 2 hr, and a nasogastric flush of 30 mL every 2 hr. What is the total intake in milliliters that the nurse should document for this client for this 12-hr period? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

2130 For the total intake, calculate: 125 mL x 12 hr = 1500 mL + 100 mL + (50 mL x 2 = 100 mL) + 250 mL + (30 mL x 6 = 180 mL) = 2130 mL.

A nurse is planning care for a group of clients receiving oxygen therapy. Which of the following clients should the nurse plan to see first?

A client who has heart failure and is receiving 100% oxygen via partial rebreather mask -The nurse should apply the safety and risk-reduction priority-setting framework, which assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's hierarchy of needs, the ABC priority-setting framework, and/or nursing knowledge to identify which risk poses the greatest threat to the client

A nurse is preparing to change the bed linens of a client who has AIDS and is incontinent of stool. Which of the following personal protective equipment (PPE) items should the nurse don prior to providing client care? (Select all that apply.)

A. Gown B. Gloves The nurse should follow standard precautions when caring for a client who has AIDS. Because the bed linens might be soiled, the nurse should don a gown. Because the nurse's hands will come in contact with the soiled bed linens, the nurse should don clean gloves in addition to other necessary PPE.

A nurse is supervising a newly licensed nurse who is suctioning a client's tracheostomy. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure?

Administering high-flow oxygen prior to the procedure -The nurse should instruct the newly licensed nurse to administer 3 to 4 breaths of 100% oxygen via a resuscitation bag before suctioning to the client to reduce the risk of hypoxia.

A provider is planning an immunization clinic for older adults. At which of the following times should an older adult client receive the influenza vaccine?

Annually in the fall -The nurse should recommend that older adult clients receive the influenza vaccine annually. Influenza outbreaks occur annually, and the influenza virus changes constantly. Consequently, an influenza vaccine from a previous year will not protect a client exposed to this year's influenza strain. Influenza in older adults can result in the development of primary viral influenza pneumonia, which causes several deaths a year. An influenza vaccine given in the fall, prior to the onset of flu season, will be most effective in preventing influenza in this target population.

A nurse is preparing to administer eye drops for a client who has glaucoma. When instilling the medication, which of the following actions should the nurse take?

Apply pressure to the puncta after instilling the medication -The nurse should instill the medication into the conjunctival sac and apply pressure to the puncta for 1 to 2 minutes afterward to prevent systemic absorption of the medication.

A nurse is assessing a client who is undergoing a physical examination. Following the inspection, which of the following techniques should the nurse use next when assessing the client's abdomen?

Auscultation -According to evidence-based practice, the nurse should listen for bowel sounds in all 4 quadrants before palpating the client's abdomen. Palpation and percussion can stimulate the bowel and increase the frequency of bowel sounds, leading to false results.

A nurse is assessing a client's vascular system. Which of the following techniques should the nurse use when evaluating the carotid arteries?

Auscultation of the arteries for bruits with the bell of the stethoscope -The bell of the stethoscope is more effective than the diaphragm in transmitting blowing or swishing sounds, such as those from turbulence in blood vessels.

A nurse is taking a client's vital signs. Which of the following findings should the nurse identify as outside the expected reference range?

BP 145/90 mmHg -This blood pressure is greater than the expected reference range and should be reported to the provider.

After assessing a client's radial pulses, the nurse documents "radial pulses 4+ bilaterally." The nurse should document this finding when a client's pulses have which of the following qualities?

Bounding A pulse of 4+ is bounding and does not disappear with moderate pressure. Pulse strength ranges from absent (0) to bounding (4+).

A nurse is beginning her shift and reviewing the medication administration records (MARs) for her clients. She notes a dosage of a medication above the safe range and sees that a nurse administered that dosage during the previous shift. Which of the following actions should the nurse take?

Call the provider to clarify the dosage. -After assessing the client for adverse effects of the medication, the nurse should notify the provider about her observations to determine the next step.

A nurse is inserting an IV catheter for a client that results in 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 proceed with hand hygiene. -Standard precautions require the use of gloves and hand hygiene in the care of all clients

A nurse is caring for a client who is having difficulty with muscle coordination following a head injury. The nurse should suspect injury to which of the following areas of the brain?

Cerebellum -The nurse should suspect an injury to the cerebellum if the client is experiencing difficulty controlling balance and coordination. A client's movements can become uncoordinated, unsure, and clumsy following an injury to this area of the brain.

A nurse documents the presence of clubbing of the fingernails for a client who has emphysema. Which of the following is the underlying cause of this finding?

Chronic hypoxemia -Clubbing of the nails of the fingers and toes is the result of chronic hypoxemia (low oxygen supply) such as with COPD. It is a change in the angle between the nail and the nail base, often with enlargement of the fingertips.

A nurse is conducting an admission interview with a client. Which of the following pieces of assessment information should the nurse collect during the introductory phase of the interview?

Client's level of comfort and ability to participate in the interview -The nurse should assess the client's level of comfort and establish a rapport during the introductory or orientation phase. The nurse should engage in active listening and present a relaxed attitude to place the client at ease and encourage client participation. This will assist the nurse in gaining the necessary data to formulate appropriate nursing diagnoses and outcomes.

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 the device to remove air after emptying -The nurse should collapse the device to remove air after emptying the contents periodically. This will create enough suction to pull fluid exudate into the collection area of the device.

A newly licensed nurse is preparing to administer medications to a client. The nurse notes that the provider has prescribed a medication that is unfamiliar to him. Which of the following actions should the nurse take?

Consult the medication reference book available on the unit -A nurse must have knowledge about medications to administer them safely. The nurse should become familiar with the medication by looking it up in the medication reference on the unit.

A nurse is preparing to assess the function of the client's trigeminal nerve (cranial nerve V). Which of the following items should the nurse gather for the test?

Cotton wisps The trigeminal nerve has both sensory and motor capabilities. -To assess its sensory function, the nurse uses a safety pin to assess for recognition of pain and a cotton wisp to evaluate recognition of touch sensations. To test motor abilities of cranial nerve (CN) V, the nurse should ask the client to clench the teeth.

A nurse is reviewing the laboratory values of a client who has a positive Chvostek's sign. Which of the following laboratory findings should the nurse expect?

Decreased calcium -Calcium is necessary for nerve conduction and muscle contractions. When the client's total calcium level is <8.4 mg/dL, tetany and muscle spasms may occur. The nurse should tap the facial nerve in front of the client's ear. If facial muscle twitching follows this stimulus, it is a positive Chvostek's sign and an indication of hypocalcemia.

A nurse is assessing 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 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 caring for client who has terminal pancreatic cancer. When the client states, "It's devastating that I will not be here to see my child graduate," the nurse should identify that the client is in which of the following stages of grief as defined by Kubler-Ross?

Depression -During the stage of depression, the client has realized the full impact of the loss or impending death and might express hopelessness and despair.

A nurse is caring for a client who is producing large amounts of urine. The nurse should document this finding as which of the following?

Diuresis -Diuresis or polyuria is the excretion of a high volume of urine. This condition has many causes, including metabolic and hormonal imbalances and diuretic therapy for treating renal, cardiovascular, and pulmonary disorders.

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 to the dietary assistant?

Don gloves when entering the room and use hand sanitizer when exiting. -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; a mask and goggles are needed if secretions from the infected area could spray into the worker's face. Delivering the tray will require contact with the client's environment; therefore, the dietary assistant must wear gloves.

A nurse is caring for a client who has an NG tube for intermittent enteral feedings. Which of the following actions should the nurse take?

Elevate the head of the client's bed to 45° before the feeding -The nurse should elevate the client's head of bed between 30° and 45° to prevent aspiration.

A nurse is teaching an assistive personnel (AP) how to obtain a capillary finger- stick blood sample. Which of the following actions by the AP requires the nurse to intervene?

Elevating the finger above heart level -The nurse should intervene if the client elevates the finger above the level of the heart. Holding the finger below the level of the heart, in a dependent position; will help increase blood flow to the area and ensure an adequate specimen for collection.

A nurse is admitting a client who will undergo a craniotomy. During the planning phase of the nursing process, which of the following actions should the nurse take?

Establish client outcomes. -The planning phase of the nursing process includes developing goals and outcomes that help the nurse create the client's plan of care.

Call the provider to clarify the dosage. After assessing the client for adverse effects of the medication, the nurse should notify the provider about her observations to determine the next step.

Faint pedal pulses -Faint pedal pulses can indicate poor circulation and tissue perfusion, which puts the client at risk of impaired skin integrity.

A nurse is providing teaching about food choices to a client who has a prescription for a clear liquid diet. Which of the following selections by the client indicates an understanding of the teaching?

Gelatin -Foods allowed on a clear liquid diet are clear and liquid at room temperature.

A nurse is providing teaching to a group of unit nurses about wound healing by secondary intention. Which of the following pieces of information should the nurse include in the teaching?

Granulation tissue fills the wound during healing. -A beefy, red tissue called granulation tissue fills the wound during healing. The wound is left open to drain and heal by secondary intention, which should occur within 5 to 21 days. Open wounds increase the risk of wound infection.

A nurse is teaching a client how to self-administer insulin. Which of the following actions should the nurse take to evaluate the client's understanding of the process within the psychomotor domain of learning?

Have the client demonstrates the procedure -Having the client demonstrate the procedure provides the nurse the ability to evaluate the client's understanding within the psychomotor domain of learning.

A nurse is teaching a client about lifestyle changes to manage a chronic illness. Which of the following strategies should the nurse use first to help the client make a commitment to these lifestyle changes?

Help the client identify ways that these changes will result in positive personal outcomes -According to evidence-based practice, the motivation to change must precede taking steps to make the change. Therefore, helping clients identify ways that the changes will promote positive outcomes should precede other educational strategies for making the changes. The client should first see how the changes directly affect his/her life, thus enhancing the motivation to make the changes.

A nurse is teaching a client who is recovering from gallbladder surgery how to use an incentive spirometer. Which of the following pieces of information should the nurse include in the teaching?

Hold the breath for 5 sec after goal volume is reached -The nurse should instruct the client to hold the breath for 3 to 5 seconds after reaching maximal inspiratory volume. This decreases the collapse of alveoli, which helps prevent the risk of atelectasis and pneumonia.

A nurse is caring for a client who has a gastric ulcer. The nurse should explain that prolonged exposure of the body to stress can also cause which of the following to occur?

Hyperglycemia -Stress causes an increased secretion of cortisol, which can lead to hypertension and hyperglycemia.

A nurse is assessing a client who is experiencing stress following a near fall out of bed. Which of the following physiological responses should the nurse expect due to the fight-or-flight response?

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

A nurse is teaching 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 -According to Kohlberg's theory of moral development, making individual decisions about moral issues is a function of the highest level of moral development, the post-conventional level. Young adults who have reached this level separate themselves from the rules and tenets of others and make their own decisions according to personal beliefs and principles.

A nurse is administering a cleansing enema to a client who is scheduled for a diagnostic procedure. Which of the following actions should the nurse take?

Insert the tip of the tubing 8 cm (3.1 in) -The nurse should insert the tip of the tubing 7 to 10 cm (3 to 4 in) along the rectal wall to prevent dislodging of the tube during the procedure and avoid injury to the rectal mucosa.

A nurse is cleaning a client's wound by swabbing from the area of least contamination to an area of greater contamination. Which of the following rationales should the nurse identify for using this technique?

Keeping microorganisms from entering the wound -Starting at the area of least contamination and working toward the area of greatest contamination prevents the spread of microorganisms within the wound.

A nurse is planning care for a client who has anorexia and nausea due to cancer treatment. Which of the following interventions should the nurse include?

Limit drinking liquids with food -Drinking beverages with food leads to early satiety and bloating, which results in the client consuming fewer calories.

A nurse in a provider's office is collecting information from an older adult client who reports taking acetaminophen 500 mg/day for severe joint pain. The nurse should instruct the client that large doses of acetaminophen could cause which of the following adverse effects?

Liver damage Acetaminophen in large doses can be toxic to the liver. -Daily intake should be limited to less than 3 to 4 grams per day for healthy individuals and 2.4 grams per day for older adults and those with a history of liver impairment.

A nurse in a rehabilitation facility is observing an assistive personnel (AP) help a client transfer from a bed to a wheelchair. Which of the following actions indicates to the nurse that the AP understands how to perform this task?

Locking the brakes on the bed and the wheelchair before moving the client -Prior to starting the transfer, the AP should make sure that both the wheelchair and the bed are stationary and will not shift when the client moves into the chair.

A nurse on a mental health unit is preparing to terminate the nurse-client relationship with a client who no longer requires care. Which of the following concepts should the nurse and client discuss in the termination phase of the relationship?

Loss -At the close of a relationship, even when planned, loss is an expected feeling for both the client and the nurse. It is important for both the nurse and the client to terminate the relationship without feelings of guilt or anxiety.

A nurse is preparing to insert an indwelling urinary catheter for a male client. Which of the following locations should the nurse secure the urinary catheter tubing?

Lower abdomen -After inserting an indwelling urinary catheter, the nurse should secure the catheter tubing to the client's upper thigh or lower abdomen, by using adhesive tape or catheter securement device. This location will decrease tension and trauma to the urethra.

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

Measure the client's apical pulse rate -The first action the nurse should take using the nursing process is to 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 in the emergency department is assessing a client who has 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 A pH of 7.25 indicates acidosis. If the cause is respiratory, pH and PaCO2 values will deviate in opposite directions. Since the PaCO2 is within the expected reference 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 in a provider's office is measuring a client and notes a loss in height from the previous year. The nurse should identify this finding as a manifestation of which of the following musculoskeletal system disorders?

Osteoporosis -A loss of height is often an early indication of osteoporosis. This occurs due to loss of calcium in the vertebrae, which can cause them to fracture and collapse.

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 -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 preparing to provide chest physiotherapy for a client who has left lower lobe atelectasis. Which of the following actions should the nurse plan to take?

Place the client in the Trendelenburg position -The nurse should place the client in a right-sided Trendelenburg position to promote drainage from the client's left lower lobe

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

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

Position the client on his left side -Positioning is an important aspect of administering an enema. Having the client lie on his left side facilitates the flow of the enema solution into the sigmoid and descending

A nurse is planning an in-service training session about nutrition. Which of the following pieces of information should the nurse include?

Protein serves as an energy source when other sources are inadequate. -Protein is used as an energy source for the body when carbohydrates and fat stores are unavailable or depleted

A nurse is caring for a client who is receiving a fluid infusion through a peripheral IV catheter. The nurse notes that the area of the arm immediately surrounding the insertion site is red and feels warm. Which of the following actions should the nurse take?

Remove the IV catheter This client's manifestations suggest phlebitis. The nurse should stop the infusion and remove the IV catheter immediately. The nurse should then apply warm compresses to the site.

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 -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 planning care for a client who is confused and requires a prescription for wrist restraints. Which of the following interventions should the nurse include in the plan of care?

Renew the prescription for the use of restrains within 24 hr -The nurse should plan to renew the prescription for the restraints within 24 hours, only after the provider has evaluated the client

A nurse is caring for a client who is in the terminal stage of cancer. Which of the following actions should the nurse take when she observes the client crying?

Sit and hold the client's hand -This action uses the therapeutic communication techniques of silence, touch, and offering of self to the client.

A nurse is caring for a client who has bilateral casts on her hands. Which of the following actions should the nurse take when assisting the client with feeding?

Sit at the bedside while feeding the client -The nurse should avoid appearing to be in a hurry. Sitting at the bedside provides the client with the nurse's full attention during the feeding.

Granulation tissue fills the wound during healing. A beefy, red tissue called granulation tissue fills the wound during healing. The wound is left open to drain and heal by secondary intention, which should occur within 5 to 21 days. Open wounds increase the risk of wound infection.

Sodium 150 mEq/L -A sodium level of 150 mEq/L is greater than the expected reference range of 135 to 145 mEq/L. This client is at risk for dehydration due to diarrhea. Hypernatremia is a manifestation of dehydration, and the nurse should report this finding to the provider.

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

A nurse is performing an abdominal assessment of a client. Which of the following positions should the nurse tell the client to assume for this examination?

Supine -The nurse should tell the client to assume the supine position to promote relaxation of the abdominal muscles. Having the client bend the knees enhances relaxation of the stomach muscles.

A nurse is caring for an adult client in the terminal stages of lung cancer who refuses any further treatment. The nurse should provide care that facilitates which of the following outcomes?

Supports self-determination -The nurse must honor the client's autonomy and ability to make health care decisions. The client has the right to refuse treatment; as the client's advocate, the nurse must support that right.

A nurse is measuring a client's vital signs. The client's heart rate is 105/min. The nurse should document this finding as which of the following alterations?

Tachycardia -Tachycardia is a heart rate over 100/min in adults.

An assistive personnel (AP) is helping a nurse care for a female client who has an indwelling urinary catheter. Which of the following actions by the AP indicates a need for further teaching?

The AP hangs the collection bag at the level of the bladder. -The AP should place the drainage bag below the level of the bladder to ensure proper drainage by gravity.

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. -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 teaching a client about the use of a straight-legged cane. Which of the following client actions indicates an understanding of the teaching?

The client holds the cane on the unaffected side. -The nurse should instruct the client to hold the cane on the unaffected side to provide a wide base of support and stability.

A nurse is preparing to administer an afternoon dose of ampicillin to a client. The client appears upset and refuses to take the medication before throwing the pill on the floor. Which of the following entries should the nurse enter into the client's medical record?

The client threw the medication on the floor. -The nurse should document exactly what took place to provide an accurate, factual account of the events. Thus, the nurse should document the client's actions in the medical record

A nurse is providing nutrition counseling to a middle-aged adult client who has a sedentary job. Which of the following factors should the nurse consider?

The client's basal metabolic rate could decrease. -The basal metabolic rate decreases as adipose tissue replaces skeletal muscle mass. This places the client at risk of weight gain if a healthy diet is not maintained.

A nurse is providing teaching to a client with heart failure about reducing his daily intake of sodium. Which of the following factors is the most important in determining the client's ability to learn new dietary habits?

The involvement of the client in planning the change According to evidence-based practice, client involvement in planning dietary changes is the most important factor in the client's ability to learn new habits.

A nurse is caring for a client who was admitted to a long-term care facility for rehabilitation after a total hip arthroplasty. At which of the following times should the nurse begin discharge planning?

Upon the client's admission to the care facility -The nurse should begin discharge planning at the time that the client is admitted to the facility.

A nurse is preparing to administer an intramuscular injection to a young adult client. Which of the following injection sites is the safest for this client?

Ventrogluteal -According to evidence-based practice, the ventrogluteal site is the safest injection site for all adults because it contains thick gluteal muscles and does not contain major nerves or blood vessels.

A nurse is assessing a client's respiratory system. Which of the following breath sounds should the nurse expect to hear over the periphery of the major lung fields?

Vesicular -The nurse will hear vesicular sounds over the periphery of the major lung fields. These sounds are soft and low-pitched.

A nurse is preparing to irrigate a client's wound. Which of the following actions should the nurse take?

Warm the irrigating solution to 37°C (98.6°F) -The nurse should prepare about 200 mL of irrigating solution and warm it to body temperature to minimize discomfort and vascular constriction.

A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA). Which of the following precautions should the nurse implement?

Wear a gown when in the client's room -The nurse should apply a gown at all times when in the client's room to maintain contact precautions. This client who has MRSA should be placed in contact isolation, which includes the use of gloves and a gown when providing care.

A nurse is performing a straight urinary catheterization for a female client who has urinary retention. Which of the following actions indicates the nurse is maintaining sterile technique?

Wiping the labia minora in an anteroposterior direction -The nurse should wipe anteroposteriorly both the right and left labia minora with separate cotton swabs to destroy any microorganisms in the area that would contaminate the catheter.

A nurse is planning to insert a nasogastric tube for a client after explaining the procedure. The client states, "You are not putting that hose down my throat." Which of the following statements should the nurse make?

"I can see that this is upsetting you." -This response uses the therapeutic communication techniques of reflecting and restating, which encourages further communication by the client.

A nurse is providing teaching about crutches to a client who has a fracture of the right foot. Which of the following instructions should the nurse include?

"Keep the rubber crutch tips securely in place." -The client should never use crutches without the rubber crutch tips. The client should inspect the tips regularly, replace them when they show signs of wear, and remove and dry them thoroughly with paper towels if they become wet.

A nurse is caring for a client who starts to experience a seizure while sitting in a chair. Which of the following actions should the nurse take?

Lower the client to the floor and place a pad under the client's head -To reduce the risk of injury to the client, the nurse should lower the client to the floor and place a pillow or another soft object under the client's head

A nurse is admitting a client who has a hearing aid. Which of the following actions should the nurse take before beginning the interview process?

Make sure the device is functioning -The nurse should ensure that all of the client's assistive devices are working before beginning the interview process.

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 -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 using the Braden scale to predict the pressure ulcer risk of a client in a long-term care facility. Using this scale, which of the following parameters should the nurse evaluate?

Nutrition -Nutrition, sensory perception, moisture, activity, mobility, and friction and shear are the parameters on the Braden scale for determining a client's risk of developing pressure ulcers.

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

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

A nurse is administering medication to a client who asks the nurse to leave the medication at the bedside to be taken at a later time. Which of the following responses should the nurse make?

"Call me when you are ready, and I will return with the medication." -The nurse is responsible for administering the medication and for following professional standards by adhering to the 6 rights of medication administration.

A nurse is providing preoperative teaching to a client who is scheduled for arthroplasty in the next month and may require a blood transfusion. The client expresses concern about the risk of acquiring an infection from the blood transfusion. Which of the following statements should the nurse share with the client?

"Donate autologous blood before the surgery." -Autologous blood transfusion is the collection and reinfusion of the client's blood. With preoperative autologous blood donation, the blood is drawn from the client 3 to 5 weeks before an elective surgical procedure and stored for transfusion at the time of the surgery. Autologous blood is the safest form of blood transfusion because exclusive use of a client's own blood eliminates exposure to a transfusion-transmitted infection.

A nurse is conducting a health promotion class for a group of college students. Which of the following statements by a student should the nurse identify as a potential problem with achieving Erikson's developmental task for this age group?

"I go home on the weekends to be with my family because I do not have any good friends here on campus." -According to Erikson, the stage of psychosocial development for young adults is intimacy vs. isolation. This statement indicates that the student is having difficulty establishing relationships outside of the immediate family.

A nurse is teaching a client who has asthma about the proper use of an albuterol inhaler. Which of the following client statements indicates an understanding of the teaching?

"I will shake the inhaler well right before I use it." -The nurse should instruct the client to shake the inhaler vigorously for 3 to 5 seconds, which will mix the medication within the inhaler evenly.

A nurse is teaching a client about how to remove a soiled dressing. Which of the following statements by the client indicates an understanding of the teaching?

"I'll wear nonsterile gloves." -Wearing gloves prevents the spread of microorganisms outside of the dressings and onto the client's hands. The gloves the client uses can be clean and do not need to be sterile unless the provider specifically prescribes sterile gloves for dressing changes.

A nurse is caring for a client who is scheduled to receive transcutaneous electrical nerve stimulation (TENS) for pain management. The client asks the nurse how a TENS unit helps relieve pain. Which of the following responses should the nurse make?

"It modulates the transmission of the pain impulse." -The nurse should inform the client that a TENS unit applies low-voltage electrical stimulation directly over a location of pain at an acupressure point. It modulates the transmission of the pain impulse and can also cause a release of endorphins to assist with pain relief.

A nurse is talking with the parent of a preschool-aged child who tells the nurse, "My child has suddenly become disinterested in certain foods." Which of the following statements should the nurse make?

"Keep a diary of the foods your child eats each day." -The nurse should encourage the parent to keep a diary of the foods the child eats throughout the day for 1 week. This can help the parent realize that the child may be eating better than expected. Evidence suggests that children can self-regulate their caloric intake. When they eat less at a meal, they can compensate by eating more at another meal or by having a snack.

While in the hospital, a client who has a terminal illness tells the nurse, "I can't believe I'm dying. A lot of bad people in the world are healthy, and here I am dying!" Which of the following responses should the nurse provide?

"Tell me more about how you feel about dying." This therapeutic response from the nurse seeks more information to form an accurate assessment of the client's feelings.

A nurse is caring for a client who is well-hydrated and has no visible evidence of nutritional deficiencies. A laboratory result within the expected reference range for which of the following substances indicates adequate protein uptake and synthesis?

Albumin -The nurse should identify that an albumin level within the expected reference range is an indication that the client has adequate protein uptake and synthesis. Albumin levels measure protein status. They are useful for identifying long-term protein depletion rather than short-term or acute changes in nutritional status.

A nurse is caring for a group of clients. Which of the following tasks should the nurse assign to an assistive personnel (AP)?

Provide oral care to a client who cannot take oral fluids -Providing oral care to a client who cannot take oral fluids is within the range of function for an AP. Therefore, the nurse can assign this task to the AP.

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-degree angle to the bed. -Positioning the wheelchair at a 45-degree angle allows the client to pivot, lessening the amount of rotation required.

A nurse is planning to perform passive range-of-motion exercises for a client. Which of the following actions should the nurse take?

Repeat each joint motion 5 times during each session -To maintain the client's joint mobility, the nurse should repeat each motion 3 to 5 times

A nurse is providing discharge teaching to an older adult client about personal safety. Which of the following statements by the client indicates an understanding of the teaching?

"I will put a night-light in the hallway." -The nurse should instruct the client to use night-lights in and around the home as an important safety measure to reduce the risk of falls in the home. Physiological changes associated with aging can affect an older adult client's ability to see surroundings. Older adults and infants are at an increased risk of serious injury from falls, and most falls occur in the client's home

A nurse is assessing a client for conductive hearing loss. When 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. -This finding indicates conductive hearing loss of the left ear.

A nurse is collecting a urine specimen for culture and sensitivity for a client who has a urinary tract infection. The client has an indwelling urinary catheter in place. Which of the following actions should the nurse take?

Clamp the tubing below the collection port -The nurse should clamp the tubing below the collection port to allow fresh, uncontaminated urine to collect before withdrawing the specimen through the port and placing it in a sterile specimen cup

A nurse is providing teaching about proper care to a client who has a new colostomy. Which of the following pieces of information should the nurse include in the teaching?

Cleanse the skin around the stoma with warm water -The nurse should instruct the client to cleanse the skin around the stoma with warm water, as using soap can leave a residue on the skin and cause poor adherence of the pouch.

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 -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 caring for a client who is receiving continuous enteral feedings through an NG tube and develops diarrhea. Which of the following actions should the nurse take?

Request a prescription for an isotonic enteral nutrition formula -The nurse should assist a client who develops diarrhea while receiving NG tube feedings by consulting with the provider and the dietitian regarding changing the client's formula to an isotonic formula. This formulation can be easier for the client to digest and can decrease diarrhea.