Fundamentals

A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the following actions should the nurse take? Encourage the child to cough frequently to clear congestion from anesthesia. Place a heating pad at the child's neck for comfort. Administer analgesics to the child on a routine schedule throughout the day and night. Provide the child with ice cream when oral intake is initiated.

Administer analgesics to the child on a routine schedule throughout the day and night. To soothe the client's throat following a tonsillectomy, the nurse should administer pain medication routinely around the clock. The nurse can provide the medication rectally or intravenously to avoid the oral route.

A nurse is collecting a urine specimen for culture and sensitivity for a client who has a urinary tract infection. The client has an indwelling urinary catheter in place. Which of the following actions should the nurse take? Withdraw the specimen from the drainage bag. Cleanse the collection port with soap and water. Place the specimen in a clean specimen cup. Clamp the tubing below the collection port.

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

A nurse is providing teaching to an older adult client who has constipation. Which of the following statements should the nurse include in the teaching? "Drink a minimum of 1,000 milliliters of fluid daily." "Increase your intake of refined-fiber foods." "Sit on the toilet 30 minutes after eating a meal." "Take a laxative every day to maintain regularity."

"Sit on the toilet 30 minutes after eating a meal." Increased peristalsis occurs after food enters the stomach. Sitting on the toilet 30 min after eating a meal, regardless of feeling the urge to defecate, is a recommended method of bowel retraining to treat constipation.

A nurse is preparing to insert an indwelling urinary catheter for a male client. Which of the following locations should the nurse secure the urinary catheter tubing? Lateral thigh Lower abdomen Mid-abdominal region Medial thigh

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

A nurse is teaching a group of older adults about expected changes of aging. Which of the following statements by a group member indicates that the teaching has been effective?

Older adults experience decreased cardiac output, which causes increased pulse rate during exercise. The pulse rate also takes longer to return to normal after exercise.

A nurse is assisting a client who is eating at mealtime. The client grabs her neck with both hands and appears frightened. Which of the following actions should the nurse take first? Place an oxygen mask on the client. Check the client's pulse. Determine whether the client is able to breathe. Wrap arms around the client from behind.

Determine whether the client is able to breathe

A nurse is caring for a client who has an NG tube for intermittent enteral feedings. Which of the following actions should the nurse take? Auscultate for bowel sounds after each feeding. Ensure the formula is cold before administering. Elevate the client's head of bed 45° before the feeding. Flush the tubing with 15 mL of water after the enteral feeding.

Elevate the client's head of bed 45° before the feeding. The nurse should elevate the client's head of bed between 30° to 45° to prevent aspiration. flush with 30 ml of water after feeding

A nurse is demonstrating postoperative deep breathing and coughing exercises to a client who will have emergency surgery for appendicitis. Which of the following statements indicates a lack of readiness to learn by the client? The client asks the nurse to repeat the instructions before attempting the exercises. The client reports severe pain. The client asks the nurse how often deep breathing should be done after surgery. The client tells the nurse that this exercise will probably be painful after surgery.

The client reports severe pain, pt is not able to concentrate and therefore is not ready to learn

A nurse is witnessing a client sign an informed consent form for surgery. Which of the following describes what the nurse is affirming by this action? -The client fully understands the provider's explanation of the procedure. -The client has been informed about the risks and benefits of the procedure. -The nurse witnessed the provider's explanation of the procedure. -The signature on the preoperative consent form is the client's.

The signature on the preoperative consent form is the client's. The nurse acts as a witness to attest that it is the client's signature on the preoperative consent form. It is the responsibility of the provider who will perform the procedure to obtain consent by explaining the procedure along with the associated risks and benefits.

A nurse on a medical-surgical unit is caring for a client. Which of the following actions should the nurse take first when using the nursing process? Identify goals for client care. Obtain client information. Document nursing care needs. Evaluate the effectiveness of care.

obtain client info

A nurse is caring for a client who has a history of dysrhythmias. Upon entering the room, the nurse discovers the client is unresponsive to verbal or painful stimuli, has no respirations, and is pulseless. Which of the following actions should the nurse take first? Start chest compressions. Provide breaths with a manual resuscitation bag. Administer oxygen. Establish an airway.

start chest compressions

A nurse is caring for an older adult client who becomes agitated when the nurse requests that the client's dentures be removed prior to surgery. Which of the following responses should the nurse make? "It's for your safety. Dentures can slip and block your airway during surgery." "You wouldn't want your teeth to be lost or broken during surgery, would you?" "The anesthesiologist requires everyone to remove their dentures." "What worries you about being without your teeth?"

what worries you about being without your teeth

A nurse is admitting a client who has decreased circulation in his left leg. Which of the following actions should the nurse take first? Evaluate pedal pulses. Obtain a medical history. Measure vital signs. Assess for leg pain.

Evaluate pedal pulses

A nurse is caring for a client who is postoperative following a vaginal hysterectomy and asks for a drink. Her postoperative diet prescription reads: clear liquids; advance diet as tolerated. Which of the following responses should the nurse make? "Lunch trays should be here within the hour." "I am going to listen to your abdomen." "I'll get you some water to drink." "I would wait a bit, or you could feel sick."

"I am going to listen to your abdomen." A common reason clients experience nausea and vomiting after surgery is delayed gastric emptying time or decreased peristalsis. The nurse should auscultate the client's abdomen to determine the presence of bowel sounds before clear liquids can be administered.

A nurse observes an assistive personnel (AP) preparing to obtain blood pressure with a regular size cuff for a client who is obese. Which of the following explanations should the nurse give the AP? "The reading will be inaudible if the cuff is too small for the client." "The width of the cuff bladder should be 75% of the circumference of the client's arm." "As long as the cuff will circle the arm the reading will be accurate." "Using a cuff that is too small will result in an inaccurately high reading."

"Using a cuff that is too small will result in an inaccurately high reading." Blood pressure cuffs come in various sizes, and the correct size cuff is necessary to obtain a reliable measurement. Blood pressure readings can be falsely high if the cuff is too small for the client.

A nurse is assessing a client who has an onset of severe back pain of unknown origin. Which of the following questions should the nurse ask to encourage discussion with the client? "Does the medication you're taking relieve the pain?" "Can you point to where the pain is the worst?" "What do you think caused the onset of your pain?" "Changing positions makes your pain worse, right?"

"What do you think caused the onset of your pain?" The nurse is using an open-ended question that allows the client to respond with a wide range of information by using more than one or two words.

A nurse is planning care for a group of clients who are receiving oxygen therapy. Which of the following clients should the nurse plan to see first? A client who has heart failure and is receiving 100% oxygen via a partial rebreather mask A client who has emphysema and is receiving oxygen at 3L/min via a transtracheal oxygen cannula A client who has an old tracheostomy and is receiving 40% humidified oxygen via tracheostomy collar A client who has COPD and is receiving oxygen at 2 L/min via nasal cannula.

A client who has heart failure and is receiving 100% oxygen via a partial rebreather mask

A nurse is inserting an IV catheter for a client that results in a blood spill on her gloved hand. The client has no documented bloodstream infection. Which of the following actions should the nurse take? -Wash the gloved hands and then throw the gloves away. -Prepare an incident report to document the event. -Carefully remove the gloves and follow with hand hygiene. -Ask the provider to order a blood culture to determine the risk of infection.

Carefully remove the gloves and follow with hand hygiene. Standard precautions require the use of gloves and hand hygiene in the care of all clients.

A nurse is providing teaching to a client who has a new colostomy about proper care. Which of the following information should the nurse include in the teaching? Change the colostomy bag following breakfast. Cleanse the skin around the stoma with warm water. Change the pouch every day. Place an aspirin in the ostomy pouch to decrease odor.

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

A nurse is caring for a client who had a mastectomy and has a self-suction drainage evacuator in place. Which of the following actions should the nurse take to ensure proper operation of the device? Irrigate the tubing with sterile normal water once each shift. Cleanse the opening with soap and water after emptying. Maintain the tubing above the level of the surgical incision. collapse the device of air after emptying

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

A nurse is planning care for a client who has a prescription for collection of a sputum specimen for culture and sensitivity. Which of the following actions should the nurse take when obtaining the specimen? Collect the specimen upon arising in the morning. Force fluids during the day and collect the specimen in the evening. Collect the specimen after antibiotics have been started. Collect 2 mL of sputum before sending the specimen to the laboratory.

Collect the specimen upon arising in the morning. The nurse should plan to collect the sputum specimen when the client arises in the morning because the client is able to more easily cough up the secretions that have accumulated during the night. Generally, the deepest specimens are obtained in the early morning, and it is preferable to collect the specimen before breakfast. The nurse should instruct the client to rinse the mouth, take a deep breath, and cough prior to expectorating into the sterile container.

A nurse is measuring vital signs for a client and notices an irregularity in the pulse. Which of the following actions should the nurse take? Measure the pulse using a Doppler ultrasound stethoscope. Check the client's pedal pulses. Count the apical pulse rate for 1 full minute, and describe the rhythm in the chart. Take the pulse at each peripheral site and count the rate for 30 seconds.

Count the apical pulse rate for 1 full minute, and describe the rhythm in the chart. If the peripheral pulse is irregular, the nurse should auscultate the apical pulse for 60 seconds to obtain an accurate rate. The nurse should document the irregularity in the client's medical record.

A nurse is caring for a client who is unstable and has vital signs measured every 15 minutes by an electronic blood pressure machine. The nurse notices the machine begins to measure the blood pressure at varied intervals and the readings are inconsistent. Which of the following actions should the nurse take? -Turn on the machine every 15 min to measure the client's blood pressure. -Record only blood pressure readings needed for the 15-min intervals. -Obtain manual and automatic readings and compare them. -Disconnect the machine, and measure the blood pressure manually every 15 min.

Disconnect the machine, and measure the blood pressure manually every 15 min. If the nurse questions the reliability of the monitoring equipment, a manual process should be used. Also, malfunctioning equipment can pose a safety risk for the client, so it must be tagged and removed.

A nurse is replacing the surgical dressings on a client who had abdominal surgery. Which of the following actions should the nurse take? Don clean gloves to remove the old dressing. Loosen the dressing by pulling the tape away from the wound. Remove the entire old dressing at once. Open sterile supplies after applying sterile gloves.

Don clean gloves to remove the old dressing

A nurse is caring for a client who has a terminal illness. The client asks several questions about the nurse's religious beliefs related to death and dying. Which of the following actions should the nurse take? -Change the topic because the client is trying to divert attention from the illness to the nurse. -Encourage the client to express his thoughts about death and dying. -Tell the client that religious beliefs are a personal matter. -Offer to contact the client's minister or the facility's chaplain.

Encourage the client to express his thoughts about death and dying. The nurse should recognize the client's need to talk about impending death, and encourage the client to discuss his thoughts on the subject. This is the therapeutic technique of reflecting. Depending on the situation, the nurse can also share some thoughts on this topic. Self-disclosure is a communication skill that can help open lines of communication when appropriate. If the nurse does not want to share personal beliefs, the communication skills of offering self and listening to the client's thoughts are appropriate.

A nurse is performing eye irrigation for a client who was exposed to smoke and ash. Which of the following actions should the nurse take? Hold the irrigator 1.25 cm (0.5 in) above the eye. Direct the irrigation solution upward toward the upper eyelid. Exert pressure on the bony prominences when holding the eyelids open. Direct the irrigation from the outer canthus to the inner canthus of the eye.

Exert pressure on the bony prominences when holding the eyelids open. The nurse should hold the upper lid against the eyebrow and the lower lid against the cheekbone when irrigating the eye.

A nurse is providing teaching to a group of unit nurses about wound healing by secondary intention. Which of the following information should the nurse include in the teaching? The wound edges are well-approximated. The wound is closed at a later date. A skin graft is placed over the wound bed. Granulation tissue fills the wound during healing.

Granulation tissue fills the wound during healing. The nurse should include in the teaching that a beefy, red tissue called granulation tissue fills the wound during healing. The wound is left open to drain and heal by secondary intention that should occur within 5 to 21 days. Open wounds place the client at an increased risk for wound infection.

A nurse in an emergency department is assessing a client who reports diarrhea and decreased urination for 4 days. Which of the following actions should the nurse take to assess the client's skin turgor? Push on a fingernail bed until it blanches, release it, and observe how long it takes the skin to become pink. Grasp a skin fold on the chest under the clavicle, release it, and note whether it springs back. Press the skin in above the ankle for 5 seconds, release it, and note the depth of the impression. Measure the skin fold thickness at the upper arm using a pair of calibrated skinfold calipers.

Grasp a skin fold on the chest under the clavicle, release it, and note whether it springs back. The nurse should use this technique for assessing skin turgor. If the client has good turgor and is properly hydrated, the skin will immediately return to normal; with dehydration, the skin will remain tented. The nurse can also assess turgor by grasping a skin fold on the back of the forearm.

A nurse is teaching a client who is recovering from gallbladder surgery how to use an incentive spirometer. Which of the following information should the nurse include in the teaching? Exhale slowly to reach goal volume. Hold breath for 5 seconds after goal volume is reached. Continue to deep breathe between each cycle. Limit repeat pattern of breathing to 5 breaths.

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

A nurse is changing the bed linens for a client who is on bed rest. Which of the following actions should the nurse plan to take? Place the soiled linens on the chair while making the bed. Hold the linens away from the body and clothing. Place the linens on the floor until able to place it in a linen bag. Shake the clean linens to unfold.

Hold the linens away from the body and clothing. The nurse should hold the linens away from the body and clothing to prevent soiling or the transfer of microorganisms. The microorganisms present on the nurse's clothing can expose other clients to microorganisms.

A nurse in an oncology clinic is assessing a client who is undergoing treatment for ovarian cancer. Which of the following statements by the client indicates she is experiencing psychological distress? "My parents are retired, and they have come to help out with our children." "I am going to ask my husband to go to counseling with me." "I keep having nightmares about my upcoming surgery." "My girlfriends bought me a nice wig."

I keep having nightmares about my upcoming surgery

A nurse is caring for a toddler at a well-child visit when the mother calls to the nurse, "Help! My baby is choking on his food." Which of the following findings indicates the toddler has an airway obstruction? Flushing of the skin Inability of the toddler to cry or speak Presence of nausea and mild emesis Capillary refill time 1.5 sec

Inability of the toddler to cry or speak When the client has no sound passing through the vocal cords, the nurse should identify a complete airway obstruction is evident. The nurse should use the Heimlich maneuver to dislodge whatever is obstructing the trachea.

A nurse is performing an abdominal assessment for an adult client. Identify the correct sequence of steps for this assessment. (Move the sequence of steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

Inspection Auscultation Palpation Percussion

A nurse is changing the dressings for a client who has two Penrose drains near an abdominal incision. Which of the following adhering devices is the best choice for the nurse to use to decrease skin irritation? Abdominal binder Montgomery straps Hypoallergenic tape Plastic tape

Montgomery straps The nurse should apply the least restrictive priority-setting framework. This framework assigns priority to nursing interventions that are least restrictive to the client, as long as those interventions do not jeopardize client safety. Least restrictive interventions promote client safety without using restraints. The nurse should only use physical or chemical restraints when the safety of the client, staff, or others is at risk. The nurse should plan to use Montgomery straps to minimize irritation to the skin near the incisional area. Montgomery straps are adhesive strips applied to the skin on either side of the surgical wound. The adhesive strips have holes for using gauze to tie the dressing securely. When the dressing is changed, the ties are released, the dressing replaced, and the ties secured again without removing the adhesive strips.

A nurse is preparing a client who is scheduled for a hysterectomy for transport to the operating room when the client states she no longer wants to have the surgery. Which of the following actions should the nurse take? Tell the client it is too late for her to change her mind because the surgery is already scheduled. Telephone the operating room and cancel the surgery. Inform the client's family about the situation. Notify the provider about the client's decision.

Notify the provider about the client's decision its up to the surgeon and the client to make this decision

A charge nurse is observing a newly licensed nurse perform tracheostomy care for a client. Which of the following actions by the newly licensed nurse requires intervention? Obtaining hydrogen peroxide for the tracheostomy care Obtaining cotton balls for the tracheostomy care Obtaining sterile gloves for the tracheostomy care Obtaining a sterile brush for the tracheostomy care

Obtaining cotton balls for the tracheostomy care Cotton ball particles can be aspirated into the tracheostomy opening, possibly causing a tracheal abscess. The charge nurse should intervene for this action.

A nurse is assessing the heart sounds of a client who has developed chest pain that becomes worse with inspiration. The nurse auscultates a high-pitched scratching sound during both systole and diastole with the diaphragm of the stethoscope positioned at the left sternal border. Which of the following heart sounds should the nurse document? Audible click Murmur Third heart sound Pericardial friction rub

Pericardial friction rub A pericardial friction rub has a high-pitched scratching, grating, or squeaking leathery sound heard best with the diaphragm of the stethoscope at the left sternal border. A pericardial friction rub is a manifestation of pericardial inflammation and can be heard with infective pericarditis with myocardial infarction, following cardiac surgery or trauma, and with some autoimmune problems, such as rheumatic fever. The client who develops pericarditis typically has chest pain which becomes worse with inspiration or coughing and which may be relieved by sitting up and leaning forward.

A nurse is preparing to remove an NG tube for a client who had a partial colectomy. Which of the following actions should the nurse take? Maintain suction while removing the NG tube. Instill 100 mL of air into the NG tube before removal. Pinch the NG tube while removing the tube. Instruct the client to breathe in and out during the removal of the NG tube.

Pinch the NG tube while removing the tube. The nurse should pinch the NG tube while removing the tube to decrease the risk of aspiration of any gastric contents.

A nurse is obtaining the blood pressure in a client's lower extremity. Which of the following actions should the nurse take? -Auscultate for the blood pressure at the dorsalis pedis artery. -Measure the blood pressure with the client sitting on the side of the bed. -Place the cuff 7.6 cm (3 in) above the popliteal artery. -Place the bladder of the cuff over the posterior aspect of the thigh.

Place the bladder of the cuff over the posterior aspect of the thigh. This is the correct position for the nurse to place the bladder of the cuff when measuring a lower extremity blood pressure.

A nurse is planning to collect a stool specimen for ova and parasites from a client who has diarrhea. Which of the following actions should the nurse take when collecting the specimen? Instruct the client to defecate into the toilet bowl. Transfer the specimen to a sterile container. Refrigerate the collected specimen. Place the stool specimen collection container in a biohazard bag.

Place the stool specimen collection container in a biohazard bag. MY ANSWER The nurse should place the specimen collection container in a biohazard bag with the client label placed on the container and the bag for easy identification, and to prevent contamination with microorganisms.

A nurse on a rehabilitation unit is preparing to transfer a client who is unable to walk from a bed to a wheelchair. Which of the following techniques should the nurse use? Stand toward the client's stronger side. Instruct the client to lean backward from the hips. Place the wheelchair at a 45° angle to the bed. Assume a narrow stance with feet 15 cm (6 in) apart.

Position the wheel chair at 45 degree angle to the bed, allows the client to pivot, lessening the amount of rotation required

A nurse is performing suctioning for a client who has a tracheostomy. Which of the following actions should the nurse take? Pull suction catheter back 1 cm (0.5 in) if the client starts coughing. Allow 30 seconds between suctioning passes. Hyperventilate the client with 50% oxygen for 30 seconds. Perform a maximum of 4 passes with the suction catheter.

Pull suction catheter back 1 cm (0.5 in) if the client starts coughing. The nurse should pull the suction catheter back 1 cm (0.5 in) when the client starts to cough, or resistance is met. This will remove the catheter from the mucosal wall of the trachea prior to suctioning.

A nurse is caring for an older adult client who is violent and attempting to disconnect her IV lines. The provider prescribes soft wrist restraints. Which of the following actions should the nurse take while the client is in restraints? -Tie the restraints to the side rails. -Perform range-of-motion exercises to the wrists every 3 hr. -Remove the restraints one at a time. -Obtain a PRN prescription for the restaints.

Remove the restraints one at a time. The nurse should remove one restraint at a time for a client who is violent or noncompliant.

A community health nurse is preparing a campaign about seasonal influenza. Which of the following plans should the nurse include as a secondary prevention? Holding a community clinic to administer influenza immunizations. Screening groups of older adults in nursing care facilities for early influenza manifestations. Educating parents of young children about dangers of influenza. Finding rehabilitation programs for older adults who have complications from influenza.

Screening groups of older adults in nursing care facilities for early influenza manifestations. Screening older adults who have some manifestations of illness to determine if they have influenza is an example of secondary prevention. Secondary prevention is focused on preventing complications of an illness or providing care to prevent illness from becoming severe.

A nurse at a screening clinic is assessing a client who reports a history of a heart murmur related to aortic valve stenosis. At which of the following anatomical areas should the nurse place the stethoscope to auscultate the aortic valve? Fifth intercostal space just medial to the midclavicular line Second intercostal space to the left of the sternum Fifth intercostal space to the left of the sternum Second intercostal space to the right of the sternum

Second intercostal space to the right of the sternum The aortic valve is located in the second intercostal space to the right of the sternum. Aortic stenosis produces a midsystolic ejection murmur that can be heard clearly at the aortic area with the client leaning forward.

A nurse is providing teaching to a client who has heart failure about how to reduce his daily intake of sodium. Which of the following factors is the most important in determining the client's ability to learn new dietary habits? The involvement of the client in planning the change The emphasis the provider places on the dietary changes The learning theory the nurse uses to teach the dietary changes The extent of the dietary changes planned for the client

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

A nurse is teaching an assistive personnel (AP) about proper hand hygiene. Which of the following statements by the AP indicates an understanding of the teaching? "There are times I should use soap and water rather than an alcohol-based hand rub to clean my hands." "I will use cold water when I wash my hands to protect my skin from becoming too dry." "I will apply friction for at least 10 seconds while washing my hands." "After washing my hands I will dry them from the elbows down."

There are times I should use soap and water rather than an alcohol based hand rub to clean my hands

A nurse is applying antiembolitic stockings for a client who has a history of deep vein thrombosis. Which of the following actions should the nurse take when applying the stockings? Roll the stocking partially down if too long. Remove the stocking once per day. Bunch and pull the stocking half way up the calf. Turn the stocking inside out up to the heel before applying.

Turn the stocking inside out up to the heel before applying. The nurse should turn the stocking inside out up to the client's heel to make the application of the stocking easier and cause less constrictive wrinkles.

A nurse is preparing to assist with ambulation of an older adult client who was on bed rest for 3 days. Which of the following actions should the nurse take to decrease the risk of a fall? Use a gait belt during ambulation. Ensure the client is wearing socks before ambulating. Instruct the client to sit on the edge of the bed for 15 seconds before ambulating. Walk 2 feet behind the client during ambulation.

Use a gait belt during ambulation. The nurse should use a gait belt to keep the client's center of gravity midline and decrease the risk of a fall.

A nurse is planning care for a client who has a wound infection following abdominal surgery. To promote healing and fight infection, which of the following vitamins and minerals should the nurse plan to increase in the client's diet? Vitamin C and zinc Vitamin D Vitamin K and iron Calcium

Vitamin C and zinc The client's body needs both vitamin C and zinc to help fight a wound infection. The client should receive a multivitamin, and a mineral supplement of both. In addition, vitamin E supplements also are needed to aid in skin and wound healing.

A nurse on a medical-surgical unit is admitting a client. Which of the following information should the nurse document in the client's record first? Assessment Plan of care Nursing interventions performed Evaluation of progress

assessment

A nurse is planning weight loss strategies for a group of clients who are obese. Which of the following actions by the nurse will improve the clients' commitment to a long-term goal of weight loss? Attempt to increase the clients' self-motivation. Keep detailed records of each client's progress. Test client learning after each teaching session. Avoid discussing areas that might cause client anxiety.

attempt to increase the clients self-motivation.

A nurse is caring for a client who has major fecal incontinence and reports irritation in the perianal area. Which of the following actions should the nurse take first? Apply a fecal collection system. Apply a barrier cream. Cleanse and dry the area. Check the client's perineum.

check the clients perineum

A charge nurse is teaching adult cardiopulmonary resuscitation (CPR) to a group of newly licensed nurses. Which of the following actions should the charge nurse teach as the first response in CPR? Call for assistance. Begin chest compressions. Confirm unresponsiveness. Give rescue breaths.

confirmed unresponsiveness

A nurse is providing preoperative teaching to a client who is scheduled for arthroplasty in the next month that might require a blood transfusion. The client expresses concern about the risk of acquiring an infection from the blood transfusion. Which of the following statements should the nurse make to the client? "Ask your provider to prescribe epoetin before the surgery." "You should ask your provider about taking iron supplements prior to the surgery." "Request a family member to donate blood for you." "Donate autologous blood before the surgery."

donate autologous blood before the surgery. Blood is drawn from the client 3-5 weeks before an elective surgical procedure and stored for transfusion at the time of the surgery

A nurse is preparing to insert an NG tube for a client who has a bowel obstruction. Which of the following actions should the nurse take first? Provide the client with a glass of water. Assist the client to a sitting position. Explain the procedure to the client. Measure the length of tubing to be inserted.

explain the procedure to the client

A nurse is preparing to provide tracheostomy care for a client. Which of the following actions should the nurse take first? Open all sterile supplies and solutions. Stabilize the tracheostomy tube. Don sterile gloves. Perform hand hygiene.

perform hand hygiene

A nurse is caring for a client who is in the terminal stage of cancer. Which of the following actions should the nurse take when she observes the client crying? Contact the family and ask them to stay with the client. Offer to call the client's minister. Sit and hold the client's hand. Leave the room and allow the client to cry privately.

sit and hold the client's hand

A nurse is caring for a client who has type 1 diabetes mellitus and is resistant to learning self-injection of insulin. Which of the following statements should the nurse make? "Tell me what I can do to help you overcome your fear of giving yourself injections." "I am sure your provider will not be pleased that you refuse to give yourself insulin injections." "It's okay. I'm sure your partner will be able to learn how to give you the insulin injections." "You won't be able to go home unless you learn to give yourself insulin injections."

tell me what I can do to help you overcome your fear of giving yourself injections

A nurse is preparing to administer an intramuscular injection to a client who is overweight. Which of the following sites should the nurse select for the injection? The lower, medial quadrant of the buttock near the coccyx The side hip between the iliac crest and anterior iliac spine The tissue of the posterior upper arm The lower, inner thigh 4 finger widths above the patella

the side hip between the iliac crest and anterior iliac spine