Fundamentals EAQ

A client with dementia and a percutaneous endoscopic gastrostomy (PEG) tube is being cared for at home. Which action provides evidence that a family member is effectively managing the client's care? Empty feeding bag stays attached to the tubing. Tube is flushed with air after medication is given. Replacement of the tube is done on a weekly basis. Head of the bed remains elevated after the feeding.

Head of bed remains elevated after the feeding

After cataract surgery the nurse teaches a client how to self-administer eyedrops. The nurse reinforces the use of what technique? Placing the drops on the cornea of the eye Raising the upper eyelid with gentle traction Holding the dropper tip above the conjunctival sac Squeezing the eye shut after instilling the medication

Holding the dropper tip above the conjunctival sac

The nurse assesses a client who is receiving total parenteral nutrition for the specific complication of what condition? Infection Hepatitis Anorexia Dysrhythmias

Infection

A client's parathyroid glands are removed. What clinical manifestation is indicative of the fluid and electrolyte imbalance associated with this surgery? Constipation Muscle spasms Hypoactive reflexes Increased specific gravity

Muscle Spasms

A nurse is caring for an older bedridden male client who is incontinent of urine. Which action should the nurse take first? Restrict fluid intake. Offer the urinal regularly. Apply incontinence pants. Insert an indwelling urinary catheter.

Offer the urinal regularly

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 Apply suction only as the catheter is being withdrawn.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

Apply suction only as the catheter is being withdrawn

A nurse administers a parenteral preparation of potassium slowly and cautiously to avoid which complication? Acidosis Cardiac arrest Psychoticlike reactions Edema of the extremities

Cardiac Arrest

The nurse is caring for a client before, during, and immediately after surgery. Which type of care is provided to the client? Care that supports physical functioning Care that supports homeostatic regulation Care that supports psychosocial functioning Care that provides immediate short-term help in physiological crises

Care that supports homeostatic regulation

Which client response during the insertion of a nasogastric tube indicates to the nurse that the client is experiencing serious difficulty with the insertion? Choking Redness Gagging Cyanosis

Cyanosis

Following a major abdominal surgery, a client has a nasogastric tube attached to continuous low suction. The nurse caring for the client postoperatively monitors the client for what signs of hypokalemia? Select all that apply. Irritability Dysrhythmias Muscle weakness Abdominal cramps Acidosis

Dysrhythmias, Muscle Weakness

A client with the diagnosis of ulcerative colitis has surgery for the creation of an ileostomy. Postoperatively, for which potential life-threatening complication should the nurse assess the client? Wound infection Ischemia of the stoma Electrolyte imbalances Excoriation of skin around the stoma

Electrolyte Imbalance

A nurse is caring for a postoperative client who has a nasogastric (NG) tube set to low intermittent suction. The nurse recalls that the primary reason that an intravenous infusion of 5% dextrose with 0.45% sodium chloride and 20 mEq of potassium has been prescribed is to prevent which complication? Constipation Dehydration Electrolyte imbalance Nausea and vomiting

Electrolyte Imbalance

A nurse receives a shift report on four adult clients who are between the ages of 25 and 55. Which client should the nurse assess first? - Male client with a hemoglobin of 15.9 (160 mmol/L) - Female client on warfarin (Coumadin) with an international normalized ratio (INR) of 7.5 - Female client taking daily calcium supplements with a serum calcium level of 9.4 (2.35 mmol/L) - Male client with a blood urea nitrogen (BUN) of 20 (7.1 mmol/L) and a creatinine of 1 (96 mcmol/L)

Female client on warfarin (Coumadin) with an international normalized ratio (INR) of 7.5

A primary healthcare provider is treating the red-color wound of a client caused by pressure ulcers. Which dressings are beneficial for wound recovery? Select all that apply. Absorptive dressings Hydrocolloid dressings Transparent film dressings Moist gauze dressings with antibiotics Telfa dressings with antibiotic ointment

Hydrocolloid dressings Transparent film dressings Telfa dressings with antibiotic ointment

A client with a history of hypertension has a blood pressure of 180/102 mm Hg. When the nurse asks whether the client has been taking any medications, the client replies, "I took the blood pressure pills the healthcare provider prescribed for a few weeks, but I didn't feel any different, so I decided I'd only take them when I feel sick." What is the best initial response by the nurse? "You must be quite frightened about having high blood pressure." "I'm glad to hear you have felt well enough to stop the medication." "It is important to take your medications daily to achieve optimal results." "You will need to document daily whether you took your medication or not."

It is important to take your medications daily to achieve optimal results

A nurse instructs a client to breathe deeply to open collapsed alveoli. What is the best explanation the nurse could offer to explain the relationship between alveoli and improved oxygenation? The alveoli need oxygen to live. The alveoli have no direct effect on oxygenation. Collapsed alveoli increase oxygen demand. Oxygen is exchanged for carbon dioxide in the alveolar membrane.

Oxygen is exchanged for carbon dioxide in the alveolar membrane

A nurse assists a client who had bariatric surgery to be more mobile. What complication is the nurse attempting to prevent? Incisional pain Wound dehiscence Anastomosis leakage Pulmonary embolism

Pulmonary Embolism

While preforming nasotracheal suctioning, the nurse notices that the client has blood pressure of 90/70 and a heart rate of 50 beats per minute. What is the priority nursing intervention in this situation? Administering intravenous fluids to the client Reporting to the primary healthcare provider Stopping the suctioning procedure immediately Administering 100% oxygen manually to the client

Stopping the suctioning procedure immediately

Which site is best for the nurse to obtain a urinalysis specimen for a critical care client with an indwelling urine catheter? Tubing luer-lok port Distal end of the tubing Urinary drainage bag Catheter insertion site

Tubing luer-lok port

A client is to continue oxygen therapy at home when discharged. Which client statement indicates the need for further instruction by the nurse? "I will use only grounded electrical equipment." "I have a new woolen blanket to keep me warm." "I have told my family they cannot smoke in the house." "I will keep a pitcher of water near me so I drink enough."

"I have a new woolen blanket to keep me warm"

A nurse is providing teaching to a client who is learning how to self-administer gastrostomy tube feedings. What should the teaching include? Administering water after the feeding is completed Maintaining the supine position during the feeding Heating the feeding to slightly above body temperature Determining tube placement by instilling water before the feeding

Administering water after the feeding is completed

A healthcare provider prescribes ophthalmic drops for a client. What should a nurse include in the instructions for a client learning to self-administer eyedrops? Lie on the unaffected side for administration. Instill drops onto the pupil to promote absorption. Close eyes tightly after administering the eyedrops. Apply pressure to the nasolacrimal duct after instillation.

Apply pressure to the nasolacrimal duct instillation

A client is receiving furosemide. For which sign of hypokalemia should the nurse monitor the client? Chvostek sign Flabby muscles Anxious behavior Abdominal cramping

Flabby Muscles

During chemotherapy, altered nutrition is a common side effect. Knowing that compromised nutrition can contribute to an increased risk of infection and other problems, what can the nurse do to offset nutritional deficiencies? Provide oral supplements. Offer the client's favorite foods. Restrict intake from dairy products. Encourage the client to drink low-protein shakes.

Provide oral supplements

Which step of the nursing process is directly affected if the nurse does not make a nursing diagnosis? Planning Evaluation Assessment Implementation

Planning

The nurse observes a client with chronic obstructive pulmonary disease (COPD) breathing rapidly and using accessory muscles of respiration. The nurse auscultates the lungs and hears crackles and wheezes. What action should the nurse take? - Encourage the client to take slow, deep breaths and administer 5 L/min oxygen per nasal cannula. - Place the client in a side-lying position and perform chest physiotherapy using clapping and vibration. - Raise the head of the bed to a high-Fowler position and administer 2 L/min oxygen per nasal cannula. - Assist the client in assuming a position of comfort and perform postural drainage.

Raise the head of the bed to a high-fowler position and administer 2 l/min oxygen per nasal cannula

A 24-hour urine test is prescribed for a client who has a tentative diagnosis of pheochromocytoma. What should the nurse do first? Start the time of the test after discarding the first voiding. Discard the last voiding in the 24-hour time period for the test. Insert a urinary retention catheter to promote the collection of urine. Strain the urine following each voiding before adding the urine to the container.

Start time of the test after discarding the first voiding

Ten minutes after the initiation of a blood transfusion, a client reports lumbar pain. What is the next nursing action? Stop the transfusion. Obtain the vital signs. Assess the pain further. Increase the flow of normal saline.

Stop the transfusion

A client's laboratory report indicates hyperkalemia. Which responses should the nurse expect the client to exhibit? Select all that apply. Anorexia Vomiting Constipation Muscle weakness Irregular heart rate

Vomiting, Muscle Weakness, Irregular Heart Rate

After administering a loop diuretic, a nurse monitors the client for increased urine output. What principle explains the secondary water loss (diuresis) of a loop diuretic? Osmosis Filtration Diffusion Active transport

Osmosis

A client asks about the purpose of a pulse oximeter. The nurse explains that it is used to measure what? Respiratory rate Amount of oxygen in the blood Percentage of oxygen-carrying hemoglobin Amount of carbon dioxide in the blood

Percentage of oxygen-carrying hemoglobin

Which intravenous fluid should the nurse classify as hypertonic? Ringer solution 5% dextrose in water Lactated Ringer solution 5% dextrose in normal saline

5% Dextrose in NS

When providing care for a client who is receiving enteral feedings via a nasogastric (NG) tube, the nurse should take measures to prevent what serious complication? Skin breakdown Aspiration pneumonia Retention ileus Profuse diarrhea

Aspiration Pneumonia

A nurse is preparing to administer an intravenous piggyback medication to a client who is receiving a continuous infusion of intravenous (IV) fluids. What is the priority nursing intervention? Get an additional IV infusion pump for the medication. Check the compatibility of the medication and the continuous IV solution. Disconnect the continuous IV solution while administering the piggyback medication. Flush the client's venous access device to ensure patency.

Check the compatibility of the medication and the continuous IV solution

A nurse is reviewing preoperative instructions with a client who is scheduled for orthopedic surgery at 8:00 AM the next day. What advice does the nurse give the client? "Have your dinner completed by 6:00 PM tonight and then no food or fluids after that." "Drink whatever liquids you want tonight and then only clear liquids tomorrow morning." "Consume a light evening meal tonight and then no food or fluids after midnight." "Eat lunch today and then do not drink or eat anything until after your surgery."

Consume a light evening meal tonight and then no food or fluids after midnight

The nurse is providing postoperative care 8 hours after a client had a total cystectomy and the formation of an ileal conduit. Which assessment finding should be reported immediately? Edematous stoma Dusky-colored stoma Absence of bowel sounds Pink-tinged urinary drainage

Dusky-colored stoma

A nurse confers with the nutritionist about the diet of a 4-year-old child with spina bifida who spends many hours in a wheelchair. What should the nurse encourage the mother to increase in her child's diet? Select all that apply. Fat Fiber Protein Calories Carbohydrates

Fiber, Protein

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

Foods that meet basic nutritional needs

A client is admitted to the hospital with a diagnosis of restrictive airway disease. The nurse expects the client to exhibit which early signs of respiratory acidosis? Select all that apply. Headache Irritability Restlessness Hypertension Lightheadedness

Headache, Irritability, Restlessness

A nurse is caring for a client who is receiving total parenteral nutrition (TPN). The nurse would monitor the client for which complications? Select all that apply. Hyperglycemia Infection Hepatitis Anorexia Dysrhythmias

Hyperglycemia Infection

Which of these is a one-on-one communication between a nurse and another person? Small-group communication Intrapersonal communication Interpersonal communication Transpersonal communication

Interpersonal Communication

An 85-year-old client has a serum potassium level of 6.7 mEq/L (6.7 mmol/L). Which nursing action is the priority at this time? Monitor for cardiovascular irregularities. Inquire about changes in bowel patterns. Assess for leg muscle twitching or weakness. Assess for signs and symptoms of dehydration.

Monitor cardiovascular irregularities

Which method of oxygen delivery should a nurse anticipate will be prescribed for a client with a pulse oximetry reading of 65%? Face tent Venturi mask Nasal cannula Nonrebreather mask

Nonrebreather mask

A client is admitted to the hospital for a surgical resection of the lower left lobe of the lung. After surgery the client has a chest tube to a closed chest drainage system. What should the nurse do to determine if the chest tube is patent? Milk the chest tube toward the drainage unit Check the amount of bubbling in the suction control chamber Observe for fluctuations of the fluid in the water-seal chamber Assess for extent of chest expansion in relation to breath sounds

Observe for fluctuations of the fluid in the water-seal chamber

An older client with shortness of breath is admitted to the hospital. The medical history reveals hypertension in the last year and a diagnosis of pneumonia three days ago. Which vital sign assessment would be seen as a sign that the client needs immediate medical attention? Oxygen Saturation: 89% Body temperature: 101°F Blood Pressure: 130/80 mmHg Respiratory rate: 26 beats/minute

Oxygen Saturation: 89%

A nurse is caring for a client whose laboratory values indicate the presence of hyponatremia. Which factors does the nurse determine were the most likely cause of the hyponatremia? Select all that apply. Diabetes insipidus Profuse diaphoresis Excess sodium intake Removal of the parathyroid glands Rapid intravenous (IV) infusion of 5% dextrose in water

Profuse diaphoresis; Rapid IV infusion of 5% dextrose in water

A healthcare team is delegated the task of assisting a client with bathing. Which member of the healthcare team is responsible and accountable for this aspect of client care? Nursing aide Registered nurse (RN) Patient care associate (PCA) Licensed vocational nurse (LVN)

RN

A nurse in the postanesthesia care unit (PACU) is providing care to a client who had an abdominal cholecystectomy and observes serosanguineous drainage on the abdominal dressing. What is the next nursing action? Change the dressing. Reinforce the dressing. Replace the tape with Montgomery ties. Support the incision with an abdominal binder.

Reinforce the dressing

A nurse is caring for a client with a history of chronic obstructive pulmonary disease (COPD) who develops a pneumothorax and has a chest tube inserted. Which primary purpose of the chest tube will the nurse consider when planning care? Lessens the client's chest discomfort Restores negative pressure in the pleural space Drains accumulated fluid from the pleural cavity Prevents subcutaneous emphysema in the chest wall

Restores negative pressure in the pleural space

A client with a spinal cord injury tends to assume the low Fowler position excessively. In which area of the body will the nurse most likely discover a pressure ulcer? Elbows Occiput Ilium Sacrum

Sacrum

When reestablishing a Jackson-Pratt drain after emptying its contents, the nurse squeezes the collection container and recaps the drain. What is the rationale for the nurse's action? To drain bile To restore suction To prevent infection To enhance gravity drainage

To restore suction

A registered nurse is educating a nursing student about the importance of nursing documentation for performing risk management. What information should the nurse give? Select all that apply. "A nurse's documentation is the evidence of care that a client receives." "Nurses' notes should not be given to attorneys in the event of a lawsuit." "The nurse should note down assessments and significant changes in the client's health." "In case an occurrence report is filed, nurses should enter the information the client's charts." "Nurses should always document the primary healthcare providers' responses whenever they are contacted."

"A nurse's documentation is the evidence of care that a client receives", "The nurse should note down assessments and significant changes in the client's health", "Nurses should always document the primary healthcare providers' responses whenever they are contacted."

A nurse provides education to a client about how to prevent constipation. The nurse concludes that the teaching is understood when the client makes which statements? Select all that apply. "I may eat potatoes at dinner daily." "I should drink at least six glasses of water every day." "I must eat eggs for breakfast three times a week." "I can include bran muffins in my breakfast daily." "I will walk every day as part of my exercise regimen."

"I should drink at least six glasses of water every day." "I can include bran muffins in my breakfast daily." "I will walk every day as part of my exercise regimen."

Which nursing action helps reduce the development of healthcare-associated methicillin-resistant Staphylococcus aureus (HA-MRSA)? - Applying triple antibiotic ointment to puncture sites - Bathing clients every other day with soap and tepid water - Bathing clients with chlorhexidine gluconate (CHG) solution - Performing hand hygiene with soap and water after removing gloves

Bathing clients with chlorhexidine gluconate (CHG) solution

Which intrinsic factors may contribute to falls in older adults? Select all that apply. Deconditioning Impaired vision Inappropriate foot wear Improper use of assistive devices Unfamiliar environment of hospital room

Deconditioning, Impaired Vision

The primary healthcare provider treats a client with a pressure ulcer. While assessing the client, the nurse identifies exposed bone and tendons. Which stage does the nurse document for this pressure ulcer? Stage I Stage II Stage III Stage IV

Stage IV

What instruction regarding sample collection should the nurse give a client who is ordered a clean-catch urine specimen? Urinate small amount, stop flow, fill half of cup Collect the last urine sample voided in the night Keep the urine sample in dry warm area if delay is anticipated Send the urine sample to the laboratory within 6 hours of collection

Urinate small amount, stop flow, fill half a cup

The nurse is providing instructions about foot care for a client with diabetes mellitus. What should the nurse include in the instructions? Select all that apply. Wear shoes when out of bed. Soak the feet in warm water daily. Dry between the toes after bathing. Remove corns as soon as they appear. Use a heating pad when the feet feel cold.

Wear shoes when out of bed, Dry between toes after bathing

The client's serum sodium is 123 mEq/L (123 mmol/L). Which prescription should the nurse question? Provide pretzels as a snack daily. Restrict fluid intake to 1000 mL per day. Assess neurologic status every 2 hours. Administer intravenous fluid of one-half normal saline (NS) at 125 mL/hr.

Administer IV fluid of 1/2 NS at 125 mL/hr

A client with acquired immunodeficiency syndrome (AIDS) and Cryptococcal pneumonia frequently is incontinent of feces and urine and produces copious sputum. When giving this client a bath, which protective equipment should the nurse make it a priority to use? Goggles Surgical mask Shoe covers Gown Gloves N95 hepa mask

Surgical Mask, Gown, Gloves

The nurse is caring for an older adult client. Which genitourinary factor that contributes to urinary incontinence in older adults should the nurse consider when planning care? Sensory deprivation Urinary tract infection Frequent use of diuretics Inaccessibility of a bathroom

Urinary Tract Infection

A client with a history of severe diarrhea for the past 3 days is admitted for dehydration. The nurse anticipates that which intravenous (IV) solution will be prescribed initially? 3% sodium chloride 0.9% sodium chloride 5% dextrose and 0.9% sodium chloride 5% dextrose and lactated Ringer solution

.9% sodium chloride

Oxygen given to clients during stage 4 of chronic obstructive pulmonary disease (COPD) should be administered in which manner? 1 to 2 L via nasal cannula to keep SaO 2 above 90%. 1 to 2 L via nasal cannula to maintain SaO 2 at or above 95%. 3 L via mask to maintain SaO 2 at 95%. Do not give oxygen because it may suppress hypoxic drive in client.

1-2 L via nasal cannula to keep sats above 90%

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

2 year old client with diarrhea

A client tells the nurse that the client's chest tube is scheduled to be removed soon. Before it is removed, what is the nurse aware of? The drainage system will be disconnected from the chest tube. A chest x-ray will be performed to determine lung re-expansion. An arterial blood gas will be obtained to determine oxygenation status. The client will be sedated 30 minutes before the procedure.

A chest x-ray will be performed to determine lung re-expansion

A nurse is explaining the nursing process to a nursing assistant. Which step of the nursing process should include interpretation of data collected about the client? Evaluation Assessment Nursing interventions Proposed nursing care

Assessment

Daily regular insulin has been prescribed for a client with type 1 diabetes. The nurse administers the insulin at 8 am. When should the nurse monitor the client for a potential hypoglycemic reaction? At breakfast Before lunch Before dinner In the early afternoon

Before lunch

What action should the nurse manager take when it becomes apparent that communication between the nurse and the client is consistently superficial? Assessing the client's ability to understand the nurse's questions Evaluating how actively the nurse has been listening to the client Reinforcing to the client how important sharing is for successful recovery Reviewing how the questioning techniques are being used by the client

Evaluating how actively the nurse has been listening to the client

A nurse administers an intravenous solution of 0.45% sodium chloride. In what category of fluids does this solution belong? Isotonic Isomeric Hypotonic Hypertonic

Hypotonic

The nurse teaching a health awareness class identifies which situation as being the highest risk factor for the development of a deep vein thrombosis (DVT)? Pregnancy Inactivity Aerobic exercise Tight clothing

Inactivity

Which client responses does the nurse determine represent the highest risk for the development of pressure ulcers? Incontinence and inability to move independently Periodic diaphoresis and occasional sliding down in bed Reaction to just painful stimuli and receiving tube feedings Adequate nutritional intake and spending extensive time in a wheelchair

Incontinence and inability to move independently

A nurse is providing tracheostomy care. Which action is priority? Place the client in the semi-Fowler position Maintain sterile technique during the procedure Monitor body temperature after the procedure is completed Clean the inner cannula with sterile water when it is removed

Maintain sterile technique during the procedure

A client with pneumonia now requires use of a nonrebreathing mask to maintain adequate oxygen saturation levels. How does the nurse interpret this information? The client's pneumonia is continually improving. Oxygen concentrations up to 44% can be obtained. Mechanical ventilation may be required next. Nasal cannula may be used while the client is eating.

Mechanical ventilation may be required next

On the second day after an abdominoperineal resection, the nurse anticipates that the colostomy stoma will have what appearance? Dry, pale pink, and flush with the skin Moist, red, and raised above the skin surface Dry, purple, and depressed below the skin surface Moist, pink, flush with the skin, and painful when touched

Moist, red and raised above the skin surface

A healthcare provider prescribes two units of blood for a client who is bleeding. Which nursing interventions are necessary before the blood transfusion is administered? Select all that apply. Obtain the client's vital signs. Monitor hemoglobin and hematocrit levels. Allow the blood to reach room temperature. Determine typing and crossmatching of blood. Use a Y-type infusion set to initiate 0.9% normal saline.

Obtain the client's vital signs. Determine typing and crossmatching of blood. Use a Y-type infusion set to initiate 0.9% normal saline.

A nurse is administering high concentrations of oxygen to a 7-year-old child. What is the nurse's most important consideration concerning the oxygen? A nonrebreather mask should be used. The tank should be labeled flammable. Oxygen must be warmed before administration. Oxygen must be humidified before administration.

Oxygen must be humidified before administration

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

Sequence of steps used to meet the clients needs

A client with a history of cardiac dysrhythmias is admitted to the hospital with dehydration. What does the nurse add to the client's plan of care? A glass of water every hour until hydrated Small, frequent intake of juices, broth, or milk Short-term nasogastric (NG) replacement of fluids and nutrients A rapid intravenous (IV) infusion of an electrolyte and glucose solution

Small, frequent intake of juices, broth, or milk

A client attending a prenatal class about nutrition tells the nurse that she is a strict vegetarian (vegan). What should the nurse encourage the client to eat that includes all of the essential amino acids? Macaroni and cheese Whole-grain cereals and nuts Scrambled eggs and buttermilk Brown rice and whole-wheat bread

Whole-grain cereals and nuts

A client is prone to hyponatremia. Which factors should the nurse identify that can precipitate hyponatremia? Select all that apply. Wound drainage Diuretic therapy Gastrointestinal (GI) suction Parenteral infusion of 0.9% sodium chloride Inappropriate anti-diuretic hormone (ADH) secretion

Wound drainage, Diuretic Therapy, GI suctioning, Inappropriate ADH secretion

A client with a chest tube is to be transported via a stretcher. When transporting the client, what should the nurse do? Keep collection device attached to mechanical suction Keep chest tube clamped distal to the water-seal chamber Keep collection device below the level of the client's chest Keep chest tube end covered with sterile gauze pads taped to the client

Keep the collection device below the level of the client's chest

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

Fluid and Electrolyte Balance

A nurse is teaching a client about the use of a metered-dose inhaler with a spacer. Which statement made by the client indicates the need for further teaching? "I will wait for at least 1 minute between puffs." "I will shake the whole unit vigorously one or two times." "I will hold my breath for at least 10 seconds after removing the mouthpiece." "I will insert the mouthpiece of the inhaler into the nonmouthpiece end of the spacer."

I will shake vigorously one or two times

Which step in the nursing process would involve promoting a safe environment for the client? Planning Diagnosis Assessment Implementation

Implementation

The nurse is using non-verbal active listening skills during a clinical therapeutic encounter with a client. Which non-verbal action bestconveys engagement in this client interaction? Sitting with a relaxed posture Leaning toward the client Making eye contact Facing the client

Leaning toward the client

A client is admitted with extensive bone and soft-tissue injuries to the leg. Sterile dressings are applied. Two days later, when removing the dressings, the nurse finds that one of the dressings has adhered to tissue in several places. Which action should the nurse take to loosen the dressing? Apply diluted hydrogen peroxide. Pull with gentle but steady traction. Soak the area in a solution of Betadine. Moisten the dressing with sterile saline.

Moisten the dressing with sterile saline

A client has chest tubes attached to a chest tube drainage system. What should the nurse do when caring for this client? Clamp the chest tubes when suctioning. Palpate the surrounding area for crepitus. Change the dressing daily using aseptic technique. Empty the drainage chamber at the end of the shift.

Palpate the surrounding area for crepitus

The nurse suspects that an intraoperative client has a distended bladder. Which method is correct to assess for this condition? Inspect and palpate in the epigastric region. Auscultate and percuss in the inguinal areas. Percuss and palpate in the hypogastric region. Percuss and palpate bilaterally in the lumbar areas.

Percuss and palpate in the hypogastric region

The nurse understands that the best way to reduce catheter-associated urinary tract infections (CAUTIs) in long-term indwelling catheters is to do what? Perform catheter care twice a day. Replace the catheter on a routine basis. Administer cranberry tablets three times each day. Give antibiotics for the duration of catheter placement.

Perform catheter care twice a day

A nurse is caring for a client with the diagnosis of emphysema, a chronic obstructive pulmonary disease (COPD). The client is hypoxemic and also has chronic hypercarbia. Which statement reflects the oxygen needs of this client? The client may need up to 60% oxygen flow via Venturi mask. The client requires lower levels of oxygen delivery, usually 1 to 3 L/min via nasal cannula. The client should receive humidified oxygen delivered by a face mask. The client's respiratory treatment plan should have oxygen eliminated from it.

The client requires lower levels of oxygen delivery, usually 1-3 l/min via nasal cannula

A client has Clostridium difficile. The nurse is providing discharge instructions related to decreasing the risk of transmission to family members. What would be appropriate to include in the client's teaching? Increase fluids. Increase fiber in the diet. Wash hands with soap and water. Wash hands with an alcohol-based hand sanitizer.

Wash hands with soap and water

What is the most important tool a nurse brings to the therapeutic nurse-client relationship? The self and a desire to help Knowledge of psychopathology Advanced communication skills Years of experience in psychiatric nursing

The self and a desire to help

The nurse provides a list of foods to prevent constipation to a client who has a history of constipation. Which statement from the client indicates the nurse needs to follow up? "I should eat eggs." "I should eat beans." "I should eat fresh fruits." "I should eat steamed vegetables."

"I should eat eggs"

A nursing student is listing the different aspects of obtaining informed consent from clients. Which point mentioned by the nursing student needs correction? "Informed consent is an important part of the nurse-client relationship; it is a vital part of the nursing duty." "Informed consent should be obtained in all situations except during extraordinary circumstances." "Informed consent is provided by clients based on the full disclosure of risks, benefits, alternatives, and consequences of refusal." "The primary healthcare provider legally has to disclose facts in terms that the client is able to understand to make an informed choice."

"Informed consent is an important part of the nurse-client relationship; it is a vital part of the nursing duty."

For a client with difficulty swallowing, the nurse should crush which medication? Metoprolol extended release Felodipine sustained release Acetaminophen extra strength Potassium chloride extended release

Acetaminophen Extra Strength

A healthcare provider prescribes enoxaparin 30 mg subcutaneously daily. Which measure would the nurse take when administering this medication? Push over 2 minutes. Administer in the abdomen. Rub site after administration. Remove air pocket from prepackaged syringe before administration.

Administer in the abdomen

A client with type 1 diabetes of long duration takes NPH insulin 70% and regular insulin 30% every morning. At 11:30 am, before eating lunch, the client is admitted to the emergency department with an acute myocardial infarction. At 1:30 pm, the client's serum glucose level drops to 30 mg/dL (1.7 mmol/L), and insulin coma is diagnosed. To what factor does the nurse attribute the reason for the development of acute hypoglycemia? - Because the client did not eat lunch, glycogenolysis increased after the client took the morning insulin. - Because of the stress brought on by the chest pain, the use of serum glucose available to the client increased. - Because the client is taking insulin shots rather than an oral antidiabetic, the client's glucose level dropped more quickly. - Because of long-term use of insulin, the client's body became sensitive to the insulin dose, causing blood glucose levels to drop erratically.

Because the client is taking insulin shots rather than an oral antidiabetic, the client's glucose level dropped more quickly.

The client is receiving high-flow intravenous (IV) fluid replacement therapy. Which nursing assessment findings are consistent with fluid volume overload? Select all that apply. Pulse quality Pulse pressure Bounding pulse Presence of dependent edema Neck vein distention in the upright position

Bounding pulse; Presence of dependent edema; Neck vein distention in the upright position

Which nursing interventions would be beneficial for providing safe oxygen therapy? Select all that apply. Check tubing for kinks Run wires under carpeting Post "no smoking" signs in the clients' rooms Place oxygen tanks flat in the carts when not in use Make sure that the client is familiar with the phrase "Stop, drop, and roll"

Check tubing for kinks; Post "no smoking" signs in the clients' rooms

A nurse assesses a client's intravenous site. What clinical finding, unique to infiltration, leads the nurse to conclude that the intravenous (IV) site has infiltrated, rather than become inflamed? Pain Coolness Localized swelling Cessation in flow of solution

Coolness

Which intervention should the nurse implement to help prevent atelectasis in a client with fractured ribs as a result of chest trauma? Apply a thoracic binder for support. Encourage coughing and deep breathing. Defer pain medication the first day after injury. Position the client face-down on a soft mattress.

Encourage coughing and deep breathing

On admission to the intensive care unit, a client is diagnosed with compensated metabolic acidosis. During the assessment, what is the nurse most likely to identify? Muscle twitching Mental instability Deep and rapid respirations Tachycardia and cardiac dysrhythmias

Deep and rapid respirations

A nurse inspects a two-day-old intravenous (IV) site and identifies erythema, warmth, and mild edema. The client reports tenderness when the area is palpated. What should the nurse do first? Irrigate the IV tubing Discontinue the infusion Slow the rate of the infusion Obtain a prescription for an analgesic

Discontinue the Infusion

The nurse educates a client on decreasing the risk of developing antibiotic-resistant infections. Which statement made by the nurse will be most significant? "Wash your hands frequently." "Do not skip any dose of your antibiotics." "Save the unfinished antibiotics for later use." "Stop taking the antibiotics when you feel better."

Do not skip any dose of your antibiotics

When caring for a client with pneumonia, which nursing intervention is the highest priority? Increase fluid intake. Employ breathing exercises and controlled coughing. Ambulate as much as possible. Maintain a nothing-by-mouth (NPO) status.

Employ breathing exercises and controlled coughing

A residual urine test is prescribed for a client with benign prostatic hyperplasia. What should the nurse instruct the client to do? Void after a urinary catheter is removed. Collect a specimen of urine during midstream. Attempt to void when a urinary catheter is in place. Empty the bladder before a urinary catheter is inserted.

Empty the bladder before urinary catheter is inserted

A client is hospitalized with pressure ulcers. Which task could be delegated to an unlicensed nursing professional (UNP)? Select all that apply. Empty wound drainage containers. Report changes in wound appearance. Apply prescribed dressings and medications. Assess and record data about wound appearance. Choose dressings and therapies for wound treatment.

Empty wound drainage containers; Report changes in wound appearance.

When obtaining a health history, the nurse is informed that a client has been taking digoxin. What therapeutic effect of digoxin does the nurse expect? Decreased cardiac output Decreased stroke volume of the heart Increased contractile force of the myocardium Increased electrical conduction through the atrioventricular (AV) node

Increased contractile force of the myocardium

After emergency surgery, the nurse teaches a client how to use an incentive spirometer. What client behavior indicates to the nurse that the spirometer is being used correctly? Inhales deeply through the mouthpiece, relaxes, and then exhales. Inhales deeply, seals the lips around the mouthpiece, and exhales. Uses the incentive spirometer for 10 consecutive breaths per hour. Coughs several times before inhaling deeply through the mouthpiece.

Inhales deeply through the mouthpiece, relaxes, then exhales

While visiting the hospital, the spouse of a client slips and falls on a recently washed floor in the hallway leading to the client's room. To meet the criteria of ethical practice, what action should the nurse who witnessed the occurrence take? Initiate an agency incident report. Report the fall to the state (provincial) health department. Write a brief description of the incident to be kept by the nurse manager. Determine that no documentation is needed because the visitor is not a client in the hospital.

Initiate an agency incident report

A registered nurse is evaluating the actions of a nursing student who is injecting an allergen in a client having a severe anaphylactic reaction to insect venom. Which action of the nursing student requires correction? Rotating the sites for each injection Aspirating for blood before giving the injection Injecting in an extremity close to a joint Observing the client for 20 minutes after an injection

Injecting in an extremity close to a joint

A nurse is caring for a client who has urinary incontinence as the result of a cerebrovascular accident (also known as "brain attack"). What action should the nurse include in the plan of care to limit the occurrence of urinary incontinence? Insert a urinary retention catheter. Institute measures to prevent constipation. Encourage an increase in the intake of caffeine. Suggest that a carbonated beverage be ingested daily.

Institute measures to prevent constipation

The nurse is transferring a client from the bed to the chair. Which action should the nurse take during the transfer? - Place the client in a semi-Fowler position. - Stand behind the client during the transfer. - Turn the chair so it faces away from the bed. - Instruct the client to dangle the legs.

Instruct the client to dangle the legs

The nurse is caring for a client who is receiving intermittent intravenous piggyback doses of vancomycin every 12 hours. The primary healthcare provider prescribes trough levels of the antibiotic. The nurse schedules the blood sample to be obtained at what time? Just before the medication is administered Between 30 and 60 minutes after the infusion is completed Six hours after the dose is completely infused In the morning before the client eats breakfast

Just before the medication is administered

A client who had a right total hip replacement is progressing from the use of a walker to the use of a cane. In which hand should the nurse teach the client to hold the cane? Left hand Right hand Stronger hand Dominant hand

Left Hand

The fire alarm is sounding in a skilled nursing facility and smoke is pouring from the kitchen. What should the nurse do to ensure the safety of the clients, staff, and family members? Select all that apply. - Move bedridden clients via stretcher - Place ambulatory clients in wheelchairs - Turn off all sources of supplemental oxygen - Provide manual respiratory support to critically ill clients - Close all windows and doors and use an ABC fire extinguisher

Move bedridden clients via stretcher, Turn off all sources of supplemental oxygen, Provide manual respiratory support to critically ill clients, Close all windows and doors and use an ABC fire extinguisher

A client with a history of heart failure is experiencing dyspnea with a respiratory rate of 32. Crackles are noted bilaterally. The client is in Sims position, receiving oxygen at 2 L/min via nasal cannula. Which action should the nurse take first? Raise the client to high-Fowler position Obtain the apical pulse and blood pressure Call the primary healthcare provider immediately Monitor the pulse oximeter to ascertain the oxygen level

Raise the client to high-fowler position

A nurse is following the guidelines for high-quality documentation and reporting. Which guideline followed by the nurse while documenting factual records indicates a need for additional training? "The client seems restless." "The client states, 'I am worried.'" "The client's pulse rate is 90 beats/min." "The client has a body temperature of 39° C (102.2° F)."

The client seems restless

To prepare a client for surgery, which explanation by a nurse would be accurate related to pneumatic compression devices? They help the venous blood return to the heart. They will not cause discomfort, but gently massage the legs. They are used instead of anticoagulant therapy. They must be worn until the first time the client gets out of bed.

They help the venous blood return to the heart

Three days after surgery for cancer of the colon, a nurse introduces the client to colostomy care. Which should the nurse teach the client about skin care around the stoma? Apply liberal amounts of Vaseline for 3 inches (7.6 centimeters) around the stoma Wash the area with soap and water and then apply a protective ointment Pour saline over the stoma and rub the area to remove hard fecal matter Rinse the area with peroxide before applying fresh gauze bandages

Wash the area with soap and water and then apply a protective ointment

A female client has a history of recurrent urinary tract infections. What should the nurse include in the teaching plan when educating the client about health practices that may help decrease future urinary tract infections? "Wear cotton underpants." "Void at least every 6 hours." "Increase foods containing alkaline ash in the diet." "Wipe from back to front after toileting."

"Wear cotton underpants"

The nurse is preparing to perform endotracheal suctioning of a client with respiratory difficulties. Before beginning the procedure, what should the nurse do? Ask the client to take several deep breaths. Instruct the client to cough before suctioning. Administer 100% oxygen to the client. Change the suctioning equipment to ensure sterility.

Administer 100% oxygen to the client

To prevent excessive bruising when administering subcutaneous heparin, what technique will the nurse employ? Administer the injection via the Z-track technique Avoid massaging the injection site after the injection Use 2 mL of sterile normal saline to dilute the heparin Inject the drug into the vastus lateralis muscle in the thigh

Avoid massaging the injection site after the injection

A Foley catheter was placed with an urimeter for a client with heart failure receiving furosemide. The output is 45 mL/hour, cloudy, and has sediment. How should the nurse interpret these findings? The furosemide is causing dehydration. Cloudy urine may be indicative of infection. The client has inadequate hourly urine output. All of the indications are within normal findings.

Cloudy urine may be indicative of infection

A nurse provides discharge teaching to an older adult about care associated with activities of daily living. Which factor should the nurse mainly consider when counseling the client on how often to take a tub bath? - Condition of the skin - Ability of the client to provide self-care - Degree of orientation to the environment - Type of allergic reactions experienced by the client

Condition of the skin

A nurse is providing immediate postoperative care to a client who had a lung resection for a malignancy. The client has a closed chest tube drainage system connected to suction. Which assessment finding requires additional evaluation by the nurse? A column of water 20 cm high in the suction control chamber 75 mL of bright red blood in the drainage collection chamber An intact occlusive dressing at the insertion site Constant bubbling in the water seal chamber

Constant bubbling in the water seal chamber

The nurse assesses a client receiving intravenous (IV) fluids. Which assessment finding should warrant the nurse calling the primary healthcare provider? Crackles in lungs Supple skin turgor Urine output of 240 mL over 8 hours Increase in blood pressure from 110/76 to 124/68 mm Hg

Crackles in the lungs

A client is admitted to the hospital for medical treatment of bronchopneumonia. Which test result should the nurse examine to help determine the effectiveness of the client's therapy? Bronchoscopy Pulse oximetry Pulmonary function studies Culture and sensitivity tests of sputum

Culture and sensitivity tests of sputum

Health promotion efforts within the healthcare system should include efforts related to secondary prevention. Which activities reflect secondary prevention interventions in relation to health promotion? Select all that apply. Encouraging regular dental checkups Facilitating smoking cessation programs Administering influenza vaccines to older adults Teaching the procedure for breast self-examination Referring clients with a chronic illness to a support group

Encouraging regular dental checkups; teaching the procedure for breast self-examination

A client is admitted to the hospital with a diagnosis of an exacerbation of asthma. What should the nurse plan to do to best help this client? Determine the client's emotional state. Give prescribed drugs to promote bronchiolar dilation. Provide education about the impact of a family history. Encourage the client to use an incentive spirometer routinely.

Give prescribed drugs to promote bronchiolar dilation

A client is admitted with multiple injuries as a result of an accident. A tracheostomy was performed. While the nurse is caring for this client, the client coughs, expelling the tracheostomy tube onto the bed. What should the nurse's first action be? - Hold the tracheostomy open with a tracheal dilator and call for assistance - Insert an obturator into the tracheostomy and gently reinsert the tracheostomy tube - Pick up the tracheostomy tube from the bed and replace it until a new tube is available - Obtain a new tracheostomy tube, prepare the new holder, and insert the tube using the obturator

Hold the tracheostomy open with a tracheal dilator and call for assistance

The nurse is teaching a client self-management care in preventing and spreading methicillin-resistant Staphylococcus aureus (MRSA). Which statements made by the client indicate the need for further learning? Select all that apply. "I can share athletic equipment." "I can participate in contact sports." "I should sit on upholstered furniture." "I should use antibacterial soaps for bathing." "I should wash all infected skin areas before covering those areas."

I can share athletic equipment, I can participate in contact sports, I should sit on upholstered furniture

A client is admitted to the hospital with urinary retention, and an indwelling urinary catheter is prescribed by the primary healthcare provider. What should the nurse do to help prevent the client from developing a urinary tract infection? Assess urine specific gravity. Collect a weekly urine specimen. Maintain the prescribed hydration. Empty the drainage bag once a day.

Maintain the prescribed hydration

When reviewing a drug to be administered, the nurse identifies that the package insert indicates that the Z-track injection technique should be used. Under what circumstance does the nurse expect that this technique will be necessary? Volume of medication to be administered is large. Medication is irritating to subcutaneous tissue and skin. Injection site must be massaged after it is administered. Procedure requires an air bubble to be drawn into the syringe.

Medication is irritating to subcutaneous tissue and skin

A nurse is caring for a client with a tracheostomy. Which action should the nurse implement when performing tracheal suctioning? Preoxygenate the client before suctioning. Employ gentle suctioning as the catheter is being inserted. Be sure the cuff of the tracheostomy is inflated during suctioning. Loosen the client's secretions before suctioning by instilling saline.

Preoxygenate the client before suctioning

A nurse repositions a client who is diagnosed with emphysema to facilitate breathing. Which position facilitates maximum air exchange? Supine Orthopneic Low-Fowler Semi-Fowler

Orthopneic

A nurse uses therapeutic communication techniques in order to achieve desired client outcomes. Which communication technique is a part of therapeutic communication? Asking for explanations Showing sympathy to the client Asking personal questions of the client Providing relevant information to the client

Providing relevant information to the client

Which intervention would be most beneficial in preventing a catheter-associated urinary tract infection in a postoperative client? Pouring warm water over the perineum Ensuring the patency of the catheter Removing the catheter within 24 hours Cleaning the catheter insertion site

Removing the catheter within 24 hours

A healthcare provider prescribes a standard walker (pick-up walker with rubber tips on all four legs). The nurse identifies what clinical findings that indicate the client is capable of using a standard walker? - Weak upper arm strength and impaired stamina - Weight bearing as tolerated and unilateral paralysis - Partial weight bearing on the affected extremity and kyphosis - Strong upper arm strength and non-weight bearing on the affected extremity

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

A nurse is providing immediate postoperative care to a client with a tracheostomy tube in place. The client suddenly develops noisy, increased respirations and an elevated heart rate. What action should the nurse take immediately? Suction the tracheostomy. Change the tracheostomy tube. Readjust the tracheostomy tube and tighten the ties. Perform a complete respiratory assessment.

Suction the tracheostomy