Foundations of Care

The primary health care provider prescribes atenolol 0.05 gm orally daily. The label on the medication bottle states atenolol 25-mg tablets. How many tablets will the nurse safely administer to the client?

0.05 gm = 50 mg ---> 50 mg/25 mg = 2 tablets

The primary health care provider prescribes 1000 mL of NS to be infused over a period of 10 hours. The drop factor is 15 drops per 1 mL. The nurse adjusts the flow rate so that the solution will infuse safely as how many drops per minute?

1000 mL/10 hr x 15 gtt/1 mL x 1 hr/60 min ---> 25 gtt/min

The primary health care provider's prescription reads cyanocobalamin 150 mcg intramuscularly. The medication labels read cyanocobalamin 100 mcg/1 mL. the nurse prepared to safely administer how many milliliters to the client?

150 mcg x 1 mL/100 mcg = 1.5 mL

Ampicillin sodium 250 mg in 500 mL of NS is being administered over a period of 30 minutes. The drop factor is 10 drops per 1 mL. The nurse determines that the infusion is running safely at the prescribed rate if the infusion is delivering how many drops per minute. (Round to the nearest whole number)

17 gtt/min 50 mL / 30 min x 10 drops / 1 mL --> 500 drops / 30 mins --> 16.6 drops/mins --> 17 drops per minute

The primary health care provider prescribes meperidine hydrochloride 20 mg for a client in pain. The medication label states meperidine hydrochloride 50 mg/1mL. How many milliliters should the nurse safely prepare to administer to the client?

20 mg x 1 mL/50 mL --> 0.4 mL

The primary health care provider prescribes a bolus of 500 mL of 0.9% NS to run over 4 hours. The drop factor is 10 drops per 1 mL. The nurse plants to safely adjust the flow rate at how many drops (gtt) per minute? Round to the nearest whole number.

21 gtt/min 500 mL / 4 hr x 1 hr / 60 min x 10 gtt/1 mL --> 5,000 gtt / 240 min --> 20.8 gtt/min --> 21 gtt/min

The primary health care provider's prescription reads ampicillin 250 mg to be administered orally. The label on the medication vial read 125 mg/mL. The nurse should prepare how may milliliters of ampicillin to administer the correct dose of medication?

250 mg x 1 ml/125 mg --> 2 mL

The primary health care provider prescribes 1000 mL of 0.9% NS to run over 8 hours. The drop factor is 15 drops (gtt) per 1 mL. The nurse safely adjusts the flow rate to run at how many drops per minute. Round to the nearest whole number.

31 gtt/min 1000 mL / 8 hr x 1 hr/60 mins x 15 gtt / 1 mL --> 15,000 gtt / 480 mins --> 31.25 gtt/min --> 31 gtt/min

The nurse is reviewing prescriptions for an adult client who has been admitted to the hospital following a back injury. Carisoprodol is prescribed for the client to relieve the muscle spasms and the prescription reads 350 mg to be administered every 6 hours. The nurse determines that this dosage would deliver how many milligrams in 24 hours?

350 mg/6 hr x 24 hr --> 1400 mg

The primary health care provider prescribes 500 mL of 0.9% NS to run over 66 hours. The drop factor is 10 drops per 1 mL. The nurse safely adjusts the flow rate to run ar how many drops per minute? (Round to the nearest whole number).

500 mL/6 hr x 1 hr/60 mins x 10 gtt/1 mL --> 5000 gtt/360 min --> 13.8 gtt/min --> 14 gtt/min

The primary health care provider prescribes amoxicillin 500 mg orally every 6 hours. The medication is supplied as 200 mg/5 mL. How many milliliters will be administered in each dose?

500 mg x 5 mL/200 mg = 12.5 mL

The nurse educator is conducting a teaching session on the types of dehydration. The nurse describes one type as water and dissolved electrolytes being lost in equal proportions. Which type of dehydration is being described? A. Isotonic C. Hypertonic B. Hypotonic D. Intracellular

A Isotonic dehydration is described as water and dissolved electrolytes being lost in equal proportions Hypotonic dehydration is electrolyte loss exceeds water loss. Hypertonic dehydration is water loss exceeds electrolyte loss

The nurse is performing closed urinary catheter irrigation on an assigned client. Which outcome indicates the NEED FOR FOLLOW-UP? A. The urine is noted to be cloudy and dark in color B. The prescribed rate is flowing into the bladder freely C. The instillation solution returns into the drainage bag D. There is no bladder distention noted during the procedure

A Rationale: Close catheter irrigation is used to flush the bladder to determine the presence of an unexpected finding, such as blood or mucus, in the bladder. An unexpected outcome during or following this procedure includes cloudy or dark urine in color or the presence of a fever. There are signs of possible infection. The prescribed rate flowing into the bladder freely, the return of instillation solution into the drainage bag, and absence of bladder distention during the procedure are normal and expected findings.

The nurse is preparing to administer a rectal suppository to a client. The nurse explains to the client that which position while prevent immediate expulsion of the suppository? A. Flat B. Semi-Fowler C. High-Fowler D. Upright with the hips at a 90-degree angle

A Rationale: after administration of a rectal suppository, the suppository should be retained to promote absorption of the medication. The client should assume a flat or side-lying position for at least 5 minutes after insertion. Semi-Fowler, high-Fowler, and upright with hips at a 90-degress angle will not assist in the retention of a suppository.

The nurse is caring for a client who is retaining carbon dioxide (CO2) due to respiratory disease. The nurse anticipates that as the client's CO2 level rises, the pH will MOST LIKELY by which value? A. 7.30 C. 7.70 B. 7.50 D. 7.88

A Rationale: CO2 acts as an acid in the body. Therefore, with a rise in CO2, there is a corresponding fall in pH ("opposite effect"). A pH less than 7.35 indicates an acidic state, and a pH greater than 7.45 indicates an alkaline state. Options B, C, & D indicate an alkaline state.

The nurse is preparing the client for transfer to the operating room (OR). The nurse should take which action in the care of this client at this time? A. Ensure that the client has voided B. Administer all the daily medications C. Practice postoperative breathing exercises D. Verify that the client has not eaten for the last 24 hours.

A Rationale: The nurse should ensure that the client has voided if a Foley catheter is not in place. The nurse does not administer all daily medications just before sending a client to the OR. Rather, the primary health care provider writes a specific prescription outlining which medications maybe given with a sip of water. The client is placed on nothing by mouth status for 8 hours before surgery, not 24 hours. The time of transfer to the OR is not the time to practice breathing exercises. This should have been accomplished earlier.

A client with liver cancer who is receving chemotherapy tells the nurse that some food taste bitter. The nurse should suggest limiting which food items that are MOST LIKELY to cause this taste for the client? (SATA) A. Beef B. Pork C. Custard D. Potatoes E. Cantaloupe F. Watermelon

A & B Chemotherapy may cause distortion of tase. Frequently, beef and pork are reported to taste bitter or rancid. The nurse can promote the client's nutrition by assisting the client to choose alternative sources of protein in the diet. Custard, potatoes, cantaloupe, and watermelon do not usually cause problems for the client.

The nurse understands that which are judgmental statements (SATA). A. "I don't think you need to do that." B. "Tell me about making that decision." C. "I'm not sure that's what is best for you." D. "When did you first notice you felt that way?" E. "I would like to be sure I understood what you said."

A & C Rationale: Statement A is a judgmental one because it specially casts judgment on an action. Statement C is providing an opinion and advise and casts judgment on a specific situation. The remaining options identify statements that seek to explore with the client.

The nurse understands that which are examples of medical asepsis? (SATA) A. Hand Hygiene B. Applying a sterile dressing C. Inserting an intravenous catheter D. Suctioning a tracheobronchial airway E. Cleaning the over-bed hospital table with agency-approved solution

A & E Rationale: Medical asepsis or clean technique includes procedures used to reduce or prevent the spread of microorganisms. Hand hygiene, barrier techniques, and environmental cleaning are examples of medical asepsis Sterile dressing, inserting IV catheter, and suctioning airways use surgical asepsis techniques.

A client is told that she is anemic, and an iron supplement is prescribed. The nurse provides dietary teaching and should tell the patient which foods are rich in iron? (SATA) A. Fish B. Liver C. Oranges D. Egg yokes E. Grapefruit F. Tangerines

A, B & D Rationale: Foods that are rich in iron include meats, liver, egg yolks, brewer's yeast, green, leafy vegetables, fish, fowl, beans, and cereal grains. Oranges, grapefruit and tangerines are high iin vitamin C.

The nurse is analyzing laboratory values that were prescribed to determine nutritional status for an older adult client. Which laboratory values would be of concern to the nurse? (SATA) A. Hematocrit 30 % (0.30) B. Albumin 3.0 g/dL (30 g/L) C. Calcium 10 mg/dL (2.5 mmol/L) D. Hemoglobin 8 g/dl (80 mmol/L) E. Creatine 0.6 mg/dL (53 mcmol/L) E. Blood Urea nitrogen 20 mg/dL (7/1 mmol/L)

A, B, & D Rationale: expected laboratory values for the older adult may very slightly when compared to that of the adult client. Laboratory values of concern to the nurse would be the hematocrit, albumin, and hemoglobin levels, for the older adult client and depending on the gender, the normal hematocrit range is 37-52% (0.37-0.52); normal albumin level is 3.5-5.0 g/dL (35-50 g/L); normal hemoglobin is 12-18 g/dL (120-180mmol/L) Calcium, Creatine, and BUN are within normal ranges

The nurse understand that which procedures are used to detect the presence of dysrhythmias? (SATA) A. Telemetry B. Holder monitor C. Pulse oximetry D. Electrocardiogram E. Blood Pressure Monitoring

A, B, & D Rationale: To detect the presence of dysrhythmias, telemetry, Holter monitors, or electrocardiograms are used. These devices assist in visualizing the trace of the heartbeat to determine the presence or and identify the dysrhythmias. Pulse oximetry is used to determine the oxygen saturation of the blood. Blood pressure monitoring will not assist in detecting dysrhythmias.

The nurse understands that personal health information can be disclosed in which situations? (SATA) A. Compliance with legal proceedings B. For research purposes in limited circumstances C. To a family member or significant other in an emergency D. To nonessential medical personnel involved in client care E. To appropriate military if a client is a member of the armed forces

A, B, C & E Rationale: Personal health information can be disclosed to a variety of situations, including those identified in the correct options. Disclosure can also be made to a personal representative designated by the client or appointed by law; to a coroner, medical examiner, or funeral director about the deceased person; to an organ procurement organization in limited circumstances; to avert a serious threat to the client's health or safety or that of others; to a government agency authorized to oversee the health care system or government program; to the DHHS for compliance with HIPAA or to fulfill other lawful request; to federal officials with lawful intelligence or national security purposes; to protect health authorities for public health purposes; and in accordance with a valid authorization signed by the client.

The nurse iis conducting a respiratory assessment and is determining respirations per minute. The nurse understands that which factors generally affect the character of respirations (SATA). A. Anxiety D. Acute Pain B. Exercise E. Body position C. Smoking F. Musculoskeletal disorders

A, B, C, D, & E Rationale: Factors that influence that character of respirations include anxiety, exercise, smoking, acute pain, body position, medications, neurological injury, and hemoglobin function. Musculoskeletal disorders do not generally affect the character of respirations.

The nurse is applying and removing personal protective equipment (PPE) hen providing care. Number the actions in the options in order of priority with regard to how the nurse should perform the procedure. A. Put on mask B. Put on gown C. Put on gloves D. Remove mask E. Remove gown F. Remove gloves

A, B, C, F, E & D Rationale: To reduce the spread of infection and employ proper use of PPE, the nurse should first put on the mask, followed by the gown, and then gloves. Upon leaving the room, the nurse should first remove the gloves, followed by the gown and mask Hand hygiene before donning PPE and afer doffing is anotuerh integral part of proper use.

The nurse s caring for a clint whose background is Orthodox Judaism. The nurse is delivering the dinner tray to the client. Which nursing actions are MOST APPROPRIATE in order to provide for the dietary needs of this client? (SATA) A. Remove the milk if there is meat on the tray B. Determine that any fish being served have scales or fins C. Ensure that if there is pork on the tray, it is thoroughly cooked D. Checking to be sure that any meat being served is from an herbivore E. Asking the client about any specific dietary preferences that need to be followed.

A, B, D & E Rationale: Clients whose religious background is Orthodox Judaism have various dietary preferences, and typically must follow a Kosher diet. Milk and meat cannot be consumed together therefore, it is appropriate to remove milk from the tray of meat is being served. Fish with scales or fins are allowed. Clients are not allowed to eat pork; meats allowed include those who are herbivores, cloven-hoofed animals, and those that are ritually slaughtered.

The nurse has developed a close relationship with the family of a client who is dying. which nursing interventions are MOST APPROPRIATE in dealing with the family? (SATA) A. Encouraging family discussion of feelings B. Accepting the family's expressions of anger C. Restricting client visits to schedules hospital visiting hours D. Facilitating the use of spiritual practices identified by the family E. Keeping the family informed of changes in the client's condition F. Making the decisions for the family during the difficult moments

A, B, D & E Rationale: Maintaining effective and open communication among family members affected by death and grief is of utmost importance. The family needs to know that comeone will be there who is supportive and nonjudgmental and will keep them informed. Spiritual practices give meaning to llife and have an impact on how people react to crisis. C & F are inappropriate and remove autonomy and decision making from the family at a time when they are already experiencing feelings of loss of control.

The nurse has a prescription to collect a 24-hour urine specimen from a patient. The nurse should perform which actions while completing this procedure (SATA) A. Place the specimen on ice B. Discard a urine specimen collected at the starting time C. Ask the client to void, save the specimen and note the start time. D. Ask the client to save a sample voided at the end of the collection time E. At the end of the collection time, ensure the specimen is labeled with the client's name and send to the laboratory promptly.

A, B, D & E Rationale: Since the 24-hour urine test is a timed quantitative determination, the test must be started with an empty bladder. Therefore, the first urine is discarded. Fifteen minutes prior to the end of the collection time, the client should be asked to void, and this specimen is added to the collection. The urine collection should be refrigerated or placed on ice to prevent changes in urine. The specimen should be labeled with the client's name and any other necessary identifying information and sent to the laboratory promptly.

The nurse is collecting data from an African American client about dietary preferences and understands that these preferences may include which foods? A. Pork B. Rice C. Fruits D. Greens E. Red Meat F. Fried Foods

A, B, D & F Rationale: African American food preferences may include pork, rice, greens, and fried foods. Fruits and red meat are eaten, but they are not preferences in this culture.

The primary health care provider prescribes the application of a heating pad to a client's back after discharge. The nurse should include which instructions to the discharge teaching? (SATA) A. Set the heating pad on a low setting B. Place the heating pad under the back C. Cover the heating pad with pillowcase or towel D. Check the heating pad periodically for proper electrical function E. Check the skin integrity regularly for signs that the pad is too warm

A, C, D & E Rationale: The heating pad should never be placed under the client, but it should be placed lightly against or on top of the involved area. Burns to the skin can occur when the client lies on the pad. In addition, a low setting and covering the pad will prevent burning. Skin integrity should be checked frequently to ensure that the heat is not burning the skin, and electrical function is checked for safety purposes.

Which Safety measure should be included in the plan of care for a client with an internal radiation implant? (SATA) A. Wear a lead shield when in the client's room B. Place the client in a room with a cohort client C. Limit the time with the client to 1 hour per shift D. Wear a dosimeter badge when entering the client's room E. Save bed linens and any dressing until the implant is removed

A, D, & E Rationales: A. protection from radiation, D. dosimeter to monitor radiation exposure, E. linens and dressing may be contamination by radiation Patient must be roomed solo and maximum in-room time is 30 minutes.

A client, brought to the emergency department, is dead on arrival (DOA). The family of the client tells the nurse that the client cannot have an autopsy because of religious beliefs. THe nurse understands that the client may be part of which religions? A. Muslim B. Mormon C. Hinduism D. Buddhism E. Eastern Orthodox F. Orthodox Judaism

A, E & F Rationale: When caring for a client who is DOA, the nurse must consider end-of-life practices and cultural and religious influences. The Muslim, Eastern Orthodox, and Orthodox Judaism religions may prohibit, discourage, or oppose autopsy. The Mormon, Hindu, and Buddhist religions do not necessarily discourage or oppose the practice.

The nurse is caring for a client with cirrhosis of the liver due to alcohol abuse. To minimize the effects of the disorder, the nurse teaches the client about high-thiamine foods. Which foods does the nurse tell the client are high in thiamine? (SATA) A. Nuts B. Milk C. Chicken D. Broccoli E. Legumes F. Whole Grain cereals

A, E, & F Rationale: A client with cirrhosis of liver due to alcohol abuse has difficulty absorbing thiamine, which is a vital vitamin. If this vitamin is not available in the boty, Wernicke enceohilopathy can result.

The nurse enters the room of a client whose wastebasket is on fire. The nurse removes the client from the room, activates the fire alarm, and closes the door. After obtaining the fire extinguisher, which action should the nurse perform NEXT in preparing to extinguish the fire? A. Pull the pin B. Sweep from side-to-side C. Aim towards the base of the fire D. Squeeze the handle of the extinguisher

A. Rationale: Fire safety principles include removing the client from the vicinity of a fire, confine the fire (closing the door of the room), activating the fire alarm, and extinguishing the fire. In order to use a fire extinguisher, the nurse should first pull the pin, aim toward the base of the fire, squeeze the handle of the extinguisher, and sweep from side to side.

The MOST accurate method for checking the placement of a nasogastric tube following insertion is by which procedure? A. Obtain a radiograph of the abdomen B. Checking the pH of the gastric contents C. Pushing air into the tube and auscultating over the stomach D. Pushing water into the tube and auscultating over the stomach

A. Rationale: Following insertion, the most accurate method of checking placement from the client with an NG tube is obtaining a radiograph of the abdomen. Checking placement of the tube by X-ray must be done after insertion before any feedings or medications can be administered. Checking the pH of the gastric contents will determine whether the gastric contents are acidic, but this does not ensure correct placement. Pushing air or water into the tube and auscultating over the stomach do not provide definitive means of determining accurate placement of the NG tube. In addition, this could be harmful if the tube is misplaced and in the lung.

The nurse who is collecting data from a client note that the client's left eyelid is drooping. The nurse documents that the client is exhibiting which condition? A. Ptosis B. Arcus senilis C. Abnormal corneal reflex D. Blockage of the lacrimal duct

A. Rationale: Ptosis is a sagging of the upper lid of the eye so that it covers part of the pupil. It can be caused by edema, third cranial nerve disorders, or neuromuscular disorders. It is not caused by blockage of the lacrimal duct or tear duct. Arcus senilis is an age-related change, characterized by formation of a yellow-gray ring around the periphery of the cornea surrounding the iris. The corneal reflex is the blink reflex.

The nurse notes that the client's mechanical ventilator is set to control mode. The nurse understands that this setting will achieve which action? A. Allow the lungs to rest B. Allow for spontaneous respirations C. Hyperventilates the client to ensure adequate oxygenation D. Provides some breaths for the client but allows the client to breathe on their own also.

A. The control mode setting on a mechanical ventilator is used to allow the lungs to rest. in this setting, all respirations are provided to the client by the ventilator. The assist-control mode allows for spontaneous breathing and will provide breaths from the ventilator if the client's respirations fall below a certain present amount. Mechanical ventilations is not used for hyperventilation

An older client with delirium becomes disoriented at night. the nurse should initiate which action FIRST to assist the client? A. Turn off the television and radio, and use a nightlight B. Keep soft lighting and the television on during the night C. Change the client's room to one nearer the nurses' station D. Play soft instrumental music all night, and keep the lights on

A. Rationale: the nurse should first turn off the television and radio and use a night light. nightlight is needed for client safety to reduce the risk of falls in case the client gets out of bed unattended. It is important to reduce environmental stimulation and provide a consistent daily routine for a disoriented client Noise levels, including radio and television, may add to the disorientation. Moving the client to a room near the nurses' station is not the first action.

The nurse is teaching a client about the use of an incentive spirometer. The nurse should include which piece of information in discussions with the client? A. Sit upright when using the device B. Inhale as rapidly and deeply as possible C. Keep a loose seal between the lips and the mouthpiece D. After maximum inspiration, hold the breath for 10 seconds and exhale

A. Rationale: For optimal lung expansion with an incentive spirometer, the client should assume the semi-Fowler or high-Fowler position. The mouthpiece should be covered completely while the client inhales slowly with a constant flow through the unit. the breath should be held for 2-3 seconds before exhaling slowly.

The nurse is conducting a cardiovascular physical assessment on a client. Which pulse point would the nurse fell equilaterally to the thyroid on the skin surface? A. Carotid B. Brachial C. Popilteal D. Temporal

A. The carotid pulse is located on the lower third of the neck. The brachial pulse is located in the groove between the biceps and triceps tendons at the antecubital fossa. The popliteal pulse is located behind the knee in the popliteal fossa. The temporal pulse is located over the temporal bone on either side of the head.

The nurse is caring for an older client who has been prescribed buspirone hydrochloride. Which nursing intervention included in the plan of care should be the PRIORITY to ensure safety? A. Document client reports of drowsiness B. Maintain the bed in the lowest position C. Instruct the client in the use of the call light D. Report client response to medication to the primary health care provider

B Rationale: Buspirone hydrochloride is classified as a nonbenzodiazepine anxiolytic. The older client is at an increased risk of falls, and safety precautions should be instituted. The priority nursing intervention to address this problem is to maintain the bed in the lowest position. Drowsiness is an expected effect of this medication, and should be documented; however, this is not the priority. Instructing the client in the use of the call light may be appropriate, however, depending on client response to the medication, may not be the most effective means of ensuring client safety Reporting the client response is indicated, but is not directly related to the subject of ensuring client safety.

The nurse should implement droplet precaution for a client with which communicable disease A. Scabies B. Pertussis C. Herpes Simplex D. Respiratory syncytial virus (RSV)

B Rationale: Droplet precautions are implemented for disorders that produce respiratory droplets larger than 5 mm. These diseases include diphtheria (pharyngeal), rubella, streptococcal pharyngitis, pneumonia, scarlet fever (infant & young children) pertussis, mumps, or pneumonic plague. A, C & D are diseases that require contact precautions

A client has been instructed to restrict the diet to low-purine foods. Which foods should the nurse instruct the client to avoid? A. Dairy products such as ice cream B. Certain fish such as shrimp or scallops C. High carbohydrate foods such as potatoes D. Dark green, leafy vegetables such as spinach

B Rationale: High-purine foods include organ meats, roe, scallops, anchovies, broth, mincemeat, herring, shrimp, mackerel, gravy, and yeast. The food items in the remaining options are acceptable to eat.

The nurse notes in a client's medical record a documentation of Snellen chart test results as 20/200 vision. The nurse understands that which description is accurate for this client's visual acuity A. Normal B. Legally blind C. Slightly abnormal D. Better than normal

B Rationale: Legal blindness is defined as 20/200 or less with corrected vision (glasses or contact lenses). A, C & D are incorrect

The nurse has a prescription to administer the morning medications to a client through a nasogastric (NG tube that is connected to wall suction. The nurse should implement which action to perform this procedure correctly? A. Clamp the NG tube for 5 minutes following medication administration B. Position the client in an upright position before medication administration C. Flush the NG tube with 5 mL of water following medication administration D. Adjust the suction to low-intermittent setting after medication administration

B Rationale: Prior to medication administration, the nurse should position the client in an upright position, the client should remain in this position for 30 minutes to 1 hour after administration of the medication or per agency policy. If a client has an NG tube connected to suction, the nurse clamps the tube and waits 30 minutes before reconnecting the tube to suction. This allows adequate time for medication absorption. Flushing the NG tube is indicated after medication administration, but 5 mL is an insufficient amount. Adjusting he suction to low-intermediate setting after medication administration would prevent absorption because this action would suck out the medication.

The nurse caring for a client with cirrhosis of the liver understands that which intervention would be included in this client's plan of care? A. Weigh the client weekly B. Elevate the head of the bed C. encourage increased fluid intake D. Measure abdominal girth hourly

B Rationale: Cirrhosis of the liver is a chronic, progressive disease of the liver characterized by diffuse degeneration and destruction of hepatocytes. The nurse should elevate the head of the bed to minimize shortness of breath due to fluid overload. Client should be weighted daily (not weekly) and the abdominal girth should be measured daily (not hourly) to monitor fluid status. The client's fluid intake should be restricted as prescribed to prevent fluid overload.

A postoperative client says to the nurse, "Don't touch me. I'll take care of myself!" Which response is therapeutic? A. "Fine, I won't touch you!" B. "Let's work together so you can do things for yourself." C. "I have to change your dressing so I have to touch you D. If that's what you want but I need to report this to the surgeon."

B Rationale: The therapeutic response is one that reflects the client's feelings and empowers the client by offering some self-control over one's own care. Option A is an aggressive and nontherapeutic communication technique. Option C reflects assault by telling that client that they need to be touched and may be perceived as too aggressive. In option D, the nurse is demeaning.

The nurse is auscultating the apical heart rate of a client who is not taking any prescribed medications and notes that the heart rate is regular. To determine beats per minute, the nurse should measure the apical pulse for how many seconds? A. 15 seconds B. 30 seconds C. 45 seconds D. 60 seconds

B Rationale: When auscultating the apical heart rate, the nurse should first determine whether the heart rate is regular. If it is regular, it is sufficient to auscultate for 30 seconds and then multiple by 2 to determine the number of beats per minute. If the heart rate is irregular, or if the client is taking cardiac medication, the apical pulse should be measured for a full 60 seconds.

When discussing a health care plan with a female Amish client, the nurse should perform which actions? (SATA) A. Speak only to the husband B. Avoid using medical terms C. Maintain adequate personal space D. Use complex scientific terminology E. Stand close to the client and speak loudly

B & C Rationale: when speaking to an Amish client and family, the nurse should maintain adequate personal space. Complex scientific or medical terminology should be avoided when communicating with an Amish client or any client. When discussing health care, most often, the husband and wife will want to discuss the plan together. Standing close and speaking loudly is inappropriate in most conversations.

The nurse is planning to teach a client about home modifications to reduce the risk of falls. Which recommendations should be included in the teaching plan? (SATA) A. Remove wall-to-wall carpeting B. Using nightlights during nighttime C. Place handrails on bathtubs and showers D. Check staircase railing for secureness and sturdiness E. Place scatter rugs on hardwood floors and at the bottom of a staircase

B, C & D Rationale: Home modifications t reduce the risk of falls include ample lighting especially during the nighttime, placing handrails in the bathtub and shower areas, and use of secure and sturdy railings on all staircases. Placing scatter rugs on hardwood floors and at the bottom of staircases leads to a risk of falls because of the possibility of the rug moving when steppe don. . Removal of wall-to-wall carpeting is not necessary.

The nurse has given postprocedural instructions to a client who underwent a colonoscopy. Successful learning would be evident if the client makes which statement? (SATA) A. "It is all right to drive once I've been home for an hour or so." B. "My abdominal muscles may be tender because of the procedure." C. "My diet should be light at first, and then I can progress to a regular diet." D. "It is normal to feel gassy pr bloated for a short while after the procedure." E. "I should expect to have a moderate amount of blood in my stool for the next few days." F. "If I develop a fever following the procedure, I should call my doctor immediately."

B, C, D & F Rationale: The client may experience gas or abdominal tenderness for a short while after the procedure because air is often instilled during the colonoscopy for better visualization. The client shouls resume intake slowly and progress as tolerated. Development of a fever may be indictive of intestinal perforation Driving is avoided for 8-12 hours. A small amount of blood may be noted, but moderate amounts need to be reported.

The nurse is preparing to examine a Hispanic child who was brought to the clinic by the mother. During the assessment of the child, the nurse should take which actions? (SATA) A. Admire the child B. Take the child's temperature C. Obtain an interpreter if necessary D. Include the child in the discussion E. Make direct eye contact with the mother F. Ask the mother questions about the child

B, C, D, & F Rationale: Hispanic clients may believe in mal ojo ("evil eye"). They believe that an individual becomes ill as a result of excessive admiration of another. Direct eye contact is also avoided as it is a sign of disrespect. The remaining options are appropriate interventions. Direct eye contact is also avoided as

The nurse understands that which are characteristics of anthrax. (SATA) A. It is caused by the bacillus Yersinia pestis B. Cutaneous lesions become black eschar C. Gastrointestinal anthrax causes bloody diarrhea D. Flu-like symptoms are a sign of pulmonary anthrax. E. Person-to-person transmission of inhalation disease does not occur F. A person can become infected through skin contact, ingestion, or inhalation of the bacillus

B, C, D, E, & F Rationale: Anthrax is an acute infectious disease caused by Bacillus anthracis, a spore-forming, gram-positive bacillus. Plague is cause by the bacillus Yersinia pestis

A nurse understands that which are examples of a nosocomial infection occurring in a health care facility (SATA). A. A common cold noted on day 1 of hospitalization B. Sepsis that results from contaminated intravenous fluid C. A urinary tract infection that develops after catheter insertion D. Streptococci wound infection that develops in a postoperative client E. The development of C. diff in an immunocompromised client F. A respiratory tract infection that develops in a client receiving frequently respiratory treatment and requiring frequent suctioning.

B, C, D, E, & F Rationale: Nosocomial infections occur in a health care facility and result from the delivery of care. A hospital is a likely setting for acquiring an infection because it harbors a high population of virulent organisms that may be resistant to antibiotics. These infections may be exogenous or endogenous. An exogenous infection arises from microorganisms external to the client that does not exists as normal flora. An endogenous infection occurs when part of the client's flora become altered, and an overgrowth occurs. The client was admitted with a common cold, so that is not a nosocomial infection

The nurse performing and eye assessment notes that the client can see objects clearly that are far away but cannot see objects clearly that are close-up. The nurse documents this finding as which condition? A. Myopia B. Hyperopia C. Photophobia D. Accommodation

B. Rationale: Hyperopia (farsightedness) occurs when the refractive ability of the eye is too weak, and images are focused behind the retina. When someone is farsighted, they had difficulty seeing objects up close myopia (nearsightedness) occurs when the refractive ability of the eye s too strong for the eye length and images are bent and fall in front of, not on, the retina. When someone is nearsighted, they have difficulty seeing objects that are far away. Photophobia is an abnormal sensitivity to light. Accommodation is the expected change in pupil size when changing gaze from a near object to a fat one, and back again. The pupils dilate when looking at the far object and constrict when looking at the near one.

The nurse is performing a vision test on a client with the use of a Snelling chart. The nurse asks the client to stand at how many feet away from the chart to perform this test? A. 10 B. 20 C. 30 D. 40

B. When performing a vision test on a client using a Snelling chart, the nurse should position the client in a well-lit area 20 feet away from the chart with the chart at eye level. The distances identified in A, C & D are incorrect

The nurse needs to plan to obtain which device for a client whose legs are paralyzed as a result of a spinal cord injury? A. Walker B. Slider board C. raised toilet seat D. Adaptive eating utensils

B. Rationale:

The nurse prepares to bathe and change the bed linens of a client with methicillin-resistant Staphylococcus aureus (MRSA) in an abdominal wound covered by a dressing. Which protective action should the nurse take during the bathing of this client? A. Wear gloves B. Wear a gown and gloves C. Wear a gown, gloves and a mask D. Wear a gown and gloves to change the bed linens and gloves only for the bath

B. Rationale: Gowns and gloves are required if the nurse anticipates contact with soiled items such as from wound drainage, or in caring for a client who is incontinent, or a client who as an ileostomy or a colostomy. Masks are not required unless droplet or airborne precautions are necessary. Regardless of the amount of wound drainage, a gown and gloves must be worn.

The nursing instructor asks a nursing student to identify the type of isolation precaution necessary for the client with active tuberculosis (TB). The student understands the route of transmission if the student states which type of isolation precaution should be maintained? A. Contact precaution C. Standard precautions B. Airborne precaution D. Hand-washing precautions

B. Rationale: TB is an infectious disease caused by Mycobacterium tuberculosis and is spread primarily by the airborne route. Contact precautions are indicated when an infection is transmitted by direct contact with the client or contaminated items in the client's environment. Standard precautions are to be used with all clients to protect health care workers from contracting and transmitting communicable diseases. Proper handwashing by healthcare workers assists with preventing of transmission od infections.

The nurse monitoring the laboratory results for a client receiving an antineoplastic medication by the intravenous (IV) route should be prepared to initiate bleeding precautions in which laboratory result is noted? A. A clotting time of 10 minutes B. An ammonia level of 20 mcg/dL (12 mcmol/L) C. A platelet count of 50,000 mm^3 (50 x 10^9/L) D. A white blood cells (WBC) count of 5000 mm^3 (5 x 10^9/L)

C Rationale: Bleeding precautions need to be initiated when the platelet count decreased. The normal platelet count is 150,000-400,00 mm^3 (150-400x10^9/L). When the platelets are less than 50,000 mm^3, any small trauma can lead to episodes of prolonged bleeding. The normal WBC count is 5000-10,000 mm^3 (5-10x10^9/L) When the WBC count drops, neutropenic precautions need to be implemented. The normal clotting time is 8-15 minutes, the normal ammonia values id 10-80 mcg/dL (6-47 mcmol/L)

The nurse is assisting a client on a low-potassium diet to select food items from the menu. Which food item, lowest in potassium and selected by the client, indicates an understanding of this dietary restriction? A. Spinach B. Cantaloupe C. Lima beans D. strawberries

C Rationale: Cantaloupe, spinach, and strawberries are high-potassium foods and average 7 mEq per serving. Lima beans average 3 mEq per serving.

The nurse is inspectine the lacrimal apparatus of a client's eye. Due to its anatomical location, the nurse should perform which action? A. Retract the lower lid and ask the client to look up B. Retract the upper eyelid and ask the client to look up C. Retract the upper eyelid and ask the client to look down D. Retract the lower eyelid and ask the client to look up

C Rationale: The lacrimal apparatus consists of the lacrimal gland (in the upper eyelid over the outer canthus) and the secretory duct that direct tears to the lacrimal sac in the inner canthus. The nurse examines part of the apparatus be retracting the upper eyelid and asking the client to look down. Abnormal findings would include edema and tenderness.

The nurse provides instructions to the client using an incentive spirometer and tells the client to sustain the inhaled breath for 3 seconds. When the client asks the nurse about the rationale for this action, the nurse incorporates the understanding that which action is the PRIMARY benefit. A. Dilate the major bronchi B. Increase surfactant production C. Maintain inflation of the alveoli D. Enhance ciliary action in the tracheobronchial tree

C Rationale: Sustained inhalation for 3-5 seconds helps maintain inflation of terminal bronchioles and alveoli, thereby promoting better gas exchange. Routine use of devices such as the incentive spirometer can help prevent atelectasis and pneumonia in clients at rick. An incentive spirometer does not achieve the actions in options A, B, or D.

A vegetarian client asks the nurse about foods to eat that are high in vitamin A. The nurse should indicate which items in a list of the foods highest in this vitamin? (SATA) A. Peas B. Corn C. Carrots D. Yellow squash E. White potatoes

C & D Rationale: Foods that are highest in vitamin A include carrots and green, leafy and yellow vegetables The other vegetables listed are high in vitamins, but do not necessarily have the highest amount of vitamin A.

The nurse performing a home assessment on an older client would be concerned about which unsafe finding? (SATA) A. nonskid surfaces on slippers B. nonskid backing on small rugs C. Electrical cords taped to the floor D. Bath mats on the shower stall floor E. Electrical appliances and cords near the sink

C & E Rationale: Electrical cords need to be secured against the baseboards, not to the floor. Electrical cords taped to the floor can result in tripping. Electrical appliances or cords should not be placed near the sink or any other water source due to the risk of electrocution. Options A, B, & D are safe measures to prevent falls.

The nurse prepares a client with right-sided weakness to get out of bed to a chair. Number the actions in the options in order of PRIORITY with regard to how the nurse should perform the actions. A. Secure the chair position B. Instructs the client about the procedure C. Places the chair at an angle on the side of the bed D. Assists the client to stand and move the left arm to the armrest E. Instructs the client to keep the body weight forward and then pivot F. Assists the client in sitting when the back of the legs touches the chair

C, A, B, D, E & F Rationale: The client should first be informed of the procedure so they are aware of the expectation. The shair should be positioned on the client's strong side and secured to maintin client safety during the transfer. After standing, the client should use their stronger upper extremity to grap the armgrest. Body weight should be pitched slightly forward for balance; the client should pivot and then sit when the legs meet the chair edge.

A client is diagnosed with myasthenia gravis and the nurse needs to administer an oral medication to this client. Number the actions in the options in order of PRIORITY with regard to how the nurse should perform the actions. A. Assess swallowing ability B. Elevate the head of the bed C. Check the medication prescription D. Administer precisely at prescribed time E. Document administration of the medication F. Monitor response to medication as the day progresses

C, B, A, D, E & F Rationale: The nurse would first check the medication prescription. Next, the nurse would elevate the head of the bed and assess swallowing ability. The medication is administered precisely at the prescribed time, administration of the dose is documented, and the nurse monitors response throughout the day

A client passes a urinary stone, and laboratory analysis indicates that it is composed of calcium oxalate. On the basis of this analysis, which directions should the nurse include in the dietary instructions (SATA). A. Drink tea rather than coffee B. increase intake of dietary products C. Eat and drink citrus fruits and citrus juice D. Eat plenty of leafy vegetables, but avoid spinach or beets E. Increase intake of foods such as meats, fish, plums, and cranberries

C, D & E Rationale: Calcium is found in dairy products and these products need to be avoided. Oxalate is found in dark green foods such as spinach. Other foods that raise urinary oxalate are rhubarb, strawberries, chocolate, wheat bran, nuts, beets, and tea. Citrus products are acceptable as are meats, fish, plums and cranberries.

The nurse is caring for a client whose religious background is Seventh Day Adventists (Church of God). Which nursing actions are MOST APPROPRIATE in terms of providing for the dietary needs for this client? (SATA) A. Providing snacks between each meal B. Providing wine with dinner as requested C. Removing coffee from the breakfast tray D. Ensuring that there is no pork on the dinner tray E. Ensuring that meals are delivered in a timely fashion

C, D, & E Rationale: Clients whose religious backgrounds is Seventh Day Adventists (Church of God) have various dietary preferences, including avoidance of overeating. At least 5-6 hours must pass between meals, and in-between meal snacking is avoided. Coffee and alcohol are usually prohibited. Many members are lacto-ovo vegetarians; those who do eat meat, however, will avoid pork. Meals should be delivered in a timely fashion because of the hours that must pass between meals for the client.

The nurse is instructing a client regarding the use of ice packs to treat an eye injury. The nurse should tell the client to perform which action? A. Keep an ice pack on the eye continuously for 24 hours B. Place a plastic bag filled with crushed ice directly on the eye socket C. Wrap a plastic bag filled with ice with a pillowcase or towel and place it on the eye D. Lie flat and place the ice bag on the eye using a rotating schedule of 8 hours on and 8 hours off for 4 days

C. Rationale: If an ice pack is placed directly against the skin or left in place for an extended period, it carries a risk of tissue damage similar to that of a hot water bottle. An ice pack should never be placed directly against the skin but should be covered with a pillowcase or towel. To prevent tissue damage from excessive cold exposure, the ice pack should be removed in most cases after 30 minutes, and after a short time, may be reapplied. Following an eye injury, the client should keep the head elevated to reduce swelling in the area.

The nurse is providing instructions to a client about food that are high in potassium. The nurse should tell the client that which food has the highest potassium content? A. Milk B. Apple C. Spinach D. Pound Cake.

C. Rationale: Spinach provides approximately 7 mEq of potassium per serving. An apple provides approximately 3 mEq of potassium per serving. Milk is high in calcium; Pound cake is not a high-potassium food and may contain fat.

The nurse receives a telephone laboratory report indicating that a client with diabetes mellitus has a glycosylated hemoglobin A1C level of 7.6%. The nurse determines a NEED FOR ADDITIONAL REINFORMENT of diabetic teaching about which measure? A. Avoiding infection B. Caring for the feet C. Preventing hyperglycemia D. Rotating insulin injection sites

C. Rationale: This test measures the amount of glucose that has been permanently bonded to the red blood cells (RBCs) from circulating glucose. The normal level for A1C is 3.5%-6.0%. Elevation in blood glucose will cause elevation in the amount of glycosylation, helping to detect otherwise unknown episodes of hyperglycemia. Elevations indicate continued need for teaching related to prevention of hyperglycemic episodes.

The nurse is analyzing the laboratory report for the client who has a specific gravity determination drawn. The report indicates a value of 1.030. the nurse understands that which condition may potentially be causing this result. A. Renal disease B. Diabetes insipidus C. Decreased renal perfusion D. Inability of the kidneys to concentrate urine

C. Rationale: the normal urine specific gravity of 1.016-1.022. An increase in urine specific gravity can occur as a result of decreased renal perfusion, increased antidiuretic hormone, or insufficient fluid intake. A decrease in urine specific gravity can occur as a result of increased fluid intake, diabetes insipidus, renal disease, or the inability of the kidneys to concentrate urine.

The client is being schedules for a positron emission tomography (PET) scan. THe nurse would plan to provide which explaination to the client? A. The test uses magnetic fields to produce images B. the test provides cross-sectional views of the brain C. the test uses a small amount of radiactive material D. the test views bones of the skull, nasla sinuses, and vertebrae

C. Rationale:

The nurse is reviewing the plan of care for the client who has just undergone bilateral knee replacement. Which intervention, if noted in the plan of care, indicated the NEED FOR FOLLOW-UP? A. Administer analgesics for pain B. Monitor surgical sites for drainage and infection C. Begin continuous passive range-of-motion exercises immediately D. Avoid total weight-bearing and instruct in the use of assistive devices

C. Rationale: For the client who has undergone bilateral knee replacement, continuous passive range-of-motion exercise should begin 24 to 48 hours after the surgery or as prescribed by the primary health care provider. Administration of analgesics for pain, monitoring surgical sites for drainage and infection, and avoiding total weight-bearing and instructing on the use of assistive devices are all appropriate interventions for this client.

A 3-year-ol child is hospitalized because of persistent vomiting. The nurse should monitor the child closely for which condition? A. Diarrhea B. Metabolic acidosis C. Metabolic alkalosis D. Hyperactive bowel sounds

C. Rationale: Vomiting will cause the loss of hydrochloric acid resulting in metabolic alkalosis. Diarrhea may not accompany vomiting. metabolic acidosis would occur in a child experiencing diarrhea because of the loss of bicarbonate. Hyperactive bowle sound are not necessarily associated with vomiting.

The nurse is assisting a client to obtain a 24-hour urine specimen to test for creatinine clearance. Which instruction should the nurse provide to the client prior to specimen collection? A. Drink coffee and tea to assist with urination B. Save all specimens, including the initial void C. Collect the urine for the entire length of the prescribed time D. Keep the specimen at room temperature during the collection period

C. Rationale: A 24-hour urine specimen is usually prescribed to test for creatinine clearance. Prior to speciment collection, the client should be instructed to drink plenty of fluids to assist with urination; however, coffee and tea should be avoided. All specimens should be included except for the inital void, which should be discarded. Urine should be collected for the entire length of the prescribed time. The specimen should be kept on ice or refrigeration during the collection period and should be sent to the laboratory promptly after the collection time is complete.

The preoperative client expresses anxiety. Which statement by the nurse is MOST APPROPRIATE at this time? A. "Let me tell you what this surgery is all about." B. "Is it normal for you to feel nervous before surgery." C. "What have you been told so far about your surgery, and what parts make you nervous?" D. "Your surgeon while explain the entire surgical procedures to you beforehand, so don't worry."

C. Rationale: Explanation should begin with the information that the client knows. A & B generalize and avoid the client's feelings. Explaining (or having the surgeon explain) the entire procedure can be overwhelming

The nurse just reassessed a postoperative client who was admitted 1 hour ago to the surgical unit. The nurse plans to MOST carefully monitor which parameter during the next hour? A. Temperature of 37.6 C (99.6 F) B. Blood pressure of 100/70 mmHg C. Urinary output of 20 mL in 1 hour D. Serous drainage on the surgical dressing

C. Rationale: Urine output should be maintained at a minimum of 30 mL/hr for an adult. A temperature above 37.7 C (100 F) or below 36.1 C (97 F) and a falling systolic blood pressure under 90 mmHg needs to be reported. The client's preoperative or baseline blood pressure is used to make informed postoperative comparisons. Moderate or light serous drainage from the surgical site is considered normal.

The nurse witnesses a construction worker fall from a ladder. The nurse rushes to the victim, who is unresponsive and uses which method to open the victim's airway? A. Head tilt - chin lift C. Jaw thrust maneuver B. Head tilt - jaw thrust D. Neutral or sniffing position

C. Rationale: Whenever a neck injury is suspected in an adult, the jaw thrust maneuver should be used to open the airway. The head tilt - chin lift produces hyperextension of the neck and could cause complications if a neck injury is present. The neutral or sniffing position may be used to open the airway of an infant. There is no position as the head tilt- jaw thrust.

Which should be included in a change-of-shift report? A. Describing routine tasks performed B. Described basic steps of a procedure C. Reviewing all biographical information about each client D. Describing objective measurements or observations about a client's condition

D Rationale: A Change-of-shift report should include information about the client and a description of the objective measurements or observations about a client's condition. The reports should include only essential biographical information about the client, not all biographical data. Routine and basic steps of a procedure are an unnecessary component of change-of-shift report.

The client who has undergone hip replacement surgery has been retaining urine, and the primary health care provider prescribes straight catheterization. In which BEST position should the nurse place the client to perform this procedure? A. High-fowler B. Trendelenburg C. Dorsal recumbent D. Side-lying on the operative side

D Rationale: A client who requires straight catheterization and who are undergoing hip replacement surgery should be placed in a side-lying position of the operative side (if acceptable to the surgeon). This is the best position because the unaffected extremity can be abducted with a pillow to allow for visualization of the urinary meatus.

The nurse notes that a 5-year-old is chocking but is awake and alert at this time. As the nurse rushes to aid the child, the nurse plans to place the hands between which landmarks to perform the abdominal thrust (Heimlich) maneuver? A. the umbilicus and the groin B. the lower abdomen and chest C. the groin and the xiphoid process D. the umbilicus and xiphoid process

D Rationale: To perform the abdominal thrust maneuver, the rescuer stands behind the victim and places the arms directly under the victim's axillae and around the victim. The thumb side of one fist is placed against the victim's abdomen in the midline slightly above the umbilicus and well below the tip of the xiphoid process. The xiphoid process and ribs are avoided to prevent damage to internal organs. The fist is grasped with the other hand and upward thrusts are delivered.

An adolescent client with a surgically wired jaw has a prescription for a full liquid diet. The nurse should implement which action to promote the client's compliance with this diet prescription? A. Offer chocolate milkshakes between meals B. Explain to the adolescent the importance of good nutrition C. Offer commercial nutritional supplements 4 to 6 times per day 4. ask about food preferences and blend these foods into liquids

D Rationale: Include the adolescent in with food choices, blended foods have same nutritional value as the food whole Chocolate milkshakes have low/no nutritional value, adolescent may or may not respond to reason for good nutrition, and commercial drinks can be costly and don't taste that good

The nurse should institute contact precaution for which disease? A. Measles B. Varicella C. Pulmonary tuberculosis D. Respiratory syncytial virus (RSV)

D. Rationale: RSV is transmitted via direct client contact or environmental contact and requires contact precautions (private room or cohort client and the use of gowns and gloves). A, B & C require airborne precautions because they are transmitted by droplet nuclei smaller than 5mm

The nurse interprets from the client's behavior that the client may be experiencing dysfunction in the area of cochlea of the ear. The nurse should base this assumption on which sign/symptom displayed by the client? A. Presence of tinnitus B. Disturbance in balance C. Conduction hearing loss D. Sensorineural hearing loss

D. Rationale: The cochlea is the structure in the inner ear that aids in the transmission of sound. Sensorineural hearing loss is caused by a deficit in the cochlea, cranial nerve VIII, or the brain itself. The presence of tinnitus, disturbance is balance, and conductive hearing loss are not specifically related to this structure.

During preparation of a continuous intravenous (IV) infusion, the nurse contaminated the IV tubing. Which is the MOST APPROPRIATE action by the nurse? A. Complete an incident report B. Wipe the tubing with alcohol C. Wipe the tubing with Betadine D. Discard the contaminated tubing and obtain new IV tubing

D. Rationale: The nurse should discard the contaminated tubing and 0btain new IV tubing because contaminated tubing could cause systemic infection in the client. There is no reason to complete an incident report. The tubing will be attached directly to the catheter device in the client's vein, so wiping the tubing with alcohol or betadine is insufficient and would be contraindicated.

The nurse is teaching a client with tuberculosis (TB) about dietary elements that should be increased in the diet. The nurse suggests that the client increase intake of which BEST food combinations? A. Cereal and milk B. Eggs and spinach C. Grains and broccoli D. Meats and citrus fruits

D. Rationale: The nurse teaches the client with TB that it is best to increase intake of protein, iron, and vitamin C. Foods rich in vitamin C include citrus fruits, berries, melons, pineapple, broccoli, cabbage, green peppers, tomatoes, potatoes, chard, lake, asparagus, and turnip greens. Food sources that are rich in iron and protein include liver, and other meats. Less than 10% of iron in absorbed from eggs, and less than %5 is absorbed from grains and most vegetables.

A hospitalized client will be self-administering tube feedings at home. When the client expresses concern about his ability to perform this procedure, the nurse should BEST respond by saying which statement? A. "Does your family know about this concern that you have?" B. "Is there a family member or friend that is willing to help you?" C. "Do you want me to prescribe home visits from the nurse for you?" D. "Let's talk about what makes it difficult for you to perform this procedure."

D. Rationale: This client has a specific fear about not being able to handle tube feeding at home. An open communication statement such as "let's talk about" is a nurse's best option This type of statement often lead to valuable information about the client and their concerns. A & B are nontherapeutic responses because that place the client's issues on hold. C may not be necessary; additionally, the nurse may need a referral for services.

Which meal selection would be MOST APPROTPRIATE for the nurse to deliver to a Mormon client? A. Waffles, bacon, fruit, and coffee B. Steak and eggs, toast, fruit, and coffee C. Scrambled eggs, hash browns, fruit, and green tea D. Sausage and cheese omelet, muffin and orange juice

D. Rationale: in the Mormon religion, alcohol, coffee, and tea are not usually consumed. A, B & C all contain coffee or tea.

The nurse removes a client's surgical abdominal dressing and notes a thin yellow drainage, separation of the incision line, and the presence of underlying tissue. The nurse should take which PRIORITY action? A. Apply a Betadine-soaked sterile dressing B. Leave the incision open to the air to dry the area C. Irrigate the wound and apply a dry sterile dressing D. Apply a sterile dressing soaked with normal saline

D. Wound dehiscence is the separation of wound edges at the suture line. Signs and symptoms of increased drainage and the exposure of underlying tissues. The client should be instructed to remain quiet and to avoid coughing or straining. The client should be positioned to prevent further stress on the wound. Sterile dressings soaked with sterile normal saline should be used to cover the wound. The primary health care provider must be notified after applying this initial dressing to the wound.

The nurse is providing home care instructions to the client diagnoses with severe acute respiratory syndrome (SARS). Which statement, if made by the client, indicates a NEED FOR FURTHER INSTRUCTION. A. "I may develop a dry cough after a few days." B. "I should avoid having visitors for some time." C. "I need to be sure to wash my hands frequently." D. It is okay to share eating utensils after a few days."

D. Rationale: The client should avoid sharing food, drinks, and eating utensils because of the potential for transmission. Severe acute respiratory syndrome (SARS) is a respiratory illness caused by the coronavirus and begins with a fever, overall feeling of discomfort, body aches, and mild respiratory symptoms. After 2 to 7 days, the client may develop a dry cough and dyspnea. The client should avoid having visitors until they are no longer contagious because this is easily spread through direct contact with infectious material, such as respiratory secretions or objects infected by respiratory droplets. Frequently handwashing will assist in preventing transmission

The prescription reads potassium chloride (KCl) 20 mEq to be added to 1000 mL NS and to be administered over an 8-hour period. The label on the KCl bottle reads 4 mEq per 1 mL. The nurse should prepare how many milliliters of KCl to administer the correct dose of medication?

[20 mEq (desired dose) / 4 mEq (available conc. dose.)] x 1 mL (available conc. volume) = 5 mL

The primary health care provider prescribes 500 mL of normal saline solution to infuse intravenously at 50 mL/hr. the drop factor is 60 drops/mL. Calculate the flow rate in drops per minute.

[Total volume (mL) x drop factor (gtt/mL)] / = 50 gtt/min time of infusion (mins)