Combo with "Evolve: Fundamentals Basics of Nursing Practice" and 1 other

A nurse understands that the primary purpose for a client to undergo reconstructive surgery is to: 1 Restore function and/or appearance. 2 Replace an organ or tissue. 3 Relieve or reduce symptoms. 4 Remove or excise an organ or tissue.

1 Restore function and/or appearance.

A client is to receive 125 mL of intravenous (IV) fluid every hour. The drop factor of the IV tubing is 10 gtt/mL. How many drops per minute should the nurse administer? Record your answer using a whole number. ______ gtts/min.

21 gtts/min

The nurse is discussing discharge plans with a client who had a myocardial infarction. The client states, "I'm worried about going home." The nurse responds, "Tell me more about this." What interviewing technique did the nurse use? 1 Exploring 2 Reflecting 3 Refocusing 4 Acknowledging

1 Exploring

A nursing supervisor sends unlicensed assistive personnel (UAP) to help relieve the burden of care on a short-staffed medical-surgical unit. Which tasks can be delegated to UAP? (Select all that apply.) 1 Taking routine vital signs. 2 Applying a sterile dressing. 3 Answering clients' call lights. 4 Administering saline infusions. 5 Changing linens on an occupied bed. 6 Assessing client responses to ambulation.

1 Taking routine vital signs. 3 Answering clients' call lights. 5 Changing linens on an occupied bed.

When caring for a client with varicella and disseminated herpes zoster, the nurse should implement which types of precautions? (Select all that apply.) 1 Airborne 2 Contact 3 Droplet 4 Hazardous Wastes 5 Standard

1 Airborne 2 Contact 5 Standard Contact precautions are used for patients with known or suspected infections transmitted by direct contact or contact with items in the environment. Airborne precautions are used for clients known or suspected to have infections transmitted by the airborne transmission route. Varicella can be transmitted by airborne and contact.

Which drug requires the nurse to monitor the client for signs of hyperkalemia? 1 Furosemide (Lasix) 2 Metolazone (Zaroxolyn) 3 Spironolactone (Aldactone) 4 Hydrochlorothiazide (HydroDIURIL

3 Spironolactone (Aldactone) Spironolactone is a potassium-sparing diuretic; hyperkalemia is an adverse effect. Furosemide, metolazone, and hydrochlorothiazide generally cause hypokalemia.

A client who is HIV positive is admitted to a surgical unit after an orthopedic procedure. The nurse should institute appropriate precautions with the awareness that HIV is highly transmissible through: (Select all that apply.) 1 feces. 2 blood. 3 semen. 4 urine. 5 sweat. 6 tears

2 blood. 3 semen

A visitor from a room adjacent to a client asks the nurse what disease the client has. The nurse responds, "I cannot discuss any client's illness with you." What legal issue supports the nurse's response? 1 Libel 2 Slander 3 Negligence 4 Invasion of privacy

4 Invasion of privacy

A nurse who promotes freedom of choice for clients in decision-making best supports which principle? 1 Justice 2 Autonomy 3 Beneficence 4 Paternalism

2 Autonomy The principle of autonomy relates to the freedom of a person to form his or her own judgments and actions. The nurse promotes autonomy nonjudgmentally so as not to infringe on the decisions or actions of others

At the conclusion of visiting hours, the parent of a 14-year-old adolescent scheduled for orthopedic surgery the next day hands the nurse a bottle of capsules and says, "These are for my child's allergy. Will you be sure my child takes one about 9 PM tonight?" What is the nurse's best response?

2 "I will get a prescription so that the medicine can be taken."

The client receives a prescription for tap water enemas until clear. The nurse is aware that no more than two enemas should be given at one time to prevent the occurrence of: 1 Hypercalcemia 2 Hypocalcemia 3 Hyperkalemia 4 Hypokalemia

4 Hypokalemia Repeated tap water enemas deplete cells and extracellular fluid of potassium and sodium resulting in hypokalemia, hyponatremia, and the potential for water intoxication.

A client expresses concern about the surgical consent that the client signed. How should the nurse respond? 1 Share the client's concern with the family 2 Inform the health care provider of the client's concern 3 Reassure the client that the surgery will be successful 4 Cancel the surgery until the client feels more comfortable with the decision

Inform the health care provider of the client's concern

A client with a fractured tibia and fibula is to be discharged from the emergency department with a right leg cast and crutches. In addition to the technical aspects of crutch walking, the nurse should teach the client to:

Remove loose rugs from the environment

A nurse is teaching a community group about the basics of nutrition. A participant questions why fluoride is added to drinking water. The nurse should respond that it is a necessary element added to drinking water to promote: 1 Dental health. 2 Growth and development. 3 Improved hearing. 4 Night vision.

1 Dental health.

The client asks the nurse to recommend foods that might be included in a diet for diverticular disease. Which foods would be appropriate to include in the teaching plan? (Select all that apply.) 1 Whole grains 2 Cooked fruit and vegetables 3 Nuts and seeds 4 Lean red meats 5 Milk and eggs

1 Whole grains 2 Cooked fruit and vegetables 5 Milk and eggs

A nurse is preparing to administer an oil-retention enema and understands that it works primarily by: 1 Stimulating the urge to defecate. 2 Lubricating the sigmoid colon and rectum. 3 Dissolving the feces. 4 Softening the feces.

2 Lubricating the sigmoid colon and rectum. The primary purpose of an oil-retention enema is to lubricate the sigmoid colon and rectum. Secondary benefits of an oil-retention enema include stimulating the urge to defecate and softening feces. An oil-retention enema does not dissolve feces .

A nurse speaking in support of the best interest of a vulnerable client reflects the nurse's duty of: 1 Caring. 2 Veracity. 3 Advocacy. 4 Confidentiality

3 Advocacy. The nurse has a professional duty to advocate for a client by promoting what is best for the client. This is accomplished by ensuring that the client's needs are met and by protecting the client's rights.

A nurse cares for a client that has been bitten by a large dog. A bite by a large dog can cause which type of trauma? 1 Abrasion 2 Fracture 3 Crush injury 4 Incisional laceration

3 Crush injury

A client reaches the point of acceptance during the stages of dying. What response should the nurse expect the client to exhibit? 1 Apathy 2 Euphoria 3 Detachment 4 Emotionalism

3 Detachment When an individual reaches the point of being intellectually and psychologically able to accept death, anxiety is reduced and the individual becomes detached from the environment. Although detached, the client is not apathetic but still may be concerned and use time constructively. Although resigned to death, the individual is not euphoric. In the stage of acceptance, the client is no longer angry or depressed.

To prevent thrombophlebitis in the immediate postoperative period, which action is most important for a nurse to include in the client's plan of care? 1 Increase fluid intake. 2 Restrict fluids. 3 Encourage early mobility. 4 Elevate the knee gatch of the bed.

3 Encourage early mobility.

An 89-year-old client with osteoporosis is admitted to the hospital with a compression fracture of the spine. The nurse identifies that a factor of special concern when caring for this client is the client's: 1 Irritability in response to deprivation 2 Decreased ability to recall recent facts 3 Inability to maintain an optimal level of functioning 4 Gradual memory loss resulting from change in environment

3 Inability to maintain an optimal level of functioning

The triage nurse in the emergency department receives four clients simultaneously. Which of the clients should the nurse determine can be treated last? 1 Multipara in active labor 2 Middle-aged woman with substernal chest pain 3 Older adult male with a partially amputated finger 4 Adolescent boy with an oxygen saturation of 91%

3 Older adult male with a partially amputated finger

A high-protein diet is recommended for a client recovering from a fracture. The nurse recalls that the rationale for a high-protein diet is to: 1 Promote gluconeogenesis. 2 Produce an anti-inflammatory effect. 3 Promote cell growth and bone union. 4 Decrease pain medication requirements

3 Promote cell growth and bone union. There is an increased need for protein with any type of body tissue trauma. High protein intake in the client with a fractured bone promotes cell growth and therefore bone union. High protein intake during recovery from a bone fracture is not related to gluconeogenesis, inflammation, or pain.

A nurse in a long-term health care setting will introduce a client who has a PhD to the other clients. The client tells the nurse, "I wish to be called Doctor." How should the nurse respond? 1 "Your wish will be respected." 2 "Why do you want to be called Doctor?" 3 "Residents here call one another by their first names." 4 "Wouldn't it be better if the others do not know you are a doctor?"

"Your wish will be respected."

A client is admitted to the hospital with a tentative diagnosis of infectious pulmonary tuberculosis. What infection control measures should the nurse take? 1 Don an N95 respirator mask before entering the room. 2 Put on a permeable gown each time before entering the room. 3 Implement contact precautions and post appropriate signage. 4 After finishing with patient care, remove the gown first and then remove the gloves.

1 Don an N95 respirator mask before entering the room.

When caring for a client who is receiving enteral feedings, the nurse should take which measure to prevent aspiration? 1 Elevate HOB 30-45 degrees. 2 Decrease flow rate at night. 3 Check for residual daily. 4 Irrigate regularly with warm tap water.

1 Elevate HOB 30-45 degrees.

A nurse is teaching a client how to use the call bell/call light system. Which level of Maslow's Hierarchy of Needs does this nursing action address? 1 Safety 2 Self-esteem 3 Physiological 4 Interpersonal

1 Safety

Alternative therapy measures have become increasingly accepted within the past decade, especially in the relief of pain. Which methods qualify as alternative therapies for pain? (Select all that apply.) 1 Prayer 2 Hypnosis 3 Medication 4 Aromatherapy 5 Guided imagery

1 Prayer 2 Hypnosis 4 Aromatherapy 5 Guided imagery

A health care provider prescribes digoxin (Lanoxin) for a client. The nurse teaches the client to be alert for which common early indication of digoxin toxicity?

1 Nausea

A nurse is caring for a client who is having diarrhea. To prevent an adverse outcome, the nurse should most closely monitor what patient data or assessment finding? 1 Skin condition 2 Fluid and electrolyte balance 3 Food intake 4 Fluid intake and output

2 Fluid and electrolyte balance

Which nursing interventions require a nurse to wear gloves? (Select all that apply.) 1 Giving a back rub. 2 Cleaning a newborn immediately after delivery. 3 Emptying a portable wound drainage system. 4 Interviewing a client in the emergency department. 5 Obtaining the blood pressure of a client who is human immunodeficiency virus (HIV) positive

2 Cleaning a newborn immediately after delivery. 3 Emptying a portable wound drainage system.

A nurse is caring for a client with diarrhea. The nurse anticipates a decrease in which clinical indicator?

2 Tissue turgor

An 85-year-old client is alert and able to participate in care. The nurse understands that, according to Erikson, a person's adjustment to the period of senescence will depend largely on adjustment to which developmental stage? 1 Industry versus inferiority 2 Identity versus role confusion 3 Generativity versus stagnation 4 Autonomy versus shame/doubt

3 Generativity versus stagnation

When teaching about aging, the nurse explains that older adults usually have: 1 Inflexible attitudes 2 Periods of confusion 3 Slower reaction times 4 Some senile dementia

3 Slower reaction times

The nurse assesses a client's pulse and documents the strength of the pulse as 3+. The nurse understands that this indicates the pulse is: 1 diminished. 2 normal. 3 full. 4 bounding.

3 full. The strength of a pulse is a measurement of the force at which blood is ejected against the arterial wall. A 3+ rating indicates a full increased pulse. A zero rating indicates an absent pulse. A rating of a 1+ indicates a diminished pulse that is barely palpable. A 2+ rating is an expected/normal pulse, and a 4+ rating is a bounding pulse.

A nurse is caring for an elderly client who has constipation. Which independent nursing intervention helps to reestablish normal bowel pattern? 1 Administer a mineral oil enema. 2 Offer one cup of fluid every hour. 3 Manually remove fecal impactions. 4 Offer a cup of prune juice.

4 Offer a cup of prune juice. Prune juice does not require a health practitioner order and helps to promote bowel movement because it contains sorbitol, which increases water retention in feces

During history taking, a client reports experiencing black, tarry stools. The nurse recognizes that this may be an indication of: 1 Hemorrhoids, internal and external. 2 An overproduction of bile. 3 An iron deficiency. 4 Upper gastrointestinal bleeding.

4 Upper gastrointestinal bleeding.

A nurse reinforces teaching a client about Coumadin (warfarin) and concludes that the teaching is effective when the client states, "I must not drink: 1 apple juice. 2 grape juice. 3 orange juice. 4 cranberry juice.

4 cranberry juice. Antioxidants in cranberry juice may inhibit the mechanism that metabolizes Coumadin, causing elevations in the international normalized ratio (INR), resulting in hemorrhage. Apple juice, grape juice, and orange juice are fine to drink.

A nurse preparing to apply restraints to a client should understand which of the following principles?

Charges of assault and battery may be leveled against nurses who use restraints improperly.

A client who only speaks Spanish is being cared for at a hospital in which nursing personnel only speak English. What communication technique would be appropriate for the nurse to utilize when discussing healthcare decisions with the client?

Contact an interpreter provided by the hospital.

The nurse is preparing discharge instructions for a client who has begun to demonstrate signs of early Alzheimer's dementia. The client lives alone. The client's adult children live nearby. According to the prescribed medication regimen the client is to take medications six times throughout the day. What is priority nursing intervention to assist the client with compliance with medication-taking?

Contact the primary healthcare provider and discuss the possibility of simplifying the medication regimen.

A health care provider has prescribed isoniazid (Laniazid) for a client. Which instruction should the nurse give the client about this medication?

Drinking alcohol daily can cause drug-induced hepatitis.

After changing a dressing that was used to cover a draining wound on a client with Vancomycin Resistant Enterococcus (VRE), the nurse should take which step to ensure proper disposal of soiled dressing?

Place the dressing in a red bag/hazardous materials bag.

What does a nurse consider the most significant influence on many clients' perception of pain when interpreting findings from a pain assessment?

Previous experience and cultural values

A client diagnosed with tuberculosis is taking isoniazid (INH). To prevent a food and drug interaction, the nurse should advise the client to avoid:

Red wine

"But you don't understand" is a common statement associated with adolescents. What is the nurse's best response when hearing this?

"It would be helpful to understand; let's talk."

A health care provider prescribes 250 mg of a medication. The vial reads 500 mg/mL. How much medication (mL) should the nurse administer? Include a leading zero if applicable. Record your answer using one decimal place. _____ mL

0.5 mL

A client is to receive 2000 mL of intravenous (IV) fluid in 12 hours. At what rate should the nurse set the electronic infusion control device? Record the answer using a whole number. ______ mL/hr

167 mL/hr

A child is to receive 60 mg of phenytoin (Dilantin). The medication is available as an oral suspension that contains 125 mg/5 mL. How many milliliters should the nurse administer? Record the answer using one decimal place. ______ mL

2.4

A child is to receive 60 mg of phenytoin (Dilantin). The medication is available as an oral suspension that contains 125 mg/5 mL. How many milliliters should the nurse administer? Record the answer using one decimal place. ______ mL

2.4 mL

A nurse assesses the lungs of a client and auscultates soft, crackling, bubbling breath sounds that are more obvious on inspiration. This assessment should be documented as: 1 Vesicular 2 Bronchial 3 Crackles 4 Rhonchi

3 Crackles Crackles are abnormal breath sounds described as soft, crackling, bubbling sounds produced by air moving across fluid in the alveoli.

A physician orders guaifenesin (Humibid) 300 mg four times a day. The dosage strength is 200 milligrams/5 milliliters. To ensure the patient's safety, how many milliliters should the nurse administer for each dose? Record your answer using one decimal place. ____ mL

300mg/x = 200mg/5mL X = 7.5 mL

The professional obligation of a nurse to assume responsibility for actions is referred to as:

Accountability.

A hospitalized client is scheduled to have a sigmoidoscopy. The nurse anticipates that pre-procedure prescriptions will include:

Administering a fleet enema 1 hour before the procedure.

The nurse assesses an elderly client with a diagnosis of dehydration and recognizes which finding as an early sign of dehydration?

Change in mental status

A client is admitted with severe diarrhea that resulted in hypokalemia. The nurse should monitor for what clinical manifestations of the electrolyte deficiency? (Select all that apply.) 1 Diplopia 2 Skin rash 3 Leg cramps 4 Tachycardia 5 Muscle weakness

Correct 4 Tachycardia Correct 5 Muscle weakness

How can a nurse best evaluate the effectiveness of communication with a client? 1 Client feedback 2 Medical assessments 3 Health care team conferences 4 Client's physiologic responses

Correct1 Client feedback

The nurse recognizes that a common conflict experienced by the older adult is the conflict between:

Independence and dependence

A client with arthritis increases the dose of ibuprofen (Motrin, Advil) to abate joint discomfort. After several weeks the client becomes increasingly weak. The client is admitted to the hospital and is diagnosed with severe anemia. What clinical indicators does the nurse expect to identify when performing an admission assessment? (Select all that apply.) 1 Melena 2 Tachycardia 3 Constipation 4 Clay-colored stools 5 Painful bowel movements

1 Melena 2 Tachycardia Ibuprofen irritates the gastrointestinal (GI) mucosa and can cause mucosal erosion, resulting in bleeding; blood in the stool (melena) occurs as the digestive process acts on the blood in the upper GI tract.

A client has received instructions to take 650 mg aspirin (ASA) every 6 hours as needed for arthritic pain. What should the nurse include in the client's medication teaching? (Select all that apply.) 1 Take the aspirin with meals or a snack. 2 Make an appointment with a dentist if bleeding gums develop. 3 Do not chew enteric-coated tablets. 4 Switch to Tylenol (acetaminophen) if tinnitus occurs. 5 Report persistent abdominal pain.

1 Take the aspirin with meals or a snack. 3 Do not chew enteric-coated tablets. 5 Report persistent abdominal pain.

A client expresses concern about being exposed to radiation therapy because it can cause cancer. What should the nurse emphasize when informing the client about exposure to radiation? 1 The dosage is kept at a minimum. 2 Only a small part of the body is irradiated. 3 The client's physical condition is not a risk factor. 4 Nutritional environment of the affected cells is a risk factor.

2 Only a small part of the body is irradiated.

A client's serum potassium level has increased to 5.8 mEq/L. What action should the nurse implement first? 1 Call the laboratory to repeat the test. 2 Take vital signs and notify the charge nurse or health care provider. 3 Inform the cardiac arrest team to place them on alert. 4 Take an electrocardiogram and have lidocaine available.

2 Take vital signs and notify the charge nurse or health care provider.

The nurse expects a client with an elevated temperature to exhibit what indicators of pyrexia? (Select all that apply.) 1 Dyspnea 2 Flushed face 3 Chest pain 4 Increased pulse rate 5 Increased blood pressure

2 Flushed face 4 Increased pulse rate Increased body heat dilates blood vessels, causing a flushed face. The pulse rate increases to meet increased tissue demands for oxygen in the febrile state. Fever may not cause difficult breathing. Pain is not related to fever. Blood pressure is not expected to increase with fever.

A prescription is written for famotidine (Pepcid) 20 mg intravenous piggyback (IVPB) every 12 hours. The vial is labeled 10 mg/1 mL. How many milliliters should the nurse administer? Record the answer using a whole number. _______ mL

2 mL

A client's chest tube has accidentally dislodged. What is the nursing action of highest priority? 1 Place the client in a left side-lying position. 2 Apply oxygen via non-rebreather mask. 3 Apply a petroleum gauze dressing over the site. 4 Prepare to reinsert a new chest tube.

3 Apply a petroleum gauze dressing over the site.

Nursing actions for the older adult should include health education and promotion of self-care. Which is most important when working with the older adult client? 1 Encouraging frequent naps 2 Strengthening the concept of ageism 3 Reinforcing the client's strengths and promoting reminiscing 4 Teaching the client to increase calories and focusing on a high carbohydrate diet

3 Reinforcing the client's strengths and promoting reminiscing

A nurse is caring for a client with pulmonary tuberculosis who is to receive several antitubercular medications. Which of the first-line antitubercular medications is associated with damage to the eighth cranial nerve? 1 Isoniazid (INH) 2 Rifampin (Rifadin) 3 Streptomycin 4 Ethambutol (Myambutol)

3 Streptomycin Streptomycin is ototoxic and can cause damage to the eighth cranial nerve, resulting in deafness. Assessment for ringing or roaring in the ears, vertigo, and hearing acuity should be made before, during, and after treatment.

What is the maximum length of time a nurse should allow an intravenous (IV) bag of solution to infuse? 1 6 hours 2 12 hours 3 18 hours 4 24 hours

4 24 hours After 24 hours there is increased risk for contamination of the solution and the bag should be changed. It is unnecessary to change the bag any less often.

What response should a nurse be particularly alert for when assessing a client for side effects of long-term cortisone therapy? 1 Hypoglycemia 2 Severe anorexia 3 Anaphylactic shock 4 Behavioral changes

4 Behavioral changes Development of mood swings and psychosis is possible during long-term therapy with glucocorticoids because of fluid and electrolyte alterations.

A nurse is caring for a postoperative client who had general anesthesia during surgery. What independent nursing intervention may prevent an accumulation of secretions? 1 Postural drainage 2 Cupping the chest 3 Nasotracheal suctioning 4 Frequent changes of position

4 Frequent changes of position

A client using fentanyl (Duragesic) transdermal patches for pain management in late-stage cancer dies. What should the hospice nurse who is caring for this client do about the patch? 1 Tell the family to remove and dispose of the patch. 2 Leave the patch in place for the mortician to remove. 3 Have the family return the patch to the pharmacy for disposal. 4 Remove and dispose of the patch in an appropriate receptacle

4 Remove and dispose of the patch in an appropriate receptacle

What should the nurse include in dietary teaching for a client with a colostomy? 1 Liquids should be limited to 1 L per day. 2 Non-digestible fiber and fruits should be eliminated. 3 A formed stool is an indicator of constipation. 4 The diet should be adjusted to include foods that result in manageable stools

4 The diet should be adjusted to include foods that result in manageable stools

A client is hospitalized because of severe depression. The client refuses to eat, stays in bed most of the time, does not talk with family members, and will not leave the room. The nurse attempts to initiate a conversation by asking questions but receives no answers. The nurse is frustrated and tells the client that if there is no response, the nurse will leave and the client will remain alone. How should the nurse's behavior be interpreted? 1 A system of rewards and punishment is being used to motivate the client. 2 Leaving the client alone allows time for the nurse to think of other strategies. 3 This behavior indicates the client's desire for solitude that the nurse is respecting. 4 This threat is considered assault, and the nurse should not have reacted in this manner.

4 This threat is considered assault, and the nurse should not have reacted in this manner. This response is a threat (assault) because the nurse is attempting to put pressure on the client to speak or be left alone. This is not a reward and punishment technique that is used in behavior modification therapy. Clients in emotional crisis should not be left alone.

Which nursing activities are examples of primary prevention? Select all that apply. 1 Preventing disabilities 2 Correcting dietary deficiencies 3 Establishing goals for rehabilitation 4 Assisting with immunization programs 5 Facilitating a program about smoking cessation

4 Assisting with immunization programs 5 Facilitating a program about smoking cessation Immunization programs prevent the occurrence of disease and are considered primary interventions. Stopping smoking prevents the occurrence of disease and is considered a primary intervention. Preventing disabilities is a tertiary intervention. Correcting dietary deficiencies is a secondary intervention. Establishing goals for rehabilitation is a tertiary intervention. Topics

A nurse is caring for a client with hemiplegia who is frustrated. How can the nurse motivate the client toward independence?

Reinforce success in tasks accomplished.

A client, who is in a late stage of pancreatic cancer, intellectually understands the terminal nature of the illness. Behaviors that indicate the client is emotionally accepting of impending death are that the client is:

Revising the client's will and planning a visit to a friend

The nurse providing care for a client with a diagnosis of neutropenia reviews isolation procedures with the client's spouse. The nurse determines that the teaching was effective when the spouse states that protective environment isolation helps prevent the spread of infection: 1 To the client from outside sources. 2 From the client to others. 3 From the client by using special techniques to destroy infectious fluids and secretions. 4 To the client by using special sterilization techniques for linens and personal items.

To the client from outside sources

A nurse is caring for an older adult who is taking acetaminophen (Tylenol) for the relief of chronic pain. Which substance is most important for the nurse to determine if the client is taking because it intensifies the most serious adverse effect of acetaminophen? 1 Alcohol 2 Caffeine 3 Saw palmetto 4 St. John's wort

1 Alcohol

Immediately after receiving spinal anesthesia a client develops hypotension. To what physiological change does the nurse attribute the decreased blood pressure? 1 Dilation of blood vessels 2 Decreased response of chemoreceptors 3 Decreased strength of cardiac contractions 4 Disruption of cardiac accelerator pathways

1 Dilation of blood vessels Paralysis of the sympathetic vasomotor nerves after administration of a spinal anesthetic results in dilation of blood vessels, which causes a subsequent decrease in blood pressure.

To decrease abdominal distention following a client's surgery, what actions should the nurse take? (Select all that apply.) 1 Encourage ambulation 2 Give sips of ginger ale 3 Auscultate bowel sounds 4 Provide a straw for drinking 5 Offer an opioid analgesic

1 Encourage ambulation 3 Auscultate bowel sounds Ambulation will stimulate peristalsis, increasing passage of flatus and decreasing distention. Monitoring bowel sounds is important because it provides information about peristalsis. Carbonated beverages, such as ginger ale, increase flatulence and should be avoided. Using a straw should be avoided because it causes swallowing of air, which increases flatulence. Opioids will slow peristalsis, contributing to increased distention.

A nurse provides teaching for a client who is scheduled for a cholecystectomy. In the initial postoperative period, the nurse explains that the most important part of the treatment plan is: 1 Early ambulation 2 Coughing and deep breathing 3 Wearing anti-embolic elastic stockings 4 Maintenance of a nasogastric tube

2 Coughing and deep breathing

What clinical finding does a nurse anticipate when admitting a client with an extracellular fluid volume excess? 1 Rapid, thready pulse 2 Distended jugular veins 3 Elevated hematocrit level 4 Increased serum sodium level

2 Distended jugular veins Because of fluid overload in the intravascular space, the neck veins become visibly distended. Rapid, thready pulse and elevated hematocrit level occur with a fluid deficit. If sodium causes fluid retention, its concentration is unchanged; if fluid is retained independently of sodium, its concentration is decreased.

The nurse observes that an older client seldom eats the meat on the meal trays. The nurse discusses this observation with the client, and the client states, "I only eat meat once a week because old people don't need protein every day." The nurse determines that the client needs to be taught about the: 1 Need for home-delivered meals 2 Foods that meet basic nutritional needs 3 Effect of aging on the need for some foods 4 Need for meat at least once per day throughout life

2 Foods that meet basic nutritional needs

A client has been admitted with a diagnosis of intractable vomiting and can only tolerate sips of water. The initial blood work shows a sodium level of 122 mEq/L and a potassium level of 3.6 mEq/L. Based on the lab results and symptoms, what is the client experiencing? 1 Hypernatremia 2 Hyponatremia 3 Hyperkalemia 4 Hypokalemia

2 Hyponatremia The normal range for serum sodium is 135 to 145 mEq/L, and for serum potassium it is 3.5 to 5 mEq/L. Vomiting and use of diuretics, such as furosemide (Lasix), deplete the body of sodium. Without intervention, symptoms of hyponatremia may progress to include neurological symptoms such as confusion, lethargy, seizures, and coma. Hypernatremia results when serum sodium is greater than 145 mEq/L; hyperkalemia results when serum potassium is greater than 5.0 mEq/L; hypokalemia results when serum potassium is less than 3.5 mEq/L.

our days after abdominal surgery a client has not passed flatus and there are no bowel sounds. Paralytic ileus is suspected. What does the nurse conclude is the most likely cause of the ileus? 1 Decreased blood supply 2 Impaired neural functioning 3 Perforation of the bowel wall 4 Obstruction of the bowel lumen

2 Impaired neural functioning Paralytic ileus occurs when neurological impulses are diminished as a result of anesthesia, infection, or surgery. Interference in blood supply will result in necrosis of the bowel. Perforation of the bowel will result in pain and peritonitis. Obstruction of the bowel initially will cause increased peristalsis and bowel sounds.

Based on the client's reported pain level, the nurse administers 8 mg of the prescribed morphine. The medication is available in a 10 mg syringe. Wasting of the remaining 2 mg of morphine should be done by the nurse and a witness. It is most appropriate for the nurse to ask which member of the health care team to be the witness? 1 Nursing supervisor 2 Licensed practical nurse (LPN) 3 Client's health care provider 4 Designated nursing assistant

2 Licensed practical nurse (LPN)

A nurse assesses drainage on a surgical dressing and documents the findings. Which documentation is most informative? 1 "Moderate amount of drainage." 2 "No change in drainage since yesterday." 3 "A 10-mm-diameter area of drainage at 1900 hours." 4 "Drainage is doubled in size since last dressing change."

3 "A 10-mm-diameter area of drainage at 1900 hours."

A nurse is hired to work in a health care facility that has a complete computer-based client information system. The nurse in charge knows that the newly hired nurse is knowledgeable about this system when the nurse says: 1. "More medication errors are made when this system is used." 2. "It is disappointing that nurses are not allowed to use this system." 3. "Client information is immediately available when this system is used." 4. "I will have less time to provide direct care to my clients with this system."

3 "Client information is immediately available when this system is used."

An adolescent that had an inguinal hernia repair is being prepared for discharge home. The nurse provides instructions about resumption of physical activities. Which statement by the adolescent indicates that the client understands the instructions? 1 "I can ride my bike in about a week." 2 "I don't have to go to gym class for 3 months." 3 "I can't perform any weightlifting for at least 3 weeks." 4 "I can never participate in football again."

3 "I can't perform any weightlifting for at least 3 weeks."

A client is being treated for Influenza A (H1N1). The nurse has provided instructions to the client about how to decrease the risk of transmission to others. Which patient statement indicates a need for further instruction/clarification? 1 "I should practice respiratory hygiene/cough etiquette." 2 "I should avoid contact with the elderly or children." 3 "I should obtain a pneumococcal vaccination each year." 4 "I should allow visitors for short periods of time only."

3 "I should obtain a pneumococcal vaccination each year."

A nurse discusses the philosophy of Alcoholics Anonymous (AA) with the client who has a history of alcoholism. What need must self-help groups such as AA meet to be successful? 1 Trust 2 Growth 3 Belonging 4 Independence

3 Belonging

The unlicensed assistive person (UAP) assigned to the 7 am shift has not been coming to work until 8 am. Nursing care is delayed and assignments are started late. What is the most appropriate action by the charge nurse/team leader? 1 Discuss the issue with a friend from another unit 2 Remind the UAP of the expected start time 3 Report the problem to the Human Resources department 4 Document the information before discussing it with the UAP

4 Document the information before discussing it with the UAP

The nurse is caring for a surgical client who develops a wound infection during hospitalization. How is this type of infection classified? 1 Primary 2 Secondary 3 Superinfection 4 Nosocomial

4 Nosocomial A nosocomial infection is acquired in a health care setting. This is also referred to as a hospital-acquired infection. It is a result of poor infection control procedures such as failure to wash hands between clients. A primary infection is synonymous with initial infection. A secondary infection is made possible by a primary infection that lowers the host's resistance and causes an infection by another kind of organism. A superinfection is a new infection caused by an organism different from that which caused the initial infection. The microbe responsible is usually resistant to the treatment given for the initial infection.

A nurse takes into consideration that the key factor in accurately assessing how a client will cope with body image changes is the: 1 Suddenness of the change 2 Obviousness of the change 3 Extent of the body changes 4 Perception of the body changes

4 Perception of the body changes

A nurse assesses a client's serum electrolyte levels in the laboratory report. What electrolyte in intracellular fluid should the nurse consider most important? 1 Sodium 2 Calcium 3 Chloride 4 Potassium

4 Potassium

When permitted by the client, the nurse always should take the time to keep the family informed about what is happening to the client. The purpose of this approach is that informed families will be:

4 better equipped to undertake necessary family role changes.

A client who weighs 176 pounds is receiving 8 mg/kg cyclosporine (Sandimmune) each day to prevent organ transplant rejection. How many milligrams should the nurse administer each day? Record your answer using a whole number. _________ mg

640 mg

A nurse suspects that a client has poison ivy. Assessment findings reveal vesicles on the arms and legs. A vesicle can be described as: 1 A lesion filled with purulent drainage. 2 An erosion into the dermis. 3 A solid mass of fibrous tissue. 4 A lesion filled with serous fluid.

A lesion filled with serous fluid. A vesicle is a small blisterlike elevation on the skin containing serous fluid. Vesicles are usually transparent. Common causes of vesicles include herpes, herpes zoster, and dermatitis associated with poison oak or ivy. A lesion filled with purulent drainage is known as a pustule; an erosion into the dermis is known as an excoriation or ulcer; and a solid mass of fibrous tissue is known as a papule.

A nurse is caring for an elderly client with dementia who has developed dehydration as a result of vomiting and diarrhea. Which assessment best reflects the fluid balance of this client?

Blood lab results

When changing the soiled bed linens of a client with a wound that is draining seropurulent material, what personal protective equipment (PPE) is most essential for the nurse to wear?

Clean gloves

A child is being treated with oral ampicillin (Omnipen) for otitis media. What should be included in the discharge instructions that the nurse provides to the parents of the client?

Complete the entire course of antibiotic therapy.

A nurse is reinforcing teaching to an adolescent about type 1 diabetes and self-care. Which questions from the client indicate a need for additional teaching in the cognitive domain? (Select all that apply.) 1 "What is diabetes?" 2 "What will my friends think?" 3 "How do I give myself an injection?" 4 "Can you tell me how the glucose monitor works?" 5 "How do I get the insulin from the vial into the syringe?"

Correct 1 "What is diabetes?" Correct 4 "Can you tell me how the glucose monitor works?" Acquiring knowledge or understanding aids in developing concepts, rather than skills or attitudes, and is a basic learning task in the cognitive domain. Values and self-realization are in the affective domain. Skills acquisition is in the psychomotor domain.

The nurse is preparing to reinforce teaching a client about self-injection of insulin. Which action by the nurse will increase the effectiveness of the teaching session? 1 Wait until a family member is also present. 2 Assess the client's barriers to learning self-injection techniques. t3 Begin with simple written instructions describing the technique. 4 Wait until the client has accepted the new diagnosis of Type 1 Diabetes Mellitus.

Correct2 Assess the client's barriers to learning self-injection

An 85-year-old client has just been admitted to a nursing home. When designing a plan of care for this older adult the nurse recalls the expected sensory losses associated with aging. (Select all that apply.) 1 Difficulty in swallowing 2 Diminished sensation of pain 3 Heightened response to stimuli 4 Impaired hearing of high-frequency sounds 5 Increased ability to tolerate environmental heat

Correct2 Diminished sensation of pain Correct4 Impaired hearing of high-frequency sounds

When being interviewed for a position as a licensed practical nurse, the applicant is asked to identify an example of an intentional tort. What is the appropriate response? 1 Negligence 2 Malpractice 3 Breach of duty 4 False imprisonment

Correct4 False imprisonment False imprisonment is a wrong committed by one person against another in a willful, intentional way without just cause or excuse. Negligence is an unintentional tort. Malpractice, which is professional negligence, is classified as an unintentional tort. Breach of duty is an unintentional tort.

A client experiences a muscle sprain of the ankle. When assessing the injury, the nurse discovers that a hematoma is developing, edema is present and that the client reports tenderness when the ankle is palpated. The nurse anticipates that the plan of care will include the applying of a/an:

Ice bag

What should the nurse consider when obtaining an informed consent from a 17-year-old adolescent?

If the client is allowed to give consent.

A health care provider prescribes a vitamin tablet that contains vitamin B complex. What should the nurse teach the client?

It may turn the urine bright yellow.

A client reports severe pain two days after surgery. After assessing the characteristics of the pain, which initial action should the nurse take next?

Obtain the vital signs.

The nurse should place the client in which position to obtain the most accurate reading of jugular vein distention? 1 Upright at 90 degrees 2 Supine position 3 Raised to 45 degrees 4 Raised to 10 degrees

Raised to 45 degrees

Which nursing action is confidential and protected from legal action? 1 Providing health teaching regarding family planning. 2 Offering first aid at the scene of an automobile collision. 3 Reporting incidents of suspected child abuse to the appropriate authorities. 4 Administering resuscitative measures to an unconscious child pulled from a swimming pool

Reporting incidents of suspected child abuse to the appropriate authorities

A health care provider prescribes a standard walker (pick-up walker with rubber tips on all four legs). The nurse identifies what clinical findings that indicate the client is capable of using a standard walker?

Strong upper arm strength and non-weight bearing on the affected extremity

A nurse is assisting a client to transfer from the bed to a chair. What should the nurse do to widen the client's base of support during the transfer? 1 Spread the client's feet away from each other. 2 Move the client on the count of three. 3 Instruct the client to flex the muscles of the internal girdle. 4 Stand close to the client when assisting with the move

1 Spread the client's feet away from each other. Spreading the feet apart widens the base of support. A wide base of support lowers the center of gravity, thereby increasing stability

A nurse is preparing to administer an ophthalmic medication to a client. What techniques should the nurse use for this procedure? (Select all that apply.)

1 Clean the eyelid and eyelashes. 3 Apply clean gloves before beginning of procedure. 5 Press on the nasolacrimal duct after instilling the solution.

A nurse in the surgical intensive care unit is caring for a client with a large surgical incision. The nurse reviews a list of vitamins and expects that which medication will be prescribed because of its major role in wound healing? 1 Vitamin A (Aquasol A) 2 Cyanocobalamin (Cobex) 3 Phytonadione (Mephyton) 4 Ascorbic acid (Ascorbicap)

4 Ascorbic acid (Ascorbicap) Vitamin C (ascorbic acid) plays a major role in wound healing. It is necessary for the maintenance and formation of collagen, the major protein of most connective tissues. Vitamin A is important for the healing process; however, vitamin C is the priority because it cements the ground substance of supportive tissue. Cyanocobalamin is a vitamin B12 preparation needed for red blood cell synthesis and a healthy nervous system. Phytonadione is vitamin K, which plays a major role in blood coagulation.

The nurse recognizes that the mental process most sensitive to deterioration with aging is: 1 Judgment 2 Intelligence 3 Creative thinking 4 Short-term memory

4 Short-term memory

A client reports nausea, vomiting, and seeing a yellow light around objects. A diagnosis of hypokalemia is made. Upon a review of the client's prescribed medication list, the nurse determines that what is the likely cause of the clinical findings? 1 Digoxin (Lanoxin) 2 Furosemide (Lasix) 3 Propranolol (Inderal) 4 Spironolactone (Aldactone)

1 Digoxin (Lanoxin)

The nurse assesses an edematous client and recalls that edema occurs in what extracellular fluid compartment? 1 Interstitial 2 Intercellular 3 Intravascular 4 Intracellular

1 Interstitial Edema is defined as the accumulation of fluid in the interstitial spaces. The incorrect answer options occur in other compartments: intercellular means between or among cells; intravascular means within a vascular space; and intracellular means within a cell.

The count of hydrocodone (Vicodin) is incorrect. After several minutes of searching the medication cart and Physiological Aspects of Care records, no explanation is found. Who should the primary nurse notify about the discrepancy? 1 Nursing unit manager 2 Hospital administrator 3 Quality control manager 4 Health care provider prescribing the medication

1 Nursing unit manager Controlled substance issues for a particular nursing unit are the responsibility of that unit's nurse manager. Responsibility flows directly from the staff of a nursing unit to the nurse manager; the nurse manager reports to a nurse administrator.

A teenager begins to cry while talking with the nurse about the problem of not being able to make friends. What is the most therapeutic nursing intervention? 1 Sitting quietly with the client. 2 Telling the client that crying is not helpful. 3 Suggesting that the client play a board game. 4 Recommending how the client can change this situation

1 Sitting quietly with the client. Sitting quietly with the client conveys the message that the nurse cares and accepts the client's feelings; this helps to establish trust. Telling the client that crying is not helpful negates feelings and the client's right to cry when upset. Distraction (suggesting that the client play a board game) closes the door on further communication of feelings. After a trusting relationship has been established, the nurse can help the client explore the problem in more depth.

A hospitalized client experiences a fall after climbing over the bed's side rails. Upon reviewing the client's medical record, the nurse discovers that restraints had been prescribed but were not in place at the time of the fall. What information should the nurse include in the follow-up incident report? 1 A statement that the nursing staff was not at fault because the client initiated the accident. 2 A listing of facts related to the incident as witnessed by the nurse. 3 The name of the nurse who was responsible for implementing the restraints. 4 The potential reasons why the restraints were not in place at the time of the fall.

2 A listing of facts related to the incident as witnessed by the nurse.

A nurse manager is evaluating the performance of the LPN/LVN who is supervising Unlicensed Assistive Personnel (UAP). What action indicates to the nurse manager that the LPN/LVN needs further instruction? 1 Requests that the UAP take vital signs on the clients assigned to their team. 2 Asks the UAP to assess the client's response to a respiratory treatment 3 Instructs the UAP to communicate to a client that the meal trays will be delayed. 4 Collaborates with the UAP to determine the best time to ambulate a client.

2 Asks the UAP to assess the client's response to a respiratory treatment

A nurse is caring for a client who is receiving an intravenous (IV) infusion. What should the nurse do first if the IV infusion infiltrates? 1 Elevate the IV site. 2 Discontinue the infusion. 3 Attempt to flush the tubing. 4 Apply a warm, moist compress.

2 Discontinue the infusion. When an IV infusion infiltrates, it should be removed to prevent edema and pain. Elevation does not change the position of the IV cannula; the infusion must be discontinued. Flushing the tubing will add to the infiltration of fluid. Soaks may be applied, if prescribed, after the IV cannula is removed.

A visitor in the waiting room of the emergency department has a syncopal episode and collapses on the floor. The event is witnessed by a nurse, who provides initial care. The nurse assessed the client, maintained safety of the environment, and gave a report to the emergency department nurse, who will provide ongoing care. What should the nurse who witnessed the event do next? 1 Contact the family 2 Document the incident 3 Report the incident to the nurse manager 4 Escort the client to the radiology department

2 Document the incident

A visitor in the waiting room of the emergency department has a syncopal episode and collapses on the floor. The event is witnessed by a nurse, who provides initial care. The nurse assessed the client, maintained safety of the environment, and gave a report to the emergency department nurse, who will provide ongoing care. What should the nurse who witnessed the event do next? 1 Contact the family 2 Document the incident 3 Report the incident to the nurse manager 4 Escort the client to the radiology department

2 Document the incident

While undergoing a soapsuds enema, the client reports abdominal cramping. What action should the nurse take? 1 Immediately stop the infusion. 2 Lower the height of the enema bag. 3 Advance the enema tubing 2 to 3 inches. 4 Clamp the tube for 2 minutes, then restart the infusion

2 Lower the height of the enema bag. Abdominal cramping during a soapsuds enema may be due to too rapid administration of the enema solution. Lowering the height of the enema bag slows the flow and allows the bowel time to adapt to the distention without causing excessive discomfort. Stopping the infusion is not necessary. Advancing the enema tubing is not appropriate. Clamping the tube for several minutes and then restarting the infusion may be attempted if slowing the infusion does not relieve the cramps.

A nurse provides crutch-walking instructions to a client that has a left-leg cast. The nurse should explain that weight must be placed: 1 In the axillae. 2 On the hands. 3 On the right side. 4 On the side that the client prefers.

2 On the hands.

A nurse is caring for a client who has paraplegia as a result of a spinal cord injury. Which rehabilitation plan will be most effective for this client? 1 Arrangements will be made by the client and the client's family. 2 The plan is formulated and implemented early in the client's care. 3 The rehabilitation is minimal and short term because the client will return to former activities. 4 Arrangements will be made for long-term care because the client is no longer capable of self-care

2 The plan is formulated and implemented early in the client's care.

Neomycin, 1 gram, is prescribed preoperatively for a client with cancer of the colon. The client asks why this is necessary. How should the nurse respond? 1 "It is used to prevent you from getting a bladder infection before surgery." 2 "It will decrease your kidney function and lessen urine production during surgery." 3 "It will kill the bacteria in your bowel and decrease the risk for infection after surgery." 4 "It is used to alter the body flora, which reduces spread of the tumor to adjacent organs."

3 "It will kill the bacteria in your bowel and decrease the risk for infection after surgery." Neomycin provides preoperative intestinal antisepsis. It is not administered to prevent bladder infection. Nephrotoxicity is an adverse, not a therapeutic, effect. Neomycin will not prevent metastasis of the tumor to other areas.

The nurse is having difficulty understanding a client's decision to have hospice care rather than an extensive surgical procedure. Which ethical principle does the client's behavior illustrate? 1 Justice 2 Veracity 3 Autonomy 4 Beneficence

3 Autonomy The client is exhibiting the freedom to make a personal decision, and this reflects the concept of autonomy. Justice refers to fairness. Veracity refers to truthfulness. Beneficence refers to implementing actions that benefit others.

The nurse instructs a client that, in addition to building bones and teeth, calcium is also important for: 1 Bile production. 2 Blood production. 3 Blood clotting. 4 Digestion of fats

3 Blood clotting. Calcium is important for blood coagulation. When tissue damage occurs, serum calcium is necessary to promote coagulation by activating certain clotting factors. Calcium acts as a catalyst in the clotting process in both the extrinsic and intrinsic pathways. Calcium is responsible for a number of body functions such as bone health, blood clotting, and muscle contraction and nerve impulses

The nurse should instruct a client with an ileal conduit to empty the collection device frequently because a full urine collection bag may: 1 Force urine to back up into the kidneys. 2 Suppress production of urine. 3 Cause the device to pull away from the skin. 4 Tear the ileal conduit

3 Cause the device to pull away from the skin.

A nurse is transcribing a practitioner's orders for a group of clients. Which order should the nurse clarify with the practitioner? 1 Discharge in am 2 Blood glucose monitoring ac and bedtime 3 Erythropoietin (Procrit) 6000 units subcutaneously TIW 4 Dalteparin (Fragmin) 5000 international units Sub-Q BID

3 Erythropoietin (Procrit) 6000 units subcutaneously TIW

A hospital has threatened to refuse the discharge of a newborn until the parents pay part of the hospital bill. The nurse is aware that the legal term that best describes this situation is: 1 False threats 2 Assault and battery 3 False imprisonment 4 Breach of confidentiality

3 False imprisonment

A nurse is preparing a community health program for senior citizens. The nurse teaches the group that the physical findings that are typical in older people include: 1 A loss of skin elasticity and a decrease in libido 2 Impaired fat digestion and increased salivary secretions 3 Increased blood pressure and decreased hormone production 4 An increase in body warmth and some swallowing difficulties

3 Increased blood pressure and decreased hormone production With aging, narrowing of the arteries causes some increase in the systolic and diastolic blood pressures; hormone production decreases after menopause. There may or may not be changes in libido; there is a loss of skin elasticity. Salivary secretions decrease, not increase, causing more difficulty with swallowing; there is some impairment of fat digestion. There may be a decrease in subcutaneous fat and decreasing body warmth; some swallowing difficulties occur because of decreased oral secretions.

A client is admitted with a diagnosis of premature labor. The nurse discovers that the client has been using heroin throughout her pregnancy. What is the most appropriate action for the nurse to take? 1 Notify the nurse manager of the unit. 2 Inform no one because all client information is confidential. 3 Inform the client's healthcare provider. 4 Alert the hospital security department because heroin is an illegal substance

3 Inform the client's healthcare provider. The fetus of a heroin-addicted mother is at risk for serious complications such as hypoxia and meconium aspiration. It is important to notify the healthcare provider of the client's heroin use, because this information will influence the care of the client and newborn.

A senior high school student, whose immunization status is current, asks the school nurse which immunizations will be included in the precollege physical. Which vaccine should the nurse tell the student to expect to receive? 1 Hepatitis C (HepC) 2 Influenza type B (HIB) 3 Measles, mumps, rubella (MMR) 4 Diphtheria, tetanus, pertussis (DTaP)

3 Measles, mumps, rubella (MMR) Individuals born after 1957 should receive one additional dose of MMR vaccine if they are students in postsecondary educational institutions. Currently there is no vaccine for hepatitis C. The HIB immunization is unnecessary. If the student received an additional DTaP at age 12, it is not necessary. A booster dose of tetanus toxoid (Td) should be received every 10 years.

To prevent footdrop in a client with a leg cast, the nurse should: 1 Encourage complete bed rest to promote healing of the foot. 2 Place the foot in traction. 3 Support the foot with 90 degrees of flexion. 4 Place an elastic stocking on the foot to provide support.

3 Support the foot with 90 degrees of flexion. To prevent footdrop (plantar flexion of the foot due to weakness or paralysis of the anterior muscles of the lower leg) in a client with a cast, the foot should be supported with 90 degrees of flexion. Bed rest can cause footdrop, and 45 degrees is not enough flexion to prevent footdrop . Applying an elastic stocking for support also will not prevent footdrop; a firmer support is required.

A nurse is caring for a client diagnosed with Methicillin-Resistant Staphylococcus Aureus (MRSA) in the urine. The health care provider orders an indwelling urinary catheter to be inserted. Which precaution should the nurse take during this procedure? 1 Droplet precautions 2 Reverse isolation 3 Surgical asepsis 4 Medical asepsis

3 Surgical asepsis

A client has been diagnosed as "brain dead". The nurse understands that this means that the client has: 1 no spontaneous reflexes. 2 shallow and slow breathing. 3 no cortical functioning with some reflex breathing. 4 deep tendon reflexes only and no independent breathing.

3 no cortical functioning with some reflex breathing. A client who is declared as being brain dead has no function of the cerebral cortex and a flat EEG. The client may have some spontaneous breathing and a heartbeat. The guidelines established by the American Association of Neurology include coma or unresponsiveness, absence of brainstem reflexes, and apnea. There are specific assessments to validate the findings. The other answer options do not fit the definition of "brain dead."

What clinical finding indicates to the nurse that a client may have hypokalemia? 1 Edema 2 Muscle spasms 3 Kussmaul breathing 4 Abdominal distention

4 Abdominal distention Hypokalemia diminishes the magnitude of the neuronal and muscle cell resting potentials. Abdominal distention results from flaccidity of intestinal and abdominal musculature. Edema is a sign of sodium excess. Muscle spasms are a sign of hypocalcemia. Kussmaul breathing is a sign of metabolic acidosis.

A 90-year-old female resident of a nursing home falls and fractures the proximal end of her right femur. The surgeon plans to reduce the fracture with an internal fixation device. The general fact about the older adult that the nurse should consider when caring for this client is that: 1 Aging causes a lower pain threshold 2 Physiological coping defenses are reduced 3 Most confused states result from dementia 4 Older adults psychologically tolerate changes well

Physiological coping defenses are reduced

What are the desired outcomes that the nurse expects when administering a nonsteroidal antiinflammatory drug (NSAID)? (Select all that apply.) 1 Diuresis 2 Pain relief 3 Antipyresis 4 Bronchodilation 5 Anticoagulation 6 Reduced inflammation

2 Pain relief 3 Antipyresis 6 Reduced inflammation

What are the best ways for a nurse to be protected legally? (Select all that apply.) 1 Ensure that a therapeutic relationship with all clients has been established. 2 Provide care within the parameters of the state's nurse practice act. 3 Carry at least $100,000 worth of liability insurance. 4 Document consistently and objectively. 5 Clearly document a client's non-adherence to the medical regimen.

2 Provide care within the parameters of the state's nurse practice act. 4 Document consistently and objectively. 5 Clearly document a client's non-adherence to the medical regimen.

A client with a terminal illness reaches the stage of acceptance. How can the nurse best help the client during this stage? 1 Acknowledge the client's crying. 2 Encourage unrestricted family visits. 3 Explain details of the care being given. 4 Stay nearby without initiating conversation

Correct4 Stay nearby without initiating conversation

When caring for a client with pneumonia, which nursing intervention is the highest priority? 1 Increase fluid intake. 2 Employ breathing exercises and controlled coughing. 3 Ambulate as much as possible. 4 Maintain an NPO status.

Employ breathing exercises and controlled coughing. For most clients, the most effective means of preventing fluid consolidation in the lungs with a diagnosis of pneumonia is to keep active by deep breathing and controlled coughing exercises. Increased fluid intake and ambulation are important aspects of care if not contraindicated, but they are secondary to deep breathing and coughing. Keeping the client NPO is not necessary; unless contraindicated, the client with pneumonia is usually offered his or her regular diet as tolerated.

Health promotion efforts with the chronically ill client should include interventions related to primary prevention. What should this include? 1 Encouraging daily physical exercise 2 Performing yearly physical examinations 3 Providing hypertension screening programs 4 Teaching a person with diabetes how to prevent complications

1 Encouraging daily physical exercise

An arterial blood gas report indicates the client's pH is 7.25, PCO2 is 35 mm Hg, and HCO3 is 20 mEq/L. Which disturbance should the nurse identify based on these results? 1 Metabolic acidosis 2 Metabolic alkalosis 3 Respiratory acidosis 4 Respiratory alkalosis

1 Metabolic acidosis

A client is being treated for Influenza A (H1N1). The nurse has provided instructions to the client about how to decrease the risk of transmission to others. Which patient statement indicates a need for further instruction/clarification? 1 "I should practice respiratory hygiene/cough etiquette." 2 "I should avoid contact with the elderly or children." 3 "I should obtain a pneumococcal vaccination each year." 4 "I should allow visitors for short periods of time only."

3 "I should obtain a pneumococcal vaccination each year."

A client is scheduled to receive phenytoin (Dilantin) 100 mg orally at 6 PM but is having difficulty swallowing capsules. What method should the nurse use to help the client take the medication? 1 Sprinkle the powder from the capsule into a cup of water. 2 Insert a rectal suppository containing 100 mg of phenytoin. 3 Contact the prescriber to determine if a change to a suspension form would be possible. 4 Obtain a change in the administration route to allow an intramuscular (IM) injection.

3 Contact the prescriber to determine if a change to a suspension form would be possible.

The nurse instructs a client with a new colostomy to avoid foods and drinks that produce a large amount of gas, and specifically to avoid the intake of: 1 Milk 2 Cheese 3 Coffee 4 Cabbage

4 Cabbage Cabbage is a gas-producing food that can cause a client with a colostomy problems with odor control and ballooning of the ostomy bag, which may break the device seal and allow leakage. Milk, cheese, and coffee, in moderation, should not cause excessive gas problems. The client with a new colostomy should slowly introduce new foods into the diet to test toleration.

A client that is scheduled for a surgical resection of the colon and creation of a colostomy for a bowel malignancy asks why preoperative antibiotics have been prescribed. The nurse explains that the primary purpose is to: 1 Decrease peristalsis. 2 Minimize electrolyte imbalance. 3 Decrease bacteria in the intestines. 4 Treat inflammation caused by the malignancy.

3 Decrease bacteria in the intestines. To decrease the possibility of contamination, the bacteria count in the colon is lowered with antibiotics before surgery. Preoperative antibiotics do not have an effect on peristalsis, electrolyte balance, or treating inflammation.

The nurse discovers several palpable elevated masses on a client's arms. Which term most accurately describes the assessment findings? 1 Erosions 2 Macules 3 Papules 4 Vesicles

3 Papules Papules are superficial and elevated up to 0.5 cm. Nodules and tumors are masses similar to papules but are elevated more than 0.5 cm and may infiltrate deeper into tissues. Erosions are characterized as loss of the epidermis layer; macules are nonpalpable, flat changes in skin color less than 1 cm in diameter; and vesicles are usually transparent, filled with serous fluid, and are a blisterlike elevation.

A nurse is discussing Alcoholics Anonymous (AA) with a client. What behavior expected of members of AA should the nurse include in the discussion? 1 Speaking aloud at weekly meetings 2 Promising to attend at least 12 meetings yearly 3 Maintaining controlled drinking after six months 4 Acknowledging an inability to control the problem

4 Acknowledging an inability to control the problem

A client is being admitted to a medical unit with a diagnosis of pulmonary tuberculosis. The nurse should assign the client to which type of room? 1 Private room 2 Semi-private room 3 Room with windows that can be opened 4 Negative airflow room

4 Negative airflow room Tuberculosis is an airborne contagious disease that is best contained in a negative airflow room. Negative airflow rooms are always private. A private room, semiprivate room, and a room with windows that can be opened are not appropriate for the standard of care for a client diagnosed with tuberculosis. Additionally, opening windows would present a possible safety hazard in a client's room.

An 82-year-old retired schoolteacher is admitted to a nursing home. During the physical assessment, the nurse identifies an ocular problem common to persons at this client's developmental level, which is: 1 Tropia 2 Myopia 3 Hyperopia 4 Presbyopia

4 Presbyopia Presbyopia is the decreased accommodative ability of the lens that occurs with aging. Tropia (eye turn) generally occurs at birth. Myopia (nearsightedness) can occur during any developmental level or be congenital. Hyperopia (farsightedness) can occur during any developmental level or be congenital.

When providing preoperative teaching, the nurse should focus primarily on: 1 Helping the client and family decide if surgery is necessary. 2 Providing emotional support to the client and family. 3 Giving minute-by-minute details of the surgery to the client and family. 4 Providing general information to reduce client and family anxiety.

4 Providing general information to reduce client and family anxiety.

The nurse is caring for a client admitted with chronic obstructive pulmonary disease (COPD). The nurse should monitor the results of which laboratory test to evaluate the client for hypoxia? 1 Red blood cell count 2 Sputum culture 3 Arterial blood gas 4 Total hemoglobin

Arterial blood gas All of these laboratory tests assist in the evaluation of a client with respiratory difficulties; however, arterial blood gas analysis is the only test that evaluates gas exchange in the lungs. This provides accurate information about the client's oxygenation status.

A spouse of a client, while visiting at the hospital, slips and falls on a recently washed floor in the hallway leading to the client's room. To meet the criteria of ethical practice, what action should the nurse that witnessed the occurrence take?

Initiate an agency incident report.

The nurse manager is planning to assign unlicensed assistive personnel (UAP) to care for clients. What care can be delegated on a medical-surgical unit to UAP? (Select all that apply.) 1 Performing a bed bath for a client on bed rest. 2 Evaluating the effectiveness of acetaminophen and codeine (Tylenol #3). 3 Obtaining an apical pulse rate before oral digoxin (Lanoxin) is administered. 4 Assisting a client who has patient-controlled analgesia (PCA) to the bathroom. 5 Assessing the wound integrity of a client recovering from an abdominal laparotomy.

1 Performing a bed bath for a client on bed rest. 4 Assisting a client who has patient-controlled analgesia (PCA) to the bathroom. Performing a bed bath for a client on bed rest is within the scope of practice of UAP. Assisting a client who has PCA to the bathroom does not require professional nursing judgment and is within the job description of UAP. Evaluating human responses to medications requires the expertise of a licensed professional nurse. Obtaining an apical pulse rate requires a professional nursing judgment to determine whether or not the medication should be administered. Evaluating human responses to health care interventions requires the expertise of a licensed professional nurse.

What is a nurse's most appropriate response, based on current research, when asked about spanking as a disciplinary technique?

"Spanking is strongly suggestive of negative role modeling."

Nurses care for clients in a variety of age groups. In which age group is the occurrence of chronic illness the greatest? 1. Older adults 2. Adolescents 3. Young children 4. Middle-aged adults

1 Older adults

A client who is to have brain surgery has a signed advance directive in the medical record. In what situation should this document be used? 1 Discharge planning is not covered by insurance. 2 Client cannot consent to his or her own surgery. 3 Postoperative complications occur that require additional treatment. 4 Client death and which client's belongings are to be given to family members.

2 Client cannot consent to his or her own surgery. Advance directives allow clients to designate another person to consent to procedures if they are unable to do so.

A client reports smoke coming from a utility room on the nursing unit. What is the initial action the nurse should take? 1 Pull the fire alarm on the unit. 2 Remove anyone that is in immediate danger. 3 Obtain a fire extinguisher and report to the fire area. 4 Close all windows and fire doors and await further instructions.

2 Remove anyone that is in immediate danger.

The nurse is caring for a client that is hyperventilating. The nurse recalls that the client is at risk for: 1 Respiratory acidosis 2 Respiratory alkalosis 3 Respiratory compensation 4 Respiratory decompensation

2 Respiratory alkalosis Hyperventilation causes excess amounts of carbon dioxide (CO2) to be eliminated, causing respiratory alkalosis.

The nurse provides a client with left-sided weakness with instructions on how to safely use a cane. The nurse should demonstrate proper use of the cane by holding it on: 1 Alternating sides. 2 The right side. 3 The side of the weakness. 4 The side of the client's choice.

2 The right side.

A client has a stage III pressure ulcer. Which nursing intervention can prevent further injury by eliminating shearing force? 1 Maintain the head of the bed at 35 degrees or less. 2 With the help of another staff member, use a drawsheet when lifting the client in bed. 3 Reposition the client at least every 2 hours and support the client with pillows. 4 At least once every 8 hours, perform passive range-of-motion exercises of all extremities

2 With the help of another staff member, use a drawsheet when lifting the client in bed.

A client who is dying appears happy and tells a nurse a joke about the situation despite becoming sicker and weaker. What is the nurse's most therapeutic response? 1 "Why are you always telling jokes?" 2 "Your laughter is a cover for your fear." 3 "Does it help to joke about your illness?" 4 "The one who laughs on the outside cries on the inside."

3 "Does it help to joke about your illness?"

A client asks the nurse, "Should I tell my partner that I just found out I'm human immunodeficiency virus (HIV) positive?" What is the nurse's most appropriate response? 1 "This is a decision you alone can make." 2 "Do not tell your partner unless asked." 3 "You are having difficulty deciding what to say." 4 "Tell your partner that you don't know how you became sick."

3 "You are having difficulty deciding what to say."

A nurse is caring for a client who has a Hemovac portable wound suction device after abdominal surgery. What is the reason why the nurse empties the device when it is half full? 1 Emptying the unit is safer when it is half full. 2 Accurate measurement of drainage is facilitated. 3 Negative pressure in the unit lessens as fluid accumulates, interfering with further drainage. 4 Fluid collecting in the unit exerts positive pressure, forcing drainage back up the tubing and into the wound

3 Negative pressure in the unit lessens as fluid accumulates, interfering with further drainage. As drainage collects and occupies space, the original level of negative pressure decreases; the less the negative pressure, the less effective the drainage. A portable wound suction device is easy and safe to empty regardless of the amount of drainage in the unit. Drainage can be measured accurately by the calibrations on the unit or in a calibrated container after emptying. A one-way valve between the tubing and the collection chamber prevents drainage from entering the tubing and causing trauma to the wound.

A client becomes hostile when learning that amputation of a gangrenous toe is being considered. After the client's outburst, what is the best indication that the nurse-client interaction has been therapeutic? 1 Increased physical activity 2 Absence of further outbursts 3 Relaxation of tensed muscles 4 Denial of the need for further discussion

3 Relaxation of tensed muscles Relaxation of muscles and facial expression are examples of nonverbal behavior; nonverbal behavior is an excellent index of feelings because it is less likely to be consciously controlled. Increased activity may be an expression of anger or hostility. Clients may suppress verbal outbursts despite feelings and become withdrawn. Refusing to talk may be a sign that the client is just not ready to discuss feelings.

The nurse plans care for a client with a somatoform disorder based on the understanding that the disorder is: 1 A physiological response to stress. 2 A conscious defense against anxiety. 3 An intentional attempt to gain attention. 4 An unconscious means of reducing stress

4 An unconscious means of reducing stress

An 80-year-old female is admitted to the hospital because of complications associated with severe dehydration. The client's daughter asks the nurse how her mother could have become dehydrated because she is alert and able to care for herself. The nurse's best response is: 1 "The body's fluid needs decrease with age because of tissue changes." 2 "Access to fluid may be insufficient to meet the daily needs of the older adult." 3 "Memory declines with age, and the older adult may forget to ingest adequate amounts of fluid." 4 "The thirst reflex diminishes with age, and therefore the recognition of the need for fluid is decreased.

4 "The thirst reflex diminishes with age, and therefore the recognition of the need for fluid is decreased.

An adolescent is taken to the emergency department of the local hospital after stepping on a nail. The puncture wound is cleansed and a sterile dressing applied. The nurse asks about having had a tetanus immunization. The adolescent responds that all immunizations are up to date. Penicillin is administered, and the client is sent home with instructions to return if there is any change in the wound area. A few days later, the client is admitted to the hospital with a diagnosis of tetanus. Legally, what is the nurse's responsibility in this situation? 1 The nurse's judgment was adequate, and the client was treated accordingly. 2 The possibility of tetanus was not foreseen because the client was immunized. 3 Nurses should routinely administer immunization against tetanus after such an injury. 4 Data collection by the nurse was incomplete, and as a result the treatment was insufficient.

4 Data collection by the nurse was incomplete, and as a result the treatment was insufficient.

A client undergoes a bowel resection. When assessing the client 4 hours postoperatively, the nurse identifies which finding as an early sign of shock? 1 Respirations of 10 2 Urine output of 30 ml/hour 3 Lethargy 4 Restlessness

4 Restlessness n the early stage shock, the client has increased epinephrine secretion. This, in turn, causes the client to become restless, anxious, nervous, and irritable. Decreased respiratory rate is a late sign of shock. A urine output of 30 ml/hour is within normal limits.

A nurse is supportive of a child receiving long-term rehabilitation in the home rather than in a health care facility. Why is living with the family so important to a child's emotional development? 1 It provides rewards and punishment. 2 The child's development is supported. 3 It reflects the mores of a larger society. 4 It is where child's identity and roles are learned

Correct4 It is where child's identity and roles are learned Socialization, values, and role definition are learned within the family and help develop a sense of self. Once established in the family, the child can move more easily into society.

The hospital's policy requires two nurses to supervise the wasting of excess opioid solutions. The nurse draws up the prescribed dose and then requests that another nurse witness wasting of the remaining medication. The second nurse states that there is no time to observe the wasting of the medication, enters the identification to serve as the witness, and leaves the area. What is the appropriate action for the first nurse to take?

Cancel the process and ask another nurse to serve as the witness and to observe the wasting of the medication.

A client is diagnosed with AIDS. When examining the client's oral cavity, the nurse assesses white patchy plaques on the mucosa. The nurse recognizes that this finding most likely represents what opportunistic infection? 1 Cytomegalovirus 2 Histoplasmosis 3 Candida albicans 4 Human papillomavirus

Candida albicans White patchy plaques on the oral mucosa would most likely be a result of C. albicans, a yeastlike fungal infection. This condition is also known as "thrush."

A nurse addresses the needs of a client who is hyperventilating to prevent what complication?

Carbonic acid deficit

A nurse is evaluating the appropriateness of a family member's initial response to grief. What is the most important factor for the nurse to consider? 1 Personality traits 2 Educational level 3 Cultural background 4 Past experiences with death

Cultural background In the initial stage of grief the degree of anguish experienced is influenced by cultural background. Although personality traits factor into the grief process, they are not as important as culture. Educational level is not related directly to a grief response. While past experience is important, it is not as significant as culture.

A client with hemiplegia is staring blankly at the wall and reports feeling like half a person. What is the most appropriate initial nursing action? 1 Use techniques to distract the client. 2 Include the client in decision making. 3 Offer to spend more time with the client. 4 Help the client to problem-solve personal issues

Correct3 Offer to spend more time with the client. Because of the profound effect of paralysis on body image, the nurse should foster an environment that permits exploration of feelings without judgment, punishment, or rejection. Attempts to distract the client may be interpreted as denial of the client's feelings and will not resolve the underlying problem. Including the client in decision making and helping the client to problem-solve personal issues are an important part of nursing care, but they are not related to the client's feelings.

What should a nurse recommend to help a client best during the period immediately after a spouse's death? 1 Crisis counseling 2 Family counseling 3 Marital counseling 4 Bereavement counseling

Correct4 Bereavement counseling Bereavement counseling involves being a part of a group of people who also have sustained a loss; members provide support to each other. Individual counseling will not provide the support that a group provides; group counseling may last longer than crisis intervention. The information provided did not indicate other family members. Marital counseling involves both a husband and a wife.

A client is admitted to the hospital because of multiple chronic health problems. What is the priority nursing intervention at this time? 1 Advising the client to join a support group immediately after discharge. 2 Assuring the family that staff members will take care of the client's needs. 3 Reminding the client to keep medical follow-up appointments after discharge. 4 Conducting a multidisciplinary staff conference early during the client's hospitalization.

Correct4 Conducting a multidisciplinary staff conference early during the client's hospitalization.

The nurse is providing restraint education to a group of nursing students. The nurse should include that it is inappropriate to use a restraint device to: 1 Prevent a client from pulling out an IV when there is concern that the client cannot follow instructions or is confused. 2 Prevent an adult client from getting up at night when there is insufficient staffing on the unit. 3 Maintain immobilization of a client's leg to prevent dislodging a skin graft. 4 Keep an older adult client from falling out of bed following a surgical procedure.

Correct2 Prevent an adult client from getting up at night when there is insufficient staffing on the unit.

A nurse has provided discharge instructions to a client who received a prescription for a walker to use for assistance with ambulation. The nurse determines that the teaching has been effective when the client: 1. Picks up the walker and carries it for short distances. 2. Uses the walker only when someone else is present. 3. Moves the walker no more than 12 inches in front of the client during use. 4. States that a walker will be purchased on the way home from the hospital

Moves the walker no more than 12 inches in front of the client during use

A 3-year-old child with eczema of the face and arms has disregarded the nurse's warnings to "stop scratching, or else!" The nurse finds the toddler scratching so intensely that the arms are bleeding. The nurse then ties the toddler's arms to the crib sides, saying, "I'm going to teach you one way or another." How should the nurse's behavior be interpreted? 1.These actions can be construed as assault and battery. 2.The problem was resolved with forethought and accountability. 3.Skin must be protected, and the actions taken were by a reasonably prudent nurse. 4.The nurse had tried to reason with the toddler and expected understanding and cooperation

These actions can be construed as assault and battery Assault is a threat or an attempt to do violence to another, and battery means touching an individual in an offensive manner or actually injuring another person.

A client has a stage III pressure ulcer. Which nursing intervention can prevent further injury by eliminating shearing force? 1 Maintain the head of the bed at 35 degrees or less. 2 With the help of another staff member, use a drawsheet when lifting the client in bed. 3 Reposition the client at least every 2 hours and support the client with pillows. 4 At least once every 8 hours, perform passive range-of-motion exercises of all extremities.

With the help of another staff member, use a drawsheet when lifting the client in bed.

A physician orders heparin 6,000 units subcutaneously daily. The pharmacy dispenses a vial containing 10,000 units per milliliter. To ensure the patient's safety, how many milliliters of heparin should the nurse administer? Include a leading zero if applicable. Record your answer using one decimal place. ______ mL

0.6 mL

A nurse is assigned to take care of a group of clients. Which client should the nurse see first? 1 A 2-yr-old male with diarrhea 2 A 35-yr-old male who is nauseated 3 A 40-yr-old female who has vomiting due to food poisoning 4 An 83-yr-old female whose last bowel movement was three days ago.

1 A 2-yr-old male with diarrhea The two-year-old child will be at higher risk for fluid and electrolyte imbalance due to higher fluid content of the body and decreased ability to regulate fluid balance, which put this client in life threatening situation.

A nurse anticipates that a hospitalized client will be transferred to a nursing home. When should the nurse begin preparing the client for the transfer? 1 At the time of admission 2 After a relative gives permission 3 When the client talks about future plans 4 As soon as the client's transfer has been approved

1 At the time of admission Preparation of clients for discharge to their own home or to a nursing home should begin on the day of admission. The client gives permission for transfer to a nursing home

A nurse is caring for a client that has been admitted with right sided heart failure. The nurse notes that the client has dependent edema around the area of the feet and ankles. In order to characterize the severity of the edema, the nurse presses the medial malleolus area and notes an 8 mm depression after release. This nurse understands that the edema should be documented as: 1 1+ 2 2+ 3 3+ 4 4+

4 4+ Dependent edema around the area of feet and ankles often indicates right sided heart failure or venous insufficiency. The nurse should assess for pitting edema by pressing firmly for several seconds then release to assess for any depression left on the skin. The grading of 1+ to 4+ characterizes the severity of the edema. A grade of grade of 4+ indicates an 8 mm depression. A grade of 1+ indicates a 2 mm depression. A grade of 2 + indicates a 4 mm depression. A grade of 3+ indicates a 6 mm depression.

The intake and output of a client over an eight-hour period is: 0800: Intravenous (IV) infusing; 900 mL left in bag; 0830: 150 mL voided; From 0900-1500 time period: 200 mL gastric tube formula + 50 mL water; Repeated x 2.; 1300: 220 mL voided; 1515: 235 mL voided; 1600: IV has 550 mL left in bag. What is the difference between the client's intake and output? Record the answer using a whole number. _________ mL

495 mL

A daughter of a Chinese-speaking client approaches a nurse and asks multiple questions while maintaining direct eye contact. What culturally related concept does the daughter's behavior reflect? 1 Prejudice 2 Stereotyping 3 Assimilation 4 Ethnocentrism

Assimilation Assimilation involves incorporating the behaviors of a dominant culture. Maintaining eye contact is characteristic of the American culture and not of Asian cultures. Prejudice is a negative belief about another person or group and does not characterize this behavior. Stereotyping is the perception that all members of a group are alike. Ethnocentrism is the perception that one's beliefs are better than those of others.

The nurse should monitor for which involuntary physiological response in a client who is experiencing pain? 1 Crying 2 Splinting 3 Perspiring 4 Grimacing

3 Perspiring Perspiration is an involuntary physiological response. It is mediated by the autonomic nervous system under a variety of circumstances, such as rising ambient temperature, high humidity, stress, and pain

On the second day of hospitalization a client is discussing with the nurse concerns about unhealthy family relationships. During the nurse-client interaction the client begins to talk about a job problem. The nurse's response is: "Let's go back to what we were just talking about." What therapeutic communication technique did the nurse use? 1 Focusing 2 Restating 3 Exploring 4 Accepting

Focusing

A client with osteoporosis is encouraged to drink milk. The client refuses the milk, explaining that it causes gas and bloating. Which food should the nurse suggest that is rich in calcium and digested easily by clients who do not tolerate milk? 1 Eggs 2 Yogurt 3 Potatoes 4 Applesauce

2 Yogurt Yogurt, which contains calcium, is digested more easily because it contains the enzyme lactase, which breaks down milk sugar. Yogurt contains approximately 274 to 415 mg of calcium for an 8-oz container, depending on how it is prepared. Eggs contain approximately 22 mg of calcium. One potato contains approximately 7 to 20 mg of calcium, depending on how it is prepared. Eight ounces of applesauce contain approximately 3 mg of calcium.

The nurse recognizes that which are important components of a neurovascular assessment? (Select all that apply.) 1 2 Orientation 3 Capillary refill 4 Pupillary response 5 Respiratory rate 6 Pulse and skin temperature 7 Movement and sensation

2 Orientation 5 Respiratory rate 6 Pulse and skin temperature A neurovascular assessment involves evaluating of nerve and blood supply to an extremity involved in an injury. The area involved may include an orthopedic and/or soft tissue injury. A correct neurovascular assessment should include evaluating of capillary refill, pulses, warmth and paresthesias, and movement and sensation. Orientation, pupillary response, and respiratory rate are components of a neurological assessment.

What are the clinical indicators that a nurse expects when an intravenous (IV) line has infiltrated? (Select all that apply.) 1 Heat 2 Pallor 3 Edema 4 Decreased flow rate 5 Increased blood pressure

2 Pallor 3 Edema 4 Decreased flow rate The accumulation of fluid in the tissues between the surface of the skin and the blood vessels makes the skin appear pale. The accumulation of fluid in the interstitial compartment causes swelling. As the needle/catheter is dislodged from the vein, the drip rate of the IV slows or ceases. Heat is associated with phlebitis; the accumulation of room temperature IV fluid in the tissue makes the site feel cool. Increased blood pressure is a sign of circulatory overload; when an IV infusion has infiltrated, the intravascular fluid volume does not increase.

A client has a right above-the-knee amputation after trauma sustained in a work-related accident. Upon awakening from surgery, the client states, "What happened to me? I don't remember a thing." What is the nurse's best initial response? 1 "Tell me what you think happened." 2 "You will remember more as you get better." 3 "You were in a work-related accident this morning." 4 "It was necessary to amputate your leg after the accident."

3 "You were in a work-related accident this morning."

A client comes to the medical clinic complaining of headaches. The nurse measures the blood pressure at 172/114. What should the nurse do first? 1 Page the on-call health care provider and continue to monitor the blood pressure. 2 Administer ibuprofen and have the client rest quietly for 20 minutes. 3 Elevate the head of the bed, provide reassurance, and reassess the blood pressure. 4 Place the client in the supine position, administer oxygen, and notify the health care provider.

Elevate the head of the bed, provide reassurance, and reassess the blood pressure. Blood pressure increases with pain and stress; reevaluation is critical before determining if the health care provider should be notified. Assessment should be completed before notifying the health care provider. Prescribing medications is a dependent function of the nurse, and medication should not be administered until the cause of the headache is determined. Oxygen is not indicated. The head of the bed should be elevated. The health care provider should be notified if a second blood pressure reading remains elevated.

A nurse is explaining the nursing process to a nursing assistant. Which step of the nursing process should include interpretation of data collected about the client? 1 Evaluation 2 Data Collection 3 Nursing interventions 4 Proposed nursing care

Evaluation

A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with acute bronchopneumonia. The client is in moderate respiratory distress. The nurse should place the client in what position to enhance comfort?

High-Fowler's position using the bedside table as an arm rest

A nurse is providing colostomy care to a client with a nosocomial infection caused by methicillin-resistant Staphylococcus aureus (MRSA). Which personal protective equipment (PPE) should the nurse use? (Select all that apply.)

1 Gloves 2 Gown 4 Goggles

When planning discharge teaching for a young adult, the nurse should include the potential health problems common in this age group. What should the nurse include in this teaching plan?

Accidents, including their prevention

A client is scheduled to receive conscious sedation during a colonoscopy. The client asks the nurse, "How will they 'knock me out' for this procedure?" Which answer by the nurse correctly describes the route of administration for conscious sedation? 1 "You will receive the anesthesia through a face mask." 2 "You will receive medication through an intravenous catheter." 3 "We will give you an oral medication about one hour before the procedure." 4 "The nurse anesthetist will inject the medication into the epidural space of your spine."

2 "You will receive medication through an intravenous catheter."

Place each step of the nursing process in the order that it should be used. a. Identify goals for care. b. Develop a plan of care. c. State client's nursing needs. d. Implement nursing interventions. e. Obtain client's nursing history.

1.Obtain client's nursing history. 2. State client's nursing needs. 3. Identify goals for care 4. Develop a plan of care. 5. Implement nursing interventions.

A nurse overhears an unlicensed assistive personnel (UAP) talking with a client about the client's marital and family problems. The nurse identifies that the UAP is providing false reassurance when the UAP states: 1 "I agree; I think you should get a divorce." 2 "Everything will be fine, just wait and see." 3 "You should be glad that you have such a loving family." 4 "In the scheme of things, you do not have a major problem."

2 "Everything will be fine, just wait and see."

While receiving a preoperative enema, a client starts to cry and says, "I'm sorry you have to do this messy thing for me." What is the nurse's best response? 1 "I don't mind it." 2 "You seem upset." 3 "This is part of my job." 4 "Nurses get used to this."

2 "You seem upset."

It is appropriate for the nurse to pull up on the client's skin, release it, and determine if the skin returns immediately to its original position to assess for: 1 Pain tolerance 2 Skin turgor 3 Ecchymosis formation 4 Tissue mass

2 Skin turgor

The physician orders intravenous fluids to be infused at 100 mL/hour. The intravenous tubing delivers 15 drops/milliliters. The nurse would infuse the solution at a flow rate of how many drops per minute to ensure that the client receives 100 mL/hour? Record your answer using a whole number. _____ gtts/min.

25

A nurse reviews a medical record of a client with ascites. What does the nurse identify that may be causing the ascites? 1 Portal hypotension 2 Kidney malfunction 3 Decreased liver function 4 Decreased production of potassium

3 Decreased liver function The liver manufactures albumin, the major plasma protein. A deficit of this protein lowers the osmotic (oncotic) pressure in the intravascular space, leading to a fluid shift. An enlarged liver compresses the portal system, causing increased, rather than decreased, pressure.

A nurse fails to act in a reasonable, prudent manner. Which legal principle is most likely to be applied? 1 Malice 2 Tort law 3 Malpractice 4 Case law

3 Malpractice

A client with Addison's disease is receiving cortisone therapy. The nurse expects what clinical indicators if the client abruptly stops the medication? (Select all that apply.) 1 Diplopia 2 Dysphagia 3 Tachypnea 4 Bradycardia 5 Hypotension

3 Tachypnea 5 Hypotension Tachypnea occurs with Addisonian crisis because of inadequate circulating glucocorticoids and mineralocorticoids. Inadequate circulating glucocorticoids and mineralocorticoids cause hypotension, pallor, weakness, tachycardia, and tachypnea. Double vision does not occur with Addisonian crisis. Difficulty swallowing does not occur with Addisonian crisis. Tachycardia, not bradycardia, occurs with Addisonian crisis.

The health care provider orders 1000 mL normal saline to be infused over 8 hours for a client with a diagnosis of dehydration. The intravenous (IV) tubing delivers 15 drops per milliliter (drop factor). The nurse should administer the IV infusion at a rate of ____ gtts/minute. Record your answer using a whole number.

31 gtts

A health care provider prescribes simvastatin (Zocor) 20 mg daily for elevated cholesterol and triglyceride levels for a female client. Which is most important for the nurse to teach when the client initially takes the medication?

Inform the health care provider if the client wishes to become pregnant.

As a nurse prepares an older adult client for sleep, actions are taken to help reduce the likelihood of a fall during the night. What nursing action is most appropriate when targeting older adults' most frequent cause of falls?

Instructing the client to call the nurse before going to the bathroom.

Which client assessment finding should the nurse document as subjective data? 1 B/P 120/82 2 Pain rating of five (5) 3 Potassium 4.0 mEq 4 Pulse oximetry reading of 96%

Pain rating of five (5)

A client who is to receive radiation therapy for cancer says to the nurse, "My family said I will get a radiation burn." What is the nurse's best response?

"A localized skin reaction usually occurs."

When caring for a client with a fractured hip, the nurse should place pillows around the injured leg to specifically maintain: 1 Abduction. 2 Adduction. 3 Traction. 4 Elevation

1 Abduction.

A nurse is evaluating the effectiveness of treatment for a client with excessive fluid volume. What clinical finding indicates that treatment has been successful? 1 Clear breath sounds 2 Positive pedal pulses 3 Normal potassium level 4 Increased urine specific gravity

1 Clear breath sounds

A nurse assesses a client with dry and brittle hair, flaky skin, a beefy-red tongue and bleeding gums. The nurse recognizes that these clinical manifestations are most likely a result of: 1 A food allergy. 2 Noncompliance with medications. 3 Side effects from medications. 4 A nutritional deficiency.

4 A nutritional deficiency.

The nurse is caring for an older adult client who is aphasic. The client's family reports to the nurse manager that the primary nurse failed to obtain a signed consent form before inserting an indwelling catheter to measure intake and output. What should the nurse manager consider before responding?

A separate signed informed consent for routine treatments is unnecessary.

A hospitalized client is scheduled to have a sigmoidoscopy. The nurse anticipates that pre-procedure prescriptions will include: 1 Providing instructions about restraints used during the procedure. 2 Administering a fleet enema 1 hour before the procedure. 3 Encouraging increased intake of clear fluids. 4 Administering morphine 30 minutes before the procedure.

Administering a fleet enema 1 hour before the procedure. To facilitate visualization of the rectum and the sigmoid colon, the lower colon must be emptied immediately before the procedure. A fleet or tap water enema should be used. The client will be kept NPO for at least 8 hours before the procedure. Morphine is not typically used as a pre-op medication before a sigmoidoscopy. Restraints are not typically used during the procedure.

The nurse is caring for a client that underwent a rhinoplasty surgical procedure 5 hours ago. After administering pain medication, the nurse notes the client is swallowing frequently. The nurse understands that the cause of frequent swallowing is most likely caused from: 1 A normal response to the analgesic 2 Oral dryness caused by nasal packing 3 An adverse reaction to anesthesia 4 Bleeding posterior to the nasal packing

Bleeding posterior to the nasal packing Frequent swallowing may indicate bleeding in the posterior pharynx. Oral dryness causes thirst, not an increase in swallowing. Frequent swallowing is not a normal response to rhinoplasty or analgesics/anesthesia.

A client has a platelet count of 49,000/mL. The nurse should instruct the client to avoid which activity? 1 Ambulation 2 Blowing the nose 3 Visiting with children 4 The semi-Fowler's position

Correct2 Blowing the nose Patients with thrombocytopenia are at a greater risk of excessive bleeding in response to minimal trauma. The nurse should instruct the patient to avoid blowing their nose as this activity can increase the risk of bleeding. The following activities are not contraindicated with thrombocytopenia: ambulation, visiting with children, and semi-Fowler's position.

The nurse performs a respiratory assessment and auscultates breath sounds that are high-pitched, creaking and accentuated on expiration. Which term best describes the findings? 1 Rhonchi 2 Wheezes 3 Pleural friction rub 4 Bronchovesicular

Correct2 Wheezes Wheezes are one of the most common breath sounds assessed and auscultated in clients with asthma and COPD. Wheezes are produced as air flows through narrowed passageways. Rhonchi are coarse rattling sounds similar to snoring and are usually caused by secretions in the bronchial airways. A pleural friction rub is an abrasive sound made by two acutely inflamed serous surfaces rubbing together during the respiratory cycle. Bronchovesicular sounds are intermediate between bronchial (upper) and vesicular (lower) breath sounds; they are normal when heard between the first and second intercostal spaces anteriorly and posteriorly between scapulae.

Considering Erikson's developmental theories, a 21-year-old male client who has sustained a spinal injury below the level of T6 will most likely have difficulty with: 1 Mastering his environment 2 Identifying with the male role 3 Developing meaningful relationships 4 Differentiating himself from the environment

Developing meaningful relationships Developing meaningful relationships is the young-adult task associated with intimacy versus isolation. Mastering his environment is a toddler's task associated with autonomy versus shame and doubt. Identifying with the male role is a preschool-age child's task associated with initiative versus guilt. Differentiating himself from the environment is a toddler's task associated with autonomy versus shame and doubt.

A visitor says to the nurse, "Can I read my client's progress record? I am the sponsor from an alcohol recovery program." How should the nurse respond? 1.Allow the visitor to review the record; sponsors have access to privileged information 2.Ask the primary health care provider about granting permission to the sponsor 3.Do not allow the sponsor to review the record 4.Allow the visitor to review the record; clients with alcoholism need reassurance from sponsors

Do not allow the sponsor to review the record

A nurse receives a shift report on four adult clients that are between the ages of 25-55. Which client should the nurse assess first? 1 Male client with a hemoglobin of 15.9 2 Female client on warfarin (Coumadin) with an International Normalized Ratio (INR) of 7.5 3 Female client taking daily calcium supplements with a serum calcium level of 9.4 4 Male client with a blood urea nitrogen (BUN) of 20 and a creatinine of 1.1

Female client on warfarin (Coumadin) with an International Normalized Ratio (INR) of 7.5 The client on warfarin (Coumadin) with an INR of 7.5 should be assessed first by the nurse, because this is an elevated result. Normal is considered between 2 and 3. This result is not therapeutic, and the nurse should assess for bleeding and hemodynamic stability. The nurse should report the result to the primary healthcare provider and implement bleeding precautions. The other results are within normal ranges: hemoglobin for a male is 14-18 g/dL; serum calcium is 9.0-10.5 mg/dL; BUN is 5-20 mg/dL and creatinine is 0.7-1.5 mg/dL.

An obese adult develops an abscess after abdominal surgery. The wound is healing by secondary intention and requires repacking and redressing every four hours. Which diet should the nurse expect the health care provider to prescribe to best meet this client's immediate nutritional needs? 1. Low in fat and vitamin D 2. High in calories and fiber 3. Low in residue and bland 4. High in protein and vitamin C

High in protein and vitamin C

A day after an explanation of the effects of surgery to create an ileostomy, a 68-year-old male client remarks to the nurse, "It will be difficult for my wife to care for a helpless old man." This comment by the client regarding himself is an example of Erikson's conflict of: 1 Initiative versus guilt 2 Integrity versus despair 3 Industry versus inferiority 4 Generativity versus stagnation

Integrity versus despair According to Erikson, poor self-concept and feelings of despair are conflicts manifested in those who are older than 65 years of age. The initiative versus guilt conflict is manifested in early childhood between 3 and 6 years of age. The industry versus inferiority conflict is manifested during the ages from 6 to 11 years. The generatively versus stagnation conflict is manifested during middle adulthood, 45 to 65 years of age.

The most effective time to teach clients who have sustained a sudden, traumatic, major loss is most often during the acceptance or adaptation stage of coping. The rationale for this fact is that clients in this stage are: 1 Ready for discharge and therefore in need of preparation 2 At the peak of mental anguish and therefore open to change 3 Less angry and therefore more compliant and more receptive 4 Less anxious and more aware of reality and therefore ready to learn

Less anxious and more aware of reality and therefore ready to learn

A client has a "prayer cloth" pinned to the hospital gown. The cloth is soiled from being touched frequently. What should the nurse do when changing the client's gown? 1 Make a new prayer cloth. 2 Discard the soiled prayer cloth. 3 Pin the prayer cloth to the clean gown. 4 Wash the prayer cloth with a detergent.

Pin the prayer cloth to the clean gown The prayer cloth has religious significance for the client and should be preserved as is. Making a new prayer cloth disregards what the prayer cloth means to the client. The prayer cloth is the property of the client and should not be discarded. Washing the prayer cloth with a detergent disregards what the prayer cloth means to the client; this never should be done without the client's permission.

An intravenous (IV) solution of 1000 mL 5% dextrose in water is to be infused at 125 mL/hr to correct a client's fluid imbalance. The infusion set delivers 15 drops/mL. To ensure that the solution will infuse over an eight-hour period, at how many drops per minute should the nurse set the rate of flow? Record the answer using a whole number. ______ gtts/min

Use the following formula to solve the problem. Drops per minute = total volume in drops (total mL x drop factor)/Total time in minutes (hours x 60) Drops per minute = 1000 mL x 15/8 x 60 = 15,000/480 = 31.25 = 31 gtts/min

A client with cancer is informed that the chemotherapy is no longer working and that death is inevitable. Keeping in mind Kübler-Ross's stages of death and dying, place the following nursing interventions that are most appropriately associated with each stage in order from the stage of denial to acceptance. 1. Provide maximal comfort measures. 2. Avoid confronting the client. 3. Redirect negative feelings constructively. 4. Help the client identify realistic versus unrealistic goals. 5. Help the client celebrate the simple pleasures in everyday life.

1.Avoid confronting the client. 2.Redirect negative feelings constructively. 3.Help the client identify realistic versus unrealistic goals. 4.Help the client celebrate the simple pleasures in everyday life. 5.Provide maximal comfort measures. DABDA During the denial stage, the nurse needs to avoid confronting the client's behavior because denial at this early stage is a self-protective mechanism. It is unwise to confront a client's coping mechanism because it leaves the client unprotected. During the anger stage, the nurse needs to accept the client's behavior and redirect negative feelings constructively. During the bargaining stage, the client generally seeks to achieve a goal. The nurse needs to help the client be realistic in this endeavor. During the depression stage, the nurse should encourage the client to engage in simple pleasures, such as sitting in the sun. During the acceptance stage, the nurse should provide comfort measures based on needs and desires.

A client with Type I Diabetes complains of hunger, thirst, tiredness, and frequent urination. Based on these findings, the nurse should take what action? 1 Notify the physician immediately about the client's symptoms. 2 Determine the client's blood glucose level. 3 Administer the client's prescribed insulin. 4 Give the client a peanut butter and graham cracker snack.

2 Determine the client's blood glucose level.

The nurse is assessing a group of older adults. Which should the nurse consider to be least likely to be affected by aging? 1 Sense of taste or smell 2 Gastrointestinal motility 3 Muscle or motor strength 4 Strategies to handle stress

4 Strategies to handle stress

What is a basic concept associated with rehabilitation that the nurse should consider when formulating discharge plans for clients? 1 Rehabilitation needs are met best by the client's family and community resources. 2 Rehabilitation is a specialty area with unique methods for meeting clients' needs. 3 Immediate or potential rehabilitation needs are exhibited by clients with health problems. 4 Clients who are returning to their usual activities following hospitalization do not require rehabilitation.

Immediate or potential rehabilitation needs are exhibited by clients with health problems. Rehabilitation refers to a process that assists clients to obtain optimal functioning. Care should be initiated immediately when a health problem exists to avoid complications and facilitate recuperation. All resources that can be beneficial to client rehabilitation, including the private health care provider and acute care facilities, should be used. Rehabilitation is a commonality in all areas of nursing practice. Rehabilitation is necessary to help clients return to a previous or optimal level of functioning.

A health care provider prescribes an antibiotic intravenous piggyback (IVPB) twice a day for a client with an infection. The health care provider prescribes peak and trough levels 48 and 72 hours after initiation of the therapy. The client asks the nurse why there is a need for so many blood tests. The nurse's best response is, "These tests will: 1 determine adequate dosage levels of the drug." 2 detect if you are having an allergic reaction to the drug." 3 permit blood culture specimens to be obtained when the drug is at its lowest level." 4 allow comparison of your fever to when the blood level of the antibiotic is at its highest."

1 determine adequate dosage levels of the drug." Drug dosage and frequency are adjusted according to peak and trough levels to enhance efficacy by maintaining therapeutic levels. Peak and trough levels reveal nothing about allergic reactions. Blood cultures are obtained when the client spikes a temperature; they are not related to peak and trough levels of an antibiotic. A sustained decrease in fever is the desired outcome, not reduction just at peak serum levels of the medication.

When assessing a client's blood pressure, the nurse notes that the blood pressure reading in the right arm is 10 mm Hg higher than the blood pressure reading in the left arm. The nurse understands that this finding: 1 is a normal occurrence. 2 may indicate atherosclerosis. 3 can be attributed to aortic disease. 4 indicates lymphedema

1 is a normal occurrence.

A nurse receives abnormal results of diagnostic testing. What action should the nurse take first? 1 Inform the client of the results. 2 Ensure that the results are placed in the client's medical record. 3 Notify the client's healthcare provider of the results. 4 Request the test be re-done to ensure accuracy.

3 Notify the client's healthcare provider of the results.

A client with a diagnosis of uncontrolled diabetes began receiving Lasix (Furosemide) two days ago. The nurse reviews the morning lab results and discovers that the client's potassium level is 2.8 mEq/L. What is the most appropriate action for the nurse to take? 1 Hold the morning dose of the diuretic and have the lab repeat the test. 2 Continue to monitor the level to ensure that it stays within the normal limits. 3 Notify the primary healthcare provider of the result, which is critically low. 4 Anticipate a prescription for an increase in the dosage of the Lasix.

3 Notify the primary healthcare provider of the result, which is critically low. The physician should be notified because a potassium level of 2.8 mEq/L is low. Normal range for serum potassium is 3.5 to 5 mEq/L. Clients who are on diuretics require monitoring of serum electrolytes, especially potassium and sodium, because they also are excreted with water. The nurse should not hold the diuretic or repeat the lab test unless advised by the physician. The client's serum potassium level is critically below the normal limit and the physician should be notified. An increase in Lasix would cause an increased loss of potassium

The nurse is providing post-procedure care for a client that had a liver biopsy. To prevent hemorrhage, it is the nurse's highest priority to place the client in what position? 1 Prone 2 High-Fowler's 3 On the right side 4 Trendelenburg

3 On the right side Placing a client on the right side after a liver biopsy compresses the liver against the abdominal wall, thus holding pressure on the biopsy site and allowing clot formation.

A nurse is teaching members of a health care team how to help disabled clients stand and transfer from the bed to a chair. To protect the caregivers from injury, the nurse teaches them to lift the client by first placing their arms under the client's axillae and next: 1 Bending and then straightening their knees 2 Bending at the waist and then straightening the back 3 Placing one foot in front of the other and then leaning back 4 Placing pressure against the client's axillae and then raising their arms

1 Bending and then straightening their knees The leg bones and muscles are used for weight bearing and are the strongest in the body. Using the knees for leverage while lifting the client shifts the stress of the transfer to the caregiver's legs. By using the strong muscles of the legs the back is protected from injury.

A nurse is caring for a newly admitted client in a long-term care facility. The nurse notes that the client has a decreased attention span and cannot concentrate. The nurse suspects which effects of sensory deprivation? 1 Cognitive response 2 Emotional response 3 Perceptual response 4 Physical response

1 Cognitive response

A client with hypothermia is brought to the emergency department. What treatment does the nurse anticipate when the patient is in the emergency department? 1 Core rewarming with warm fluids 2 Ambulation to increase metabolism 3 Frequent oral temperature assessments 4 Gastric tube feedings to increase fluid volume

1 Core rewarming with warm fluids

A nurse on the medical-surgical unit tells other staff members, "That client can just wait for the lorazepam (Ativan); I get so annoyed when people drink too much." What does this nurse's comment reflect? 1 Demonstration of a personal bias. 2 Problem solving based on assessment. 3 Determination of client acuity to set priorities. 4 Consideration of the complexity of client care.

1 Demonstration of a personal bias.

A 2-g sodium diet is prescribed for a client with stage 2 hypertension, and the nurse teaches the client the rationale for this diet. The client reports distaste for the food. The primary nurse hears the client request that the family "bring in a ham and cheese sandwich and fries." What is the most effective nursing intervention? 1 Discuss the diet with the client and family. 2 Tell the client why salty foods should not be eaten. 3 Explain the dietary restriction to the client's visitors. 4 Ask the dietitian to teach the client and family about sodium restrictions

1 Discuss the diet with the client and family.

A nurse assesses the vital signs of a 50-year-old female client and documents the results. Which of the following are considered within normal range for this client? (Select all that apply.) 1 Oral temperature 98.2° F 2 Apical pulse 88 beats per minute and regular 3 Respiratory rate of 30 per minute 4 Blood pressure 116/78 mm Hg while in a sitting position 5 Oxygen saturation of 92%

1 Oral temperature 98.2° F 2 Apical pulse 88 beats per minute and regular 4 Blood pressure 116/78 mm Hg while in a sitting position

A nurse is obtaining a health history from the newly admitted client who has chronic pain in the knee. What should the nurse include in the pain assessment? (Select all that apply.) 1 Pain history including location, intensity and quality of pain 2 Client's purposeful body movement in arranging the papers on the bedside table 3 Pain pattern including precipitating and alleviating factors 4 Vital signs such as increased blood pressure and heart rate 5 The client's family statement about increases in pain with ambulation

1 Pain history including location, intensity and quality of pain 3 Pain pattern including precipitating and alleviating factors

A nurse is providing preoperative teaching for a client regarding use of an incentive spirometer and should include what instructions? 1 "Inhale completely and exhale in short, rapid breaths." 2 "Inhale deeply through the spirometer, hold it as long as possible, and slowly exhale." 3 "Exhale completely; take a slow, deep breath; hold it as long as possible, and slowly exhale." 4 "Exhale halfway, then inhale a rapid, small breath; repeat several times."

2 "Inhale deeply through the spirometer, hold it as long as possible, and slowly exhale." The correct procedure to maximize use of an incentive spirometer is to exhale completely, then take a slow, deep breath through the spirometer, and hold it as long as possible. This procedure will maximize inspiratory function by expanding the lungs. The client should practice using the incentive spirometer before surgery.

A newly hired nurse, during orientation, is approached by a surveyor from the department of health. The surveyor asks the nurse about the best way to prevent the spread of infection. What is the most appropriate nursing response? 1 "Let me get my preceptor." 2 "Wash your hands before and after any client care." 3 "Clean all instruments and work surfaces with an approved disinfectant." 4 "Ensure proper disposal of all items contaminated with blood or body fluids.

2 "Wash your hands before and after any client care."

A client who has reached the stage of acceptance in the grieving process appears peaceful, but demonstrates a lack of involvement with the environment. How should the nurse address this behavior? 1 Ignore the client's behavior when possible. 2 Accept the behavior the client is exhibiting. 3 Explore the reality of the situation with the client. 4 Encourage participation within the client's environment.

2 Accept the behavior the client is exhibiting. Detachment is a coping mechanism that the client needs, especially when faced with the inevitability of death; the nurse should accept this behavior.

A client reports fatigue and dyspnea and appears pale. The nurse questions the client about medications currently being taken. In light of the symptoms, which medication causes the nurse to be most concerned? 1 Famotidine (Pepcid) 2 Methyldopa (Aldomet) 3 Ferrous sulfate (Feosol) 4 Levothyroxine (Synthroid)

2 Methyldopa (Aldomet) Methyldopa is associated with acquired hemolytic anemia and should be discontinued to prevent progression and complications. Famotidine will not cause these symptoms; it decreases gastric acid secretion, which will decrease the risk of gastrointestinal bleeding. Ferrous sulfate is an iron supplement to correct, not cause, symptoms of anemia. Levothyroxine is not associated with red blood cell destruction.

What is the most important factor relative to a therapeutic nurse-client relationship when a nurse is caring for a client who is terminally ill? 1 Knowledge of the grieving process 2 Personal feelings about terminal illness 3 Recognition of the family's ability to cope 4 Previous experience with terminally ill clients

2 Personal feelings about terminal illness To be effective in a relationship with a client, the nurse must know and understand personal feelings about terminal illness and death.

A client has a paracentesis, and the health care provider removes 1500 mL of fluid. To monitor for a serious postprocedure complication, the nurse should assess for: 1 Dry mouth 2 Tachycardia 3 Hypertensive crisis 4 Increased abdominal distention

2 Tachycardia

A nurse hired to work in a metropolitan hospital provides services for a culturally diverse population. One of the nurses on the unit says it is the nurses' responsibility to discourage "these people" from bringing all that "home medicine stuff" to their family members. Which response by the recently hired nurse is most appropriate? 1 "Hospital policies should put a stop to this." 2 "Everyone should conform to the prevailing culture." 3 "Nontraditional approaches to health care can be beneficial." 4 "You are right because they may have a negative impact on people's health."

3 "Nontraditional approaches to health care can be beneficial." Studies demonstrate that some nontraditional therapies are effective. Culturally competent professionals should be knowledgeable about other cultures and beliefs. Many health care facilities are incorporating both Western and nontraditional therapies. The statement "Everyone should conform to the prevailing culture" does not value diversity. The statement "You are right because they may have a negative impact on people's health" is judgmental and prejudicial. Some cultural practices may bring comfort to the client and may be beneficial, and they may not interfere with traditional therapy.

An older client is apprehensive about being hospitalized. The nurse realizes that one of the stresses of hospitalization is the unfamiliarity of the environment and activity. How can the nurse best limit the client's stress? 1 Use the client's first name. 2 Visit with the client frequently. 3 Explain what the client can expect. 4 Listen to what the client has to say.

3 Explain what the client can expect.

A nurse assesses for hypocalcemia in a postoperative client. One of the initial signs that might be present is: 1 Headache. 2 Pallor. 3 Paresthesias. 4 Blurred vision.

3 Paresthesias. Normally, calcium ions block the movement of sodium into cells. When calcium is low, this allows sodium to move freely into cells, creating increased excitability of the nervous system. Initial symptoms are paresthesias. This can lead to tetany if untreated. Headache, pallor, and blurred vision are not signs of hypocalcemia.

What factors are most important for the nurse to consider when delegating responsibilities? 1 Preferences of the clients and staff 2 Physical layout of the unit and client rooms 3 Staff member's level of education and expertise 4 Client's diagnosis and length of time in the hospital

3 Staff member's level of education and expertise

A client with a history of ulcerative colitis is admitted to the hospital because of severe rectal bleeding. The client engages in angry outbursts and places excessive demands on the staff. One day an unlicensed assistive personnel (UAP) tells the nurse, "I've had it. I am not putting up with that behavior. I'm not going in there again." What is the best response by the nurse? 1 "You need to try to be patient. The client is going through a lot right now." 2 "I'll talk with the client. Maybe I can figure out the best way for us to handle this." 3 "Just ignore it and get on with your work. I'll assign someone else to take a turn." 4 "The client's frightened and taking it out on the staff. Let's think of approaches we can take."

4 "The client's frightened and taking it out on the staff. Let's think of approaches we can take."

A recent immigrant from mainland China is critically ill and dying. What question should the nurse ask when collecting information to meet the emotional needs of this client? 1 "Do you like living in this country?" 2 "When did you come to this country?" 3 "Is there a family member who can translate for you?" 4 "Which family member do you prefer to receive information?"

4 "Which family member do you prefer to receive information?"

The nurse is caring for a client who is receiving therapy for vitamin B12 deficiency. Which finding indicates that the therapy is having the desired effect? 1 Normal serum electrolyte levels 2 Healthy skin integrity 3 Resolution of peripheral edema 4 Improved hemoglobin and hematocrit levels

4 Improved hemoglobin and hematocrit levels Vitamin B12 is essential for appropriate maturation of red blood cells; therefore relieving the deficiency is expected to improve hemoglobin and hematocrit (H&H) levels and decrease hypoxia-related problems. This disorder is known as pernicious anemia.

Refusing to follow the prescribed treatment regimen, a client plans to leave the hospital against medical advice. The nurse recognizes that it is important to inform the client that he or she: 1 Is acting irresponsibly. 2 Is violating the hospital policy. 3 Must obtain a new healthcare provider for future medical needs. 4 Must accept full responsibility for possible undesirable outcomes

4 Must accept full responsibility for possible undesirable outcomes

The nurse prepares to give a prescribed capsule of hydroxyzine (Vistaril) to a client. The client begins to vomit so the nurse holds the oral medication. The nurse has not opened the medication package. Proper and safe disposal of the capsule of hydroxyzine requires the nurse to: 1 Drop the capsule into the sharps container 2 Crush the capsule and flush it into the sewer system 3 Place the capsule into a red biohazard bag and tie it shut 4 Return the capsule to the pharmacy

4 Return the capsule to the pharmacy Medication taken from a stock supply cannot be returned; it should be returned to the pharmacy for safe disposal.

A client with a terminal illness reaches the stage of acceptance. How can the nurse best help the client during this stage? 1 Acknowledge the client's crying. 2 Encourage unrestricted family visits. 3 Explain details of the care being given. 4 Stay nearby without initiating conversation

4 Stay nearby without initiating conversation The nurse's presence communicates concern and provides an opportunity for the client to initiate communication; silence is an effective interpersonal technique that permits the client to direct the content and extent of verbalizations without the nurse imposing on the client's privacy.

A pharmacy technician arrives on the nursing unit to deliver opioids and, following hospital protocol, asks the nurse to receive the medications. The nurse is assisting a confused and unsteady client back to the client's room. How should the nurse respond to the technician? 1 "I can't receive them right now. Please wait a few minutes or come back." 2 "Please leave the medications and sign-out sheet in a location where I can see them." 3 "Please bring them to me and I will be sure to put them away in a couple of minutes." 4 "I can't receive them right now. Please give them to the unlicensed assistive personnel (UAP)."

Correct1 "I can't receive them right now. Please wait a few minutes or come back." The transfer of controlled substances from one authorized person to another must occur according to protocol. In this situation the controlled substance must be returned to the pharmacy and delivered at a later time. The controlled substances cannot be left unattended. The nurse cannot delay the securing of controlled substances; if time is not available when the medications are delivered, they must be returned to the pharmacy. The UAP does not have the authority to receive controlled substances.

A nurse applies an ice pack to a client's leg for 20 minutes. The cold application will cause what physiological effect? 1 Local anesthesia 2 Peripheral vasodilation 3 Depression of vital signs 4 Decreased viscosity of blood

1 Local anesthesia Cold reduces the sensitivity of pain receptors in the skin. In addition, local blood vessels constrict, limiting the amount of edema and its related pressure and discomfort. Local blood vessels constrict. Local cold applications do not depress vital signs. Local cold applications do not affect blood viscosity directly.

When performing a postoperative assessment, which parameter would alert the nurse to a common side effect of epidural anesthesia? 1 Decreased blood pressure 2 Increased oral temperature 3 Diminished peripheral pulses 4 Unequal bilateral breath sounds

1 Decreased blood pressure The most important side effect to monitor in a client who has received epidural anesthesia is hypotension due to autonomic nervous system blockade. Therefore, in the immediate postoperative recovery period, the blood pressure should be assessed frequently. Other side effects include bradycardia, nausea, and vomiting. Increased oral temperature and unequal bilateral breath sounds are not effects associated with epidural anesthesia. Diminished peripheral pulses may result from hypotension, although they are not the most common side effects.

The nurse is preparing discharge instructions for a client who was prescribed enalapril maleate (Vasotec) for treatment of hypertension. Which is appropriate for the nurse to include in the client's teaching? 1 Do not change positions suddenly. 2 Light-headedness is a common adverse effect that need not be reported. 3 The medication may cause a sore throat for the first few days. 4 Schedule blood tests weekly for the first 2 months.

1 Do not change positions suddenly. Vasotec (enalapril) is classified as an ACE Inhibitor. ACE stands for angiotensin-converting enzyme. Vasotec is used to treat high blood pressure (hypertension) and congestive heart failure. It can also be used to treat a disorder of the ventricles. Angiotensin is a chemical that causes the arteries to become narrow. ACE inhibitors help the body produce less angiotensin, which helps the blood vessels relax and open up, which, in turn, lowers blood pressure. Clients should be advised to change position slowly to minimize orthostatic hypotension. A healthcare provider should be notified immediately if the client is experiencing light-headedness or feeling like he or she is about to faint, as this is a serious side effect.

A client with a leg prosthesis and a history of syncopal episodes is being admitted to the hospital. When formulating the plan of care for this client, the nurse should include that the client is at risk for: 1 Falls 2 Impaired cognition 3 Imbalanced nutrition 4 Impaired gas exchange

1 Falls The client is at risk for falls related to the leg prosthesis and history of syncope. There is no evidence or contributing factors in the patient scenario of the other nursing problems.

While instructing a community group regarding risk factors for coronary artery disease, the nurse provides a list of risk factors that cannot be modified. What should be included on the list? 1 Heredity 2 Hypertension 3 Cigarette smoking 4 Diabetes mellitus

1 Heredity Heredity refers to genetic makeup and cannot be changed. Cigarette smoking is a lifestyle habit that involves behavior modification. Hypertension and diabetes mellitus are risk factors of coronary artery disease that can be controlled with diet, medication, and exercise.

A nurse is preparing to change a client's dressing. What is the reason for using surgical asepsis during this procedure? 1 Keeps the area free of microorganisms. 2 Confines microorganisms to the surgical site. 3 Protects self from microorganisms in the wound. 4 Reduces the risk for growing opportunistic microorganisms.

1 Keeps the area free of microorganisms. Surgical asepsis means that practices are employed to keep a defined site or objects free of all microorganisms. Confining microorganisms to the surgical site and protecting self from microorganisms in the wound applies to personal protective equipment and medical asepsis. Reducing the risk for growing opportunistic microorganisms applies to medical asepsis.

After gastric surgery a client has a nasogastric tube in place. What should the nurse do when caring for this client? 1 Monitor for signs of electrolyte imbalance. 2 Change the tube at least once every 48 hours. 3 Connect the nasogastric tube to high continuous suction. 4 Assess placement by injecting 10 mL of water into the tube.

1 Monitor for signs of electrolyte imbalance. Gastric secretions, which are electrolyte rich, are lost through the nasogastric tube; the imbalances that result can be life threatening. Changing the nasogastric tube every 48 hours is unnecessary and can damage the suture line. High continuous suction can cause trauma to the suture line. Injecting 10 mL of water into the nasogastric tube to test for placement is unsafe; if respiratory intubation has occurred aspiration will result.

A client being treated for Influenza A (H1N1) is scheduled for a computed tomography (CT) scan. To ensure client and visitor safety during transport, the nurse should take which precaution? 1 Place a surgical mask on the client. 2 Other than Standard Precautions, no additional precautions are needed. 3 Minimize close physical contact. 4 Cover the client's legs with a blanket.

1 Place a surgical mask on the client. Nurses should provide influenza clients with face masks to wear for source control and tissues to contain secretions when outside of their room. Special precautions such as face masks should be taken to decrease the risk of further outbreak.

An emaciated older adult with dementia develops a large pressure ulcer after refusing to change position for extended periods of time. The family blames the nurses and threatens to sue. What is considered when determining the source of blame for the pressure ulcer? 1 The client should have been turned regularly. 2 Older clients frequently develop pressure ulcers. 3 The nurse is not responsible to the client's family. 4 Nurses should respect a client's right not to be moved.

1 The client should have been turned regularly. Clients should change position at least every two hours to prevent pressure ulcers. The nurse should not deviate from this standard of practice because of the cognitively-impaired client's refusal to move. The nurse was negligent for not changing the client's position. Although pressure ulcers may occur, nursing care must include preventive measures. The family is included in the health team. When a capable client refuses necessary health care, the nurse should provide health teaching to promote understanding of the treatment plan. If the client makes an informed decision after an explanation, then the client's rights must be respected; however, this client is cognitively impaired.

An older client who is receiving chemotherapy for cancer has severe nausea and vomiting and becomes dehydrated. The client is admitted to the hospital for rehydration therapy. Which interventions have specific gerontologic implications the nurse must consider? (Select all that apply.) 1 Assessment of skin turgor 2 Documentation of vital signs 3 Assessment of intake and output 4 Administration of antiemetic drugs 5 Replacement of fluid and electrolytes

1 Assessment of skin turgor 4 Administration of antiemetic drugs 5 Replacement of fluid and electrolytes

What is a nurse's responsibility when administering prescribed opioid analgesics? (Select all that apply.) 1 Count the client's respirations. 2 Document the intensity of the client's pain. 3 Withhold the medication if the client reports pruritus. 4 Verify the number of doses in the locked cabinet before administering the prescribed dose. 5 Discard the medication in the client's toilet before leaving the room if the medication is refused.

1 Count the client's respirations. 2 Document the intensity of the client's pain. 4 Verify the number of doses in the locked cabinet before administering the prescribed dose.

A nurse is caring for an older adult with a hearing loss secondary to aging. What can the nurse expect to identify when assessing this client? (Select all that apply.) 1 Dry cerumen 2 Tears in the tympanic membrane 3 Difficulty hearing high-pitched voices 4 Decrease of hair in the auditory canal 5 Overgrowth of the epithelial auditory lining

1 Dry cerumen 3 Difficulty hearing high-pitched voices Cerumen (ear wax) becomes drier and harder as a person ages. Generally, female voices have a higher pitch than male voices; older adults with presbycusis (hearing loss caused by the aging process) have more difficulty hearing higher-pitched sounds. There is no greater incidence of tympanic tears caused by the aging process. The hair in the auditory canal increases, not decreases. The epithelium of the lining of the ear becomes thinner and drier

A client has received instructions to take 650 mg aspirin (ASA) every 6 hours as needed for arthritic pain. What should the nurse include in the client's medication teaching? (Select all that apply.) 1 Take the aspirin with meals or a snack. 2 Make an appointment with a dentist if bleeding gums develop. 3 Do not chew enteric-coated tablets. 4 Switch to Tylenol (acetaminophen) if tinnitus occurs. 5 Report persistent abdominal pain

1 Take the aspirin with meals or a snack 3 Do not chew enteric-coated tablets. 5 Report persistent abdominal pain

A client with rheumatoid arthritis does not want the prescribed cortisone and informs the nurse. Later, the nurse attempts to administer cortisone. When the client asks what the medication is, the nurse gives an evasive answer. The client takes the medication and later discovers that it was cortisone. The client states an intent to sue. What factors in this situation must be considered in a legal action? (Select all that apply.)

1 Clients have a right to refuse treatment. 2 Nurses are required to answer clients truthfully. 3 The health care provider should have been notified.

Filgrastim (Neupogen) 5 mcg/kg/day by injection is prescribed for a client who weighs 132 lb. The vial label reads filgrastim 300 mcg/mL. How many milliliters should the nurse administer? Record the answer using a whole number. ______ mL

1 mL

A client becomes anxious after being scheduled for a colostomy. What is the most effective way for the nurse to help the client? 1 Administer the prescribed as needed (prn) sedative. 2 Encourage the client to express feelings. 3 Explain the postprocedure course of treatment. 4 Reassure the client that there are others with this problem.

2 Encourage the client to express feelings.

A nurse is providing care to a client eight hours after the client had surgery to correct an upper urinary tract obstruction. Which assessment finding should the nurse report to the charge nurse or surgeon? 1 Incisional pain 2 Absent bowel sounds 3 Urine output of 20 mL/hour 4 Serosanguineous drainage on the dressing

3 Urine output of 20 mL/hour A urinary output of 50 mL/hr or greater is necessary to prevent stasis and consequent infections after this type of surgery. The nurse should notify the surgeon of the assessment findings, as this may indicate a urinary tract obstruction.

When suctioning a client with a tracheostomy, an important safety measure for the nurse is to: 1 Hyperventilate the client with room air prior to suctioning. 2 Apply suction only as the catheter is being withdrawn. 3 Insert the catheter until the cough reflex is stimulated. 4 Remove the inner cannula before inserting the suction catheter

2 Apply suction only as the catheter is being withdrawn. Use of suction upon withdrawal of a suction catheter reduces unnecessary removal of oxygen. In addition, suction should be applied intermittently during the withdrawal procedure to prevent hypoxia. A sterile catheter is used to prevent infection, and the catheter should only be inserted approximately 1 to 2 cm past the end of the trach tube to prevent tissue trauma. Hyperventilating a client before suctioning should always be with oxygen, not room air. Inserting the catheter until the cough reflex is stimulated frequently occurs and does help to mobilize secretions but is not a safety measure. Removal of the inner cannula before inserting the suction catheter is not necessary. Topics

A nurse is caring for a client admitted with cardiovascular disease. During the assessment of the client's lower extremities, the nurse notes that the client has thin, shiny skin, decreased hair growth, and thickened toenails. The nurse understands that this may indicate: 1 Venous insufficiency 2 Arterial Insufficiency 3 Phlebitis 4 Lymphedema

2 Arterial Insufficiency Clients suffering from arterial insufficiency present with pale colored extremities when elevated and dusky red colored extremities when lowered. Lower extremities may also be cool to touch, pulses may be absent or mild, and skin may be shiny, thin, with decreased hair growth, and thickened nails. Clients suffering from venous insufficiency often have normal colored extremities, normal temperature, normal pulses, marked edema, and brown pigmentation around ankles. Phlebitis is an inflammation of a vein that occurs most often after trauma to the vessel wall, infection, and immobilization. Lymphedema is swelling in one or more extremities that is a direct result from impaired flow of the lymphatic system.

A client is admitted to the hospital and benazepril hydrochloride (Lotensin) is prescribed for hypertension. Which is an appropriate nursing action for clients taking this medication? 1 Monitor the EEG. 2 Assess for dizziness. 3 Administer the drug after meals. 4 Assess for dark, tarry stools.

2 Assess for dizziness. Dizziness may occur during the first few weeks of therapy until the client adapts physiologically to the medication. An electroencephalogram is unnecessary. Cardiac monitoring may be instituted because of possible dysrhythmias. Administering the drug after meals is unnecessary; however, if nausea occurs, the medication may be taken with food or at bedtime. The blood pressure should be monitored before and after administration. Dark, tarry stools are not a side effect of Lotensin.

Elbow restraints have been prescribed for a confused client to keep the client from pulling out a nasogastric tube and indwelling urinary retention catheter. What is most important for the nurse to do? 1 Have the prescription renewed every 48 hours 2 Assess the client's condition every hour 3 Provide range of motion to the client's elbows every shift 4 Document output from the tube and catheter every two hours

2 Assess the client's condition every hour A restraint impedes the movement of a client; therefore, a client's condition needs to be assessed every hour. All restraints are required to be represcribed every 24 hours. Restraints should be removed and activity and skin care provided at least every two hours to prevent contractures and skin breakdown. Output from tubes may be monitored hourly, but generally do not need to be documented as frequently as every two hours. Generally output from tubes is emptied, measured, and documented at the end of each shift. A client who is in critical condition or in the immediate postoperative period may have urinary output measured hourly because this reflects cardiovascular status.

A client admitted to the hospital with a diagnosis of malabsorption syndrome exhibits signs of tetany. The nurse concludes that the tetany was precipitated by the inadequate absorption of which electrolyte? 1 Sodium 2 Calcium 3 Potassium 4 Phosphorus

2 Calcium The muscle contraction-relaxation cycle requires an adequate serum calcium-phosphorus ratio; the reduction of the ionized serum calcium level associated with malabsorption syndrome causes tetany (spastic muscle spasms).

An adult client presents to the Emergency Department with a nosebleed. After applying pressure, what is the next nursing action? 1 Obtain a medication history from the client 2 Check the blood pressure 3 Instruct the client to avoid picking the nose 4 Check the pulse

2 Check the blood pressure Nosebleeds can be indicative of high blood pressure in an adult. Of the choices provided, the first action of the nurse should be to check the client's blood pressure. If elevated, the nurse can initiate measures to decrease the blood pressure.

The nurse is caring for a client with a closed soft tissue injury. The nurse describes the injury as a/an: 1 Abrasion 2 Contusion 3 Laceration 4 Avulsion

2 Contusion Closed wounds are considered contusions and hematomas because the skin is not broken. Abrasions, lacerations, and avulsions are considered open because there is a break in the skin integrity.

A client with an abdominal wound infected with methicillin-resistant Staphylococcus aureus (MRSA) is scheduled for a computed tomography (CT) scan of the abdomen. To ensure client and visitor safety during transport, the nurse should implement which precaution? 1 No special precautions are required. 2 Cover the infected site with a dressing. 3 Drape the client with a covering labeled as biohazardous. 4 Place a surgical mask on the client.

2 Cover the infected site with a dressing.

The nurse understands that the action of an antidiuretic hormone (ADH) is to: 1 Reduce blood volume. 2 Decrease water loss in urine. 3 Increase urine output. 4 Initiate the thirst mechanism.

2 Decrease water loss in urine. ADH is released by the posterior pituitary gland. It is mainly released in response to a decrease in blood volume, or an increased concentration of sodium or other substances in plasma. It acts to decrease the production of urine by increasing the reabsorption of water by renal tubules. A decrease in ADH would cause reduced blood fluid volume, decreased ability of the kidneys to reabsorb water resulting in increased urine output, and an increase in the thirst mechanism

According to Kübler-Ross, during which stage of grieving are individuals with serious health problems most likely to seek other medical opinions? 1 Anger 2 Denial 3 Bargaining 4 Depression

2 Denial Denial includes feelings that the health care provider has made a mistake, so the client seeks additional opinions.

A client's intravenous (IV) infusion infiltrates. The nurse concludes that what is most likely the cause of the infiltration? 1 Excessive height of the IV bag 2 Failure to secure the catheter adequately 3 Contamination during the catheter insertion 4 Infusion of a chemically irritating medication

2 Failure to secure the catheter adequately Infiltration is caused by catheter displacement, allowing fluid to leak into the tissues. Excessive height of the IV bag will affect the flow rate, not cause infiltration. Contamination during the catheter insertion can lead to infection and phlebitis, not infiltration. Infusion of a chemically irritating medication can lead to phlebitis, not infiltration.

A client reports vomiting and diarrhea for three days. What clinical finding most accurately will indicate that the client has a fluid deficit? 1 Presence of dry skin 2 Loss of body weight 3 Decrease in blood pressure 4 Altered general appearance

2 Loss of body weight Dehydration is measured most readily and accurately by serial assessments of body weight; 1 L of fluid weighs 2.2 lb.

A health care provider prescribes transdermal fentanyl (Duragesic) 25 mcg/hr every 72 hours. During the first 24 hours after starting the fentanyl, what is the most important nursing intervention? 1 Change the dose until pain is tolerable. 2 Manage pain with oral pain medication. 3 Assess the client for anticholinergic side effects. 4 Instruct the client to take the medication with food.

2 Manage pain with oral pain medication.

A pain scale of 1 to 10 is used by a nurse to assess a client's degree of pain. The client rates the pain as an 8 before receiving an analgesic and a 7 after being medicated. What conclusion should the nurse make regarding the client's response to pain medication? 1 Client has a low pain tolerance. 2 Medication is not adequately effective. 3 Medication has sufficiently decreased the pain level. 4 Client needs more education about the use of the pain scale.

2 Medication is not adequately effective. The expected effect should be more than a 1-point decrease in the pain level.

When monitoring fluids and electrolytes, the nurse recalls that the major cation-regulating intracellular osmolarity is: 1 Sodium 2 Potassium 3 Calcium 4 Calcitonin

2 Potassium A decrease in serum potassium causes a decrease in the cell wall pressure gradient and results in water moving out of the cell. Besides intracellular osmolarity regulation, potassium also regulates metabolic activities, transmission and conduction of nerve impulses, cardiac conduction, and smooth and skeletal muscle contraction.

A client who sustained a large open wound as a result of an accident is receiving daily sterile dressing changes. To maintain sterility when changing the dressing, the nurse should: 1 Put the unopened sterile glove package carefully on the sterile field 2 Remove the sterile drape from its package by lifting it by the corners 3 Don sterile gloves before opening the package containing the field drape 4 Pour irrigation liquid from a height of at least three inches above the sterile container

2 Remove the sterile drape from its package by lifting it by the corners The outer one inch of the sterile field is considered contaminated and can be touched without wearing sterile gloves. The outside of an unopened sterile glove package is not sterile. The field will become contaminated if the unopened package is placed on the sterile field. The outer package, which contains a sterile field drape, is not sterile; if it is touched with sterile gloves, the sterile gloves will become contaminated. Liquids should be poured from a height of 4 to 6 inches; this ensures that the solution bottle does not contaminate the sterile container.

A nurse educator is presenting information about the nursing process to a class of nursing students. What definition of the nursing process should be included in the presentation? 1 Procedures used to implement client care. 2 Sequence of steps used to meet the client's needs. 3 Activities employed to identify a client's problem. 4 Mechanisms applied to determine nursing goals for the client.

2 Sequence of steps used to meet the client's needs.

A nurse is caring for a client on bed rest. How can the nurse help prevent a pulmonary embolus? 1 Limit the client's fluid intake. 2 Teach the client how to exercise the legs. 3 Encourage use of the incentive spirometer. 4 Maintain the knee gatch position at an angle

2 Teach the client how to exercise the legs.

A toddler screams and cries noisily after parental visits, disturbing all the other children. When the crying is particularly loud and prolonged, the nurse puts the crib in a separate room and closes the door. The toddler is left there until the crying ceases, a matter of 30 or 45 minutes. Legally, how should this behavior be interpreted? 1 Limits had to be set to control the child's crying. 2 The child had a right to remain in the room with the other children. 3 The child had to be removed because the other children needed to be considered. 4 Segregation of the child for more than half an hour was too long a period of time.

2 The child had a right to remain in the room with the other children. Legally, a person cannot be locked in a room (isolated) unless there is a threat of danger either to the self or to others. Limit setting in this situation is not warranted. This is a reaction to separation from the parent, which is common at this age. Crying, although irritating, will not harm the other children. A child should never be isolated.

A client has undergone a subtotal thyroidectomy. The client is being transferred from the post anesthesia care unit/recovery area to the inpatient nursing unit. What emergency equipment is most important for the nurse to have available for this client? 1 A defibrillator 2 An IV infusion pump 3 A tracheostomy tray 4 An electrocardiogram (ECG) monitor

3 A tracheostomy tray The client who has undergone a subtotal thyroidectomy is at high risk for airway occlusion resulting from postoperative edema. With this in mind, emergency airway equipment such as a tracheostomy set and intubation supplies should be immediately available to the client. A defibrillator, an IV infusion pump, and an electrocardiogram (ECG) monitor are all equipment items that should be available to all postoperative clients.

A client is admitted voluntarily to a psychiatric unit. Later, the client develops severe pain in the right lower quadrant and is diagnosed as having acute appendicitis. How should the nurse prepare the client for the appendectomy? 1 Have two nurses witness the client signing the operative consent form. 2 Ensure that the health care provider and the psychiatrist sign for the surgery because it is an emergency procedure. 3 Ask the client to sign the operative consent form after the client has been informed of the procedure and required care. 4 Inform the client's next of kin that it will be necessary for one of them to sign the consent form because the client is on a psychiatric unit.

3 Ask the client to sign the operative consent form after the client has been informed of the procedure and required care.

The nurse receives a report on a newly admitted client who is positive for Clostridium difficile. Which category of isolation would the nurse implement for this client? 1 Airborne precautions 2 Droplet precautions 3 Contact precautions 4 Protective environment

3 Contact precautions Contact precautions should be used for direct client or environmental contact with blood or body fluids from an infected client. This includes colonization of infection with multidrug-resistant organisms (MDRO) such as MRSA, stool infected with Clostridium difficle, draining wounds where secretions are not contained, or scabies.

Which nursing behavior is an intentional tort? 1 Miscounting gauze pads during a client's surgery. 2 Causing a burn when applying a wet dressing to a client's extremity. 3 Divulging private information about a client's health status to the media. 4 Failing to monitor a client's blood pressure before administering an antihypertensive.

3 Divulging private information about a client's health status to the media.

What effect of povidone-iodine (Betadine) does a nurse consider when using it on the client's skin before obtaining a specimen for a blood culture? 1 Makes the skin more supple 2 Avoids drying the skin as does alcohol 3 Eliminates surface bacteria that may contaminate the culture 4 Provides a cooling agent to diminish the feeling from the puncture wound

3 Eliminates surface bacteria that may contaminate the culture Povidone-iodine exerts bactericidal action that helps eliminate surface bacteria that will contaminate culture results

The nurse reviews a medical record and is concerned that the client may develop hyperkalemia. Which disease increases the risk of hyperkalemia? 1 Crohn's 2 Cushing's 3 End-stage renal 4 Gastroesophageal reflux

3 End-stage renal One of the kidneys' functions is to eliminate potassium from the body; diseases of the kidneys often interfere with this function, and hyperkalemia may develop, necessitating dialysis.

A primary nurse receives prescriptions for a newly admitted client and has difficulty reading the health care provider's writing. Who should the nurse ask for clarification of this prescription? 1 Nurse practitioner 2 House health care provider that is on-call 3 Health care provider who wrote the prescription 4 Nurse manager familiar with the health care provider's writing

3 Health care provider who wrote the prescription

To minimize the side effects of the vincristine (Oncovin) that a client is receiving, what type of dietary plan does the nurse expect? 1 Low in fat 2 High in iron 3 High in fluids 4 Low in residue

3 High in fluids

A nurse identifies that an older adult has not achieved the desired outcome from a prescribed proprietary medication. When assessing the situation, the client shares that the medication is too expensive and the prescription was never filled. What is an appropriate nursing response? 1 Ask the pharmacist to provide a generic form of the medication. 2 Encourage the client to acquire the medication over the internet. 3 Inform the health care provider of the inability to afford the medication. 4 Suggest that the client purchase insurance that covers prescription medications.

3 Inform the health care provider of the inability to afford the medication.

An assessment of the client on total parenteral nutrition (TPN) reveals a bounding pulse, distended jugular veins, dyspnea, and cough. What is the priority nursing intervention? 1 Ask the registered nurse start the client's infusion at a peripheral site 2 Slow the rate of the client's infusion of the TPN 3 Interrupt the client's infusion and notify the charge nurse or health care provider 4 Obtain the vital signs and continue monitoring the client's status

3 Interrupt the client's infusion and notify the charge nurse or health care provider The client is experiencing pulmonary edema because of a fluid volume excess. The high concentration of TPN precipitates a fluid shift from the interstitial compartment into the intravascular compartment. Fluid will continue to be infused, which will continue to increase the intravascular volume. TPN is not infused in a peripheral IV and the rate is not to be changed by the LPN, especially without a health care provider's order.

The nurse is caring for a client who is on a low carbohydrate diet. With this diet, there is decreased glucose available for energy, and fat is metabolized for energy resulting in an increased production of which substance in the urine? 1 Protein 2 Glucose 3 Ketones 4 Uric acid

3 Ketones As a result of fat metabolism, ketone bodies are formed and the kidneys attempt to decrease the excess by filtration and excretion. Excessive ketones in the blood can cause metabolic acidosis. A low carbohydrate diet does not cause increased protein, glucose, or uric acid in the urine.

A client is placed on a stretcher and restrained with straps while being transported to the x-ray department. A strap breaks, and the client falls to the floor, sustaining a fractured arm. Later the client shows the strap to the nurse manager, stating, "See, the strap is worn just at the spot where it snapped." What is the nurse's accountability regarding this incident? 1 Exempt from any lawsuit because of the doctrine of respondeat superior 2 Totally responsible for the obvious negligence because of failure to report defective equipment 3 Liable, along with the employer, for misapplication of equipment or use of defective equipment that harms the client 4 Exonerated, because only the hospital, as principal employer, is responsible for the quality and maintenance of equipment

3 Liable, along with the employer, for misapplication of equipment or use of defective equipment that harms the client

A client with respiratory difficulties asks why the percussion procedure is being performed. The nurse explains that the primary purpose of percussion is to: 1 Relieve bronchial spasm. 2 Increase depth of respirations. 3 Loosen pulmonary secretions. 4 Expel carbon dioxide from the lungs.

3 Loosen pulmonary secretions. Percussion (chest physiotherapy) loosens pulmonary secretions by mechanical means. This is accomplished by vibrations over the lung fields on the client's posterior, anterior, and lateral chest. Percussion does not relieve bronchial spasms. Once pulmonary secretions are loosened by percussion and the client has a clearer airway, the depth of respirations may increase and facilitate removal of carbon dioxide from the lungs.

A nurse is helping a client who observes the traditional Jewish dietary laws to prepare a dietary menu. What considerations should the nurse make? 1 Eating beef and veal is prohibited. 2 Consumption of fish with scales is forbidden. 3 Meat and milk at the same meal are forbidden. 4 Consuming alcohol, coffee, and tea are prohibite

3 Meat and milk at the same meal are forbidden. Jewish dietary laws prohibit any combination of milk and meat at the same meal. The Hindu, not Jewish, religion prohibits the ingestion of beef and veal; many Hindus believe that the cow is sacred. Fish that have scales and fins are considered clean, and therefore allowed in the diet. Seventh Day Adventists, Baptists, Mormons, and Muslims prohibit some or all of these beverages.

A client has been admitted with a urinary tract infection. The nurse receives a urine culture and sensitivity report that reveals the client has Vancomycin Resistant Enterococcus (VRE). After notifying the physician, which action should the nurse take to decrease the risk of transmission to others? 1 Insert a urinary catheter. 2 Initiate Droplet Precautions. 3 Move the client to a private room. 4 Use a high efficiency particulate air (HEPA) respirator during care.

3 Move the client to a private room.

The nurse caring for a client with a systemic infection is aware that the assessment finding that is most indicative of a systemic infection is: 1 White blood cell (WBC) count of 8200/mm3 2 Bilateral 3+ pitting pedal edema 3 Oral temperature of 101.3º F 4 Pale skin and nail beds

3 Oral temperature of 101.3º F An elevated temperature of 101.3° F is most indicative of a systemic infection. A white blood cell (WBC) count of 8200/mm3 is within the WBC normal range of 5000-10,000/mm3. Pedal edema is generally not related to an infectious process. Pale skin and nail beds may be related to an infectious process but not necessarily.

A client is admitted with metabolic acidosis. The nurse considers that two body systems interact with the bicarbonate buffer system to preserve healthy body fluid pH. What two body systems should the nurse assess for compensatory changes? 1 Skeletal and nervous 2 Circulatory and urinary 3 Respiratory and urinary 4 Muscular and endocrine

3 Respiratory and urinary Increased respirations blow off carbon dioxide (CO2 ), which decreases the hydrogen ion concentration and the pH increases (less acidity). Decreased respirations result in CO2 buildup, which increases hydrogen ion concentration and the pH falls (more acidity). The kidneys either conserve or excrete bicarbonate and hydrogen ions, which helps to adjust the body's pH . The buffering capacity of the renal system is greater than that of the pulmonary system, but the pulmonary system is quicker to respond.

When nurses are conducting health assessment interviews with older clients, they should: 1 Leave a written questionnaire for clients to complete at their leisure 2 Ask family members rather than the client to supply the necessary information 3 Spend time in several short sessions to elicit more complete information from the clients 4 Keep referring to previous questions to ascertain that the information given by clients is correct

3 Spend time in several short sessions to elicit more complete information from the clients Spending time in several short sessions reduces client fatigue and compensates for a shortened attention span, which is common in the older adult. The questionnaire may never be completed if it is left for the client to complete at his or her leisure. Asking family members rather than the client to supply the necessary information is degrading to the client; the client should be asked initially and, if necessary, family can be asked to fill in details later. Constantly referring to previous questions may be overwhelming and create feelings of anger and resentment.

A client receiving intravenous vancomycin (Vancocin) reports ringing in both ears. Which initial action should the nurse take? 1 Notify the primary healthcare provider. 2 Consult an audiologist. 3 Stop the infusion. 4 Document the finding and continue to monitor the client.

3 Stop the infusion.

A client comes to the clinic complaining of a productive cough with copious yellow sputum, fever, and chills for the past two days. The first thing the nurse should do when caring for this client is to: 1 Encourage fluids 2 Administer oxygen 3 Take the temperature 4 Collect a sputum specimen

3 Take the temperature Baseline vital signs are extremely important; physical assessment precedes diagnostic measures and intervention. This is done after the health care provider makes a medical diagnosis; this is not an independent function of the nurse. Encouraging fluids might be done after it is determined whether a specimen for blood gases is needed; this is not usually an independent function of the nurse. Oxygen is administered independently by the nurse only in an emergency situation. A sputum specimen should be obtained after vital signs and before administration of antibiotics.

A client has been instructed to stop smoking. The nurse discovers a pack of cigarettes in the client's bathrobe. What is the nurse's initial action? 1 Notify the health care provider. 2 Report this to the nurse manager. 3 Tell the client that the cigarettes were found. 4 Discard the cigarettes without commenting to the client

3 Tell the client that the cigarettes were found.

A nurse is teaching staff members about the legal terminology used in child abuse. What definition of battery should the nurse include in the teaching? 1 Maligning a person's character while threatening to do bodily harm. 2 A legal wrong committed by one person against property of another. 3 The application of force to another person without lawful justification. 4 Behaving in a way that a reasonable person with the same education would not.

3 The application of force to another person without lawful justification. Battery means touching in an offensive manner or actually injuring another person. Battery refers to actual bodily harm rather than threats of physical or psychological harm. Battery refers to harm against persons instead of property. Behaving in a way that a reasonable person with the same education would not is the definition of negligence.

A client has been diagnosed with type 1 Diabetes Mellitus. When providing instructions on sharps disposal, the nurse should instruct the client to place the syringes in: 1 Bubble wrap/packaging wrap 2 A garbage bag in the trash can 3 A cardboard box with a firmly secured lid 4 A plastic liquid detergent bottle with a screw-top lid

4 A plastic liquid detergent bottle with a screw-top lid

hen planning discharge teaching for a young adult, the nurse should include the potential health problems common in this age group. What should the nurse include in this teaching plan? 1 Kidney dysfunction 2 Cardiovascular diseases 3 Eye problems, such as glaucoma 4 Accidents, including their prevention

4 Accidents, including their prevention

Which of the following legal defenses is the most important for a nurse to develop? 1 Dedication 2 Certification 3 Assertiveness 4 Accountability

4 Accountability The concept of accountability is of high priority in nursing practice. As a licensed professional, the nurse is always accountable, which means liable and answerable for his or her actions.

The nurse providing post-procedure care to a client who had a cardiac catheterization through the femoral artery discovers a large amount of blood under the client's buttocks. After donning gloves, which action should the nurse take first? 1 Apply pressure to the site. 2 Obtain vital signs. 3 Change the client's gown and bed linens. 4 Assess the catheterization site.

4 Assess the catheterization site. Observing standard precautions is the first priority when dealing with any body fluid, followed by assessment of the catheterization site as the second priority. This action establishes the source of the blood and determines how much blood has been lost. Once the source of the bleeding is determined the priority goal for this client is to stop the bleeding and ensure stability of the client by monitoring the vital signs.

A terminally ill client is furious with one of the staff nurses. The client refuses the nurse's care and insists on doing self-care. A different nurse is assigned to care for the client. What should be the newly assigned nurse's initial step in revising the client's plan of care? 1 Get a full report from the first nurse and adjust the plan accordingly. 2 Ask the health care provider for a report on the client's condition and plan appropriately. 3 Tell the client about the change in staff responsibilities and assess the client's reaction. 4 Assess the client's present status and include the client in a discussion of revisions to the plan of care

4 Assess the client's present status and include the client in a discussion of revisions to the plan of care

A nurse working in an emergency department is concerned about a recent increase in malpractice claims against nurses. What is the best way for the nurse to avoid being named in a lawsuit? 1 Carry malpractice insurance. 2 Write vague incident reports. 3 Transfer to another department. 4 Attend professional development programs.

4 Attend professional development programs. The best ways to prevent professional negligence (malpractice) are to attend continuing education programs and improve practice; additional education is advisable when one is working in specialty areas, such as emergency departments or intensive care areas.

A client is being discharged from the hospital with an indwelling urinary catheter. The client asks about the best way to prevent infection and keep the catheter clean. Which would be appropriate for the nurse to include in the client teaching? 1 Once a day, clean the tubing with a mild soap and water, starting at the drainage bag and moving toward the insertion site. 2 After cleaning the catheter site, it is important to keep the foreskin pushed back for 30 minutes to ensure adequate drying. 3 Clean the insertion site daily using a solution of one part vinegar to two parts water. 4 Change the drainage bag at least once a week as needed.

4 Change the drainage bag at least once a week as needed.

While assessing an immobilized client, the nurse notes that the client has shortened muscles over a joint, preventing full extension. This condition is known as: 1 Osteoarthritis 2 Osteoporosis 3 Muscle atrophy 4 Contracture

4 Contracture

After abdominal surgery a client reports pain. What action should the nurse take first? 1 Reposition the client. 2 Obtain the client's vital signs. 3 Administer the prescribed analgesic. 4 Determine the characteristics of the pain.

4 Determine the characteristics of the pain. The exact nature of the pain must be determined to distinguish whether or not it is a result of the surgery. Repositioning the client, obtaining the client's vital signs, and administering the prescribed analgesic should be done later; the first action is to determine the cause of the pain.

What should the nurse do initially when obtaining consent for surgery? 1 Describe the risks involved in the surgery. 2 Explain that obtaining the signature is routine for any surgery. 3 Witness the client's signature, which the nurse's signature will document. 4 Determine whether the client's knowledge level is sufficient to give consent

4 Determine whether the client's knowledge level is sufficient to give consent

A nurse in the health clinic is counseling a college student who recently was diagnosed with asthma. On what aspect of care should the nurse focus? 1 Teaching how to make a room allergy-free. 2 Referring to a support group for individuals with asthma. 3 Arranging with the college to ensure a speedy return to classes. 4 Evaluating whether the necessary lifestyle changes are understood

4 Evaluating whether the necessary lifestyle changes are understood

The nurse is teaching a client about adequate hand hygiene. What component of hand washing should the nurse include that is most important for removing microorganisms? 1 Soap 2 Time 3 Water 4 Friction

4 Friction

Which action by a home care nurse would be considered an act of euthanasia? 1 Implementing a "do not resuscitate" order in the home health setting. 2 Abiding by the decision of a living will signed by the client's family. 3 Encouraging a client to consult an attorney to document and assign a power of attorney. 4 Knowing that a dying client is overmedicating and not acting on this information.

4 Knowing that a dying client is overmedicating and not acting on this information. In this situation being aware that a client is overmedicating and taking no action can be considered an act of euthanasia on the part of the home care nurse. Implementing a "do not resuscitate" order, abiding by the decision of a living will signed by the client's family, and encouraging the client to consult an attorney are all appropriate actions for a home care nurse.

A health care provider prescribes famotidine (Pepcid) and magnesium hydroxide/aluminum hydroxide (Maalox) for a client with a peptic ulcer. The nurse should teach the client to take the Maalox at what time? 1 Only at bedtime, when famotidine is not taken. 2 Only if famotidine is ineffective. 3 At the same time as famotidine, with a full glass or water. 4 One hour before or two hours after famotidine

4 One hour before or two hours after famotidine Antacids interfere with complete absorption of famotidine; therefore, antacids should be administered at least one hour before or two hours after famotidine. Magnesium hydroxide/aluminum hydroxide usually is taken one hour after meals and at bedtime. Famotidine usually is prescribed once a day at bedtime. The client has received a prescription for both medications; the client should not be instructed to omit one of the medications without checking with the health care provider first.

A nurse is reviewing a plan of care for a client who was admitted with dehydration as a result of prolonged watery diarrhea. Which prescription should the nurse question? 1 Oral psyllium (Metamucil) 2 Oral potassium supplement 3 Parenteral half normal 4 Parenteral albumin (Albuminar)

4 Parenteral albumin (Albuminar) Albumin is hypertonic and will draw additional fluid from the tissues into the intravascular space. Oral psyllium will absorb the watery diarrhea, giving more bulk to the stool. An oral potassium supplement is appropriate because diarrhea causes potassium loss. Parenteral half normal saline is a hypotonic solution, which can correct dehydration.

A nurse is reviewing a plan of care for a client who was admitted with dehydration as a result of prolonged watery diarrhea. Which prescription should the nurse question? 1 Oral psyllium (Metamucil) 2 Oral potassium supplement 3 Parenteral half normal saline 4 Parenteral albumin (Albuminar)

4 Parenteral albumin (Albuminar) Albumin is hypertonic and will draw additional fluid from the tissues into the intravascular space. Oral psyllium will absorb the watery diarrhea, giving more bulk to the stool. An oral potassium supplement is appropriate because diarrhea causes potassium loss. Parenteral half normal saline is a hypotonic solution, which can correct dehydration.

A nurse manager works on a unit where the nursing staff members are uncomfortable taking care of clients from cultures that are different from their own. How should the nurse manager address this situation? 1 Assign articles about various cultures so that they can become more knowledgeable. 2 Relocate the nurses to units where they will not have to care for clients from a variety of cultures. 3 Rotate the nurses' assignments so they have an equal opportunity to care for clients from other cultures. 4 Plan a workshop that offers opportunities to learn about the cultures they might encounter while at work.

4 Plan a workshop that offers opportunities to learn about the cultures they might encounter while at work.

A nurse must establish and maintain an airway in a client who has experienced a near-drowning in the ocean. For which potential danger should the nurse assess the client? 1 Alkalosis 2 Renal failure 3 Hypervolemia 4 Pulmonary edema

4 Pulmonary edema Additional fluid from surrounding tissues will be drawn into the lung because of the high osmotic pressure exerted by the salt content of the aspirated ocean water; this results in pulmonary edema. Hypoxia and acidosis may occur after a near-drowning. Renal failure is not a sequela of near-drowning. Hypovolemia occurs because fluid is drawn into the lungs by the hypertonic saltwater.

After several weeks of caring for clients who are in the terminal stage of illness, the nurse becomes aware of feeling depressed when coming to work. What should the nurse do? 1 Talk with other nurses on the unit. 2 Take several personal days off from work. 3 Limit emotional involvement with the clients. 4 Request a transfer to another area of the hospital.

Correct1 Talk with other nurses on the unit. Talking with nurses who cope with similar issues allows the nurse to share feelings and obtain constructive emotional support. Avoidance may provide an immediate solution, but it works only for a short time. The nurse will eventually have to work through feelings. Limiting emotional involvement with the clients avoids personal feelings about death and dying and is an unacceptable attitude when caring for dying clients. Emotional withdrawal may be perceived by the clients as rejection. Avoidance may provide an immediate solution, but it works only for a short time. The nurse will eventually have to work through feelings.

A 2-year-old child admitted with a diagnosis of pneumonia was administered antibiotics, fluids, and oxygen. The child's temperature increased until it reached 103° F. When notified, the health care provider determined that there was no need to change treatment, even though the child had a history of febrile seizures. Although concerned, the nurse took no further action. Later, the child had a seizure that resulted in neurological impairment. Legally, who is responsible for the child's injury? 1 Health care provider, because this decision took precedence over the nurse's concern 2 Health care provider, because of total responsibility for the child's health and treatment regimen 3 Nurse, because failure to further question the health care provider about the child's status placed the child at risk 4 Neither, because high fevers are common in children and the health care provider had little cause for concern

Nurse, because failure to further question the health care provider about the child's status placed the child at risk It is the nurse's responsibility to foresee potential harm and prevent risks by acting as a client advocate. This is not acceptable as a rationale for inaction. The nurse and health care provider share interdependent roles in the assessment and care of clients. High temperatures are common in children but are nonetheless a valid cause for concern.