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16. A nurse is responding to a parent's question about his infant's expected physical development during the first year of life. Which of the following information should the nurse include?

A 10-month-old infant can pull up to a standing position. Rationale: An 8 to 10-month-old infant can pull himself to a standing position.

9. A nurse is explaining the use of written consent forms to a newly-licensed nurse. The nurse should ensure that a written consent form has been signed by which of the following clients?

A client who has a prescription for a transfusion of packed red blood cells Rationale: Administration of blood is a procedure that carries risk; therefore, the client must sign a consent form prior to the procedure.

27. A nurse is applying an ice bag to the ankle of a client following a sports injury. Which of the following actions should the nurse take?

Fill the bag two-thirds full with ice. Rationale: The nurse should fill the bag two-thirds full with ice, which makes it possible to mold the bag around the client's ankle.

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

Gelatin Rationale: Foods allowed on a clear liquid diet are those that are clear and liquid at room temperature.

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

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

50. A nurse on a telemetry unit is caring for a client who had a myocardial infarction. The client states "All this equipment is making me nervous." Which of the following responses should the nurse make?

"All of this equipment can be frightening." Rationale: This statement is therapeutic because the nurse is reflecting the client's statement. The client is feeling fearful, and this response shows that the nurse understands those feelings, which will encourage the client to communicate more.

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

"I can see that this is upsetting you." Rationale: The nurse is using the therapeutic communication techniques of reflecting and restating, which encourages communication by the client.

14. A nurse is teaching a client who has lower extremity weakness how to use a four-point crutch gait. Which of the following instructions should the nurse include in the teaching?

"Bear weight on both of your legs." Rationale: The client has three points on the ground at all times. Therefore, he must be able to bear weight on both legs.

32. A nurse on a surgical unit is receiving a client who had abdominal surgery from the postanesthesia care unit. Which of the following assessments should the nurse make first?

Airway Rationale: The nurse should apply the ABC priority-setting framework when caring for this client. This framework emphasizes the basic core of human functioning and prioritizes having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these can indicate a threat to life. Therefore, this is the nurse's priority concern. When applying the ABC priority-setting framework, airway is always the highest priority because the airway must be clear and open for oxygen exchange to occur. Breathing is the second highest priority in the ABC priority-setting framework because adequate ventilatory effort is essential in order for oxygen exchange to occur. Circulation is the third highest priority in the ABC priority-setting framework because delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them; therefore, the nurse should first assess the client's airway.

11. A nurse in a provider's office is assessing a client who has heart failure. The client has gained weight since her last visit and her ankles are edematous. Which of the following findings by the nurse is another clinical manifestation of fluid volume excess?

Bounding pulse Rationale: Bounding pulse is an expected finding of fluid volume excess.

39. A nurse is caring for a client who has a terminal illness. Which of the following findings indicates that the client's death is imminent?

Cold extremities Rationale: Cold extremities, first in the feet and then in the hands, are a physical change that occurs when a client's death is imminent.

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

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

21. A nurse is teaching a client who is postoperative how to use a flow-oriented incentive spirometer. Which of the following instructions should the nurse include?

Cough deeply after each use. Rationale: Proper use of the incentive spirometer loosens secretions in the client's lungs. The client should cough deeply to facilitate removal of secretions from his lungs.

7. A nurse is caring for a client who has acute renal failure. Which of the following assessments provides the most accurate measure of the client's fluid status?

Daily weight Rationale: According to the evidence-based priority-setting framework, daily weight provides important information about the client's fluid status. A gain or loss of 1 kg (2.2 lb) indicates a gain or loss of 1 liter of fluid; therefore, weighing the client daily will provide the nurse with the most accurate fluid status measurement.

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

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

5. A nurse is caring for a client who is receiving IV therapy via a peripheral catheter. The nurse should identify that which of the following findings is an indication of infiltration?

Edema at the infusion site Rationale: Edema due to fluid entering subcutaneous tissue is an indication of infiltration.

3. A home health nurse is planning to provide health promotion activities for a group of clients in the community. Which of the following activities is an example of the nurse promoting primary prevention?

Educating clients about the recommended immunization schedule for adults Rationale: Primary prevention includes health education about disease prevention.

45. A nurse is called away for an emergency while conversing with a client who is concerned about his medical diagnosis. The nurse returns to the client promptly, as promised. Which of the following ethical principles is the nurse demonstrating?

Fidelity Rationale: The nurse is demonstrating the ethical principle of fidelity by keeping a promise that was made.

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

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

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

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

34. A nurse is cqaring for a client who has a fecal impaction. Before digital removal of the mass, which of the following types of enemas should the nurse plan to administer to soften the feces?

Oil retention Rationale: The nurse should administer an oil retention enema prior to removal of a fecal impaction to soften the stool. This makes the procedure less painful for the client.

15. A nurse is planning to document care provided for a client. Which of the following abbreviations should the nurse use?

PC for after meals Rationale: The nurse can use this abbreviation. It is an approved, not an error prone, abbreviation.

36. A nurse is reviewing the correct use of a fire extinguisher with a client. Which of the following actions should the nurse direct the client to take first?

Remove the safety pin from the extinguisher. Rationale: Evidenced-based practice indicates removing the safety pin from the extinguisher is the first action to take when using a fire extinguisher; therefore, this is the action the nurse should instruct the client to take first.

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

Repeat each joint motion five times during each session. Rationale: To maintain the client's joint mobility the nurse should repeat each motion three to five times.

24. A nurse is performing a neurological assessment for a client. Which of the following examinations should the nurse use to check the client's balance?

Romberg test Rationale: When using the Romberg test, the nurse instructs the client to stand with his feet together and arms at sides, first with his eyes open and then with eyes closed. The inability to maintain balance is a positive Romberg test.

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

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

46. A nurse in the emergency department is caring for a client who has abdominal trauma. Which of the following assessment findings should the nurse identify as an indication of hypovolemic shock?

Tachycardia Rationale: Due to the decrease in circulating blood volume that occurs with internal bleeding, the oxygen-carrying capacity of the blood is reduced. The body attempts to relieve the hypoxia by increasing the heart rate and cardiac output, along with increasing the respiratory rate.

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

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

33. A nurse is caring for a client who has a prescription for a vest restraint. Which of the following actions should the nurse take?

Tie the restraint with a quick-release knot. Rationale: The nurse should use a quick-release knot that can be untied easily in case the client's well-being requires quickly removing the restraints.

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

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

44. A nurse is planning care for a client who has a single-lumen nasogastric (NG) tube for gastric decompression. Which of the following actions should the nurse include in the plan of care? (Select all that apply.)

-Provide oral hygiene frequently. -Measure the amount of drainage from the NG tube every shift. -Secure the NG tube to the client's gown. Rationale: -Provide oral hygiene frequently is correct. Frequent oral hygiene provides comfort for the client since mucous membranes easily become dry and uncomfortable when a client cannot drink fluids. -Measure the drainage from the NG tube every shift is correct. Measuring the drainage at least every shift helps the provider to calculate fluid loss and prescribe appropriate replacement therapy. -Secure the NG tube to the client's gown is correct. An unsecured NG tube can irritate the nares if the tube is pulled or caught on the bed or other equipment. The tube can also be dislodged if not secured appropriately.

4. A nurse is using the I-SBAR communication tool to provide the client's provider with information about the client. The nurse should convey the client's pain status in which portion of the report?

Assessment Rationale: The nurse provides information about assessment findings in this portion of the report. This includes vital signs, pain assessment, and changes in assessment findings.

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

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

38. A nurse is planning care for a client who is postoperative and has a history of poor nutritional intake. Which of the following actions should the nurse include in the plan of care to promote wound healing?

Provide a protein intake of 1.5 g/kg of body weight per day. Rationale: A protein intake of 1 to 1.5 g/kg of body weight per day is necessary to maintain a positive nitrogen balance, which promotes wound healing.

10. A nurse in a long-term care facility is admitting a client who is incontinent and smells strongly of urine. His partner, who has been caring for him at home, is embarrassed and apologizes for the smell. Which of the following responses should the nurse make?

"It must be difficult to care for someone who is confined to bed." Rationale: This response addresses the feelings of the partner by reflecting on her feelings. It facilitates therapeutic communication because it is nonjudgmental and encourages the partner to express her feelings.

48. An adolescent client in an outpatient mental health facility tells the nurse that it is hard to follow his treatment plans because his friends discourage him. Which of the following statements should the nurse make?

"Tell me more about how your friends discourage you." Rationale: The nurse should ask an open-ended question that encourages the client to elaborate about the problems that he is having.

12. A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following actions should the nurse take first after discovering that the client's wound has eviscerated?

Cover the incision with a moist sterile dressing. Rationale: The nurse should apply the safety and risk reduction priority-setting framework when caring for this client. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. An open wound places the client at risk for peritonitis, and any exposed organ tissue could dry out. Therefore, covering the wound with a moist sterile dressing is the first action the nurse should take to protect the client.

40. A nurse is caring for a client who is receiving a blood transfusion. The client reports flank pain and the nurse notes reddish-brown urine in the client's urinary catheter bag. The nurse recognizes these manifestations as which of the following types of transfusion reactions?

Hemolytic Rationale: A hemolytic reaction occurs when the client's blood is incompatible with the donor's blood. Chills, low back pain, hypotension, and tachycardia are indications of a hemolytic transfusion reaction.

29. A nurse is caring for a client who is 48 hr postoperative following a small bowel resection. The client reports gas pains in the periumbilical area. The nurse should plan care based on which of the following factors contributing to this postoperative complication?

Impaired peristalsis of the intestines Rationale: Normal bowel function is delayed for up to several days following a bowel resection. When peristalsis is absent or sluggish, intestinal gas builds up, producing pain and abdominal distention. The nurse should plan to assist the client to ambulate to promote peristalsis.

8. A nurse is planning to assess the abdomen of a client who reports feeling bloated for several weeks. Which of the following methods of assessment should the nurse use first?

Inspection Rationale: According to evidence-based practice, the nurse should inspect the abdomen first by observing the contour of the abdomen, the condition of the skin, and the position of the umbilicus. Findings from this step of assessment are used by the nurse in the subsequent steps.

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

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

35. A nurse is providing education about cultural and religious traditions and rituals related to death for the assistive personnel on the unit. Which of the following information should the nurse include?

People who practice Judaism stay with the body of the deceased until burial. Rationale: In the Jewish faith, a family member often stays with the body until burial occurs.

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

Place the client in Trendelenburg's position. Rationale: The nurse should place the client in right side lying position in Trendelenburg's position to promote drainage from the client's left lower lobe.

19. A nurse is providing oral care for a client who is unconscious. Which of the following actions should the nurse take?

Place the client in a lateral position with the head turned to the side before beginning the procedure. Rationale: The nurse should place the client in a lateral position with the head turned to the side to reduce the risk of aspiration of fluids and secretions.

28. A client is being discharged home with oxygen therapy via a nasal cannula. Which of the following instructions should the nurse provide to the client and family?

Wear cotton clothing to avoid static electricity. Rationale: The use of cotton clothing will limit the buildup of static electricity. Oxygen is a highly combustible gas. The use of oxygen in high concentrations has great combustion potential and readily fuels fire. Although it will not spontaneously burn or cause an explosion, it can easily cause a fire in a client's room if it contacts a spark.

25. A nurse in a provider's office is reviewing the laboratory findings of a client who reports chills and aching joints. The nurse should identify which of the following findings as an indication that the client has an infection?

WBC 15,000 mm3 Rationale: This finding is above the expected reference range and is an indication of infection.

6. A nurse is providing discharge teaching to a client who is recovering from lung cancer. The provider instructed the client that he could resume lower-intensity activities of daily living. Which of the following activities should the nurse recommend to the client?

Washing dishes Rationale: Washing dishes requires a low level of activity and is appropriate for this client.

43. A nurse is caring for a client who has Clostridium difficile and is in contact isolation. Which of the following actions should the nurse take?

Wear gloves when changing the client's gown. Rationale: The nurse should wear gloves when handling articles that have the potential to contaminate the hands when caring for a client who is in contact isolation.

49. A nurse is reviewing measures to prevent back injuries with assistive personnel (AP). Which of the following instructions should the nurse include?

When lifting an object, spread your feet apart to provide a wide base of support. Rationale: The AP should spread his feet apart because a wide base of support increases stability.