Fundamentals Practice Exam A
A nurse is caring fro a client who is postoperative and has signs of hemorrhagic shock. when the nurse notifies the surgeon, he directs her to continue to take the client's vital signs every 15 min and call him back in 1 hr. from a legal perspective, which of the following actions should the nurse take next? Document the provider's statement in the medical record. Complete an incident report. Consult the facility's risk manager. Notify the nursing manager.
Notify the nurse manager The greatest risk to the client is not receiving timely intervention for a deterioration in physiological status; therefore, the next action the nurse should take is to activate the chain of command to ensure that the client receives the necessary care. -The nurse should document the provider's directions in the medical record for later reference; however, another action is the nurse's priority. -The nurse should prepare an incident report detailing the delay in treatment for later review and action for prevention of future occurrences; however, another action is the nurse's priority. -The nurse should discuss the situation with the facility's risk management department to help determine the need for preventive actions; however, another action is the nurse's priority.
A nurse is caring for a client who has a terminal illness and is at the end of life. The nurse should recognize that which of the following statements by the client's partner indicates effective coping ? "I am not worried because I still have hope that he will be okay." "I am relying on support from our family during this time." "We can plan our family reunion once he recovers and comes home." "We don't see any reason to start discussing funeral arrangements right now."
"I am relying on support from our family during this time." This statement indicates effective coping because the partner is relying on others in the family for support during a time of crisis. -This statement reflects false hope and possible denial of the terminal nature of the client's illness. Denial involves the blocking of painful thoughts or feelings that induce anxiety. This statement reflects false hope and possibly denial of the terminal nature of the client's illness. Denial involves the blocking of painful thoughts or feelings that induce anxiety. -This statement reflects potential false hope about and possible denial of the terminal nature of the client's illness. It also indicates the partner's potential inability or unwillingness to address unpleasant or challenging issues related to the client's death.
A nurse manager is preparing to review medication documentation with a group of newly licensed nurses. Which of the following statements should the nurse manager plan to include in the teaching? "Delete the space between the numerical dose and the unit of measure." "Write the letter U when noting the dosage of insulin." "Use the abbreviation SC when indicating an injection."
"Use the complete name of the medication magnesium sulfate." The Institute for Safe Medication Practices designates that nurses and providers write the complete medication name for magnesium sulfate when documenting medications to avoid any misinterpretation of MgSO4 as MSO4, which means morphine sulfate. -The Institute for Safe Medication Practices recommends including a space between the dose and the unit of measure, such as in 10 mg, to avoid confusion when documenting medication dosages. -The Institute for Safe Medication Practices designates "unit(s)" as the correct term for use in medication documentation. -The Institute for Safe Medication Practices designates either "subcut" or "subcutaneously" as the correct terms for use in medication documentation.
A nurse is responding to a call light and finds a client lying on the bathroom floor. Which of the following actions should the nurse take first? Check the client for injuries. Move hazardous objects away from the client. Notify the provider. Ask the client to describe how she felt prior to the fall.
Check the client for injuries Explanations: The first action the nurse should take when using the nursing process is to assess the client for injuries. -Moving hazardous objects away from the client can prevent further injury; however, there is another action the nurse should take first. -The nurse should notify the provider of the client's fall; however, there is another action the nurse should take first. -Determining the facts that surrounded the fall is important to help prevent subsequent falls; however, there is another action the nurse should take first.
The nurse is admitting a client who has an abdominal wound with a large amount of purulent drainage. Which type of transmission precautions should the nurse initiate? Protective environment Airborne precautions Droplet precautions Contact precautions
Contact precautions Major wound infections require contact precautions, which means the nurse should admit the client to a private room. All caregivers should wear a gown and gloves during direct contact with patient) -Clients who have a compromised immune system require a protective environment. -Airborne precautions are a requirement for clients who have infections that spread via droplet nuclei that are smaller than 5 microns in diameter, including tuberculosis and measles. -Droplet precautions are a requirement for clients who have infections that spread via droplet nuclei that are larger than 5 microns in diameter, including rubella, meningococcal pneumonia, and streptococcal pharyngitis.
A nurse is assessing a client's readiness to learn about insulin self-administration. Which of the following statements should the nurse identify as an indication that the client's ready to learn? I can concentrate best in the morning." "It is difficult to read the instructions because my glasses are at home." "I'm wondering why I need to learn this." "You will have to talk to my wife about this."
I can concentrate best in the morning." Explanation: The client's statement indicates a readiness to learn because he is verbalizing the best time for him to learn. -The client's statement indicates the client is not ready to learn. The client has to have the tools he needs to learn and comprehend the information. -The client's statement indicates a reluctance to learn information he thinks he might not need to know. -With this statement, the client is redirecting the nurse's attempt to teach toward someone else, indicating that he is not ready to learn.
A nurse is talking with an older adult client who is contemplating retirement. The client states, "I keep thinking about how much I enjoy my job. I'm not sure if I want to retire." Which of the following responses should the nurse make?
Let's talk about how the change in your job status will affect you Explanation: This response is therapeutic because the nurse is encouraging the client to verbalize feelings about the life transition of retirement
A nurse is initiating a protective environment for a client who has had an allogeneic stem cell transplant. Which of the following precautions should the nurse plan for this client? Make sure the client's room has at least six air exchanges per hour. Make sure the client wears a mask when outside her room if there is construction in the area. Place the client in a private room with negative-pressure airflow. Wear an N95 respirator when giving the client direct care.
Make sure the client wears a mask when outside her room if there is construction in the area. explanation: An allogeneic stem cell transplant compromises the client's immune system, greatly increasing the risk for infection. The client will need protection from breathing in any pathogens in the environment. -A protective environment requires at least 12 air exchanges per hour. -The nurse should place the client in a private room that provides -The nurse should wear an N95 respirator mask when caring for clients who require airborne precautions, not a protective environment.
A nurse is using an open irrigation technique to irrigate a client's indwelling urinary catheter. Which of the following actions should the nurse take? Place the client in a side-lying position. Instill 15 mL of irrigation fluid into the catheter with each flush. Subtract the amount of irrigant used from the client's urine output. Perform the irrigation using a 20-mL syringe.
Subtract the amount of irrigant used from the client's urine output. The nurse should calculate the fluid used for irrigation and subtract it from the client's total urinary output. -For a catheter irrigation, the nurse should place the client in a supine or dorsal recumbent position for maximal access to the catheter. -Open irrigation technique requires instilling 30 to 40 mL of irrigation fluid. -The nurse should use a 30- to 50-mL syringe to perform open irrigation.
A nurse is evaluating a client's use of a cane. Which of the following actions should the nurse identify as an indication of correct use? The top of the cane is parallel to the client's waist. When walking, the client moves the cane 46 cm (18 in) forward. The client holds the cane on the stronger side of her body. The client moves her stronger limb forward with the cane.
The client should hold the cane on the stronger side of her body to increase support and maintain alignment. -The top of the cane should be parallel to the client's greater trochanter. -To maintain balance, the client should advance the cane about 15 to 30 cm (6 to 12 in) at a time. -The client should move her weaker leg forward with the cane. This divides the client's body weight between the cane and the stronger leg.
A nurse is caring for a client who has a terminal illness and is approaching death. The client is short of breath and has noisy respirations from secretions in their airway. Which of the following actions should the nurse take? Turn the client every 2 hr. Administer an antiemetic every 6 hr. Hold oral care. Increase the room's temperature.
Turn the client every 2 hr. Explanation: The nurse should turn the client at least once every 2 hr to break up the secretions in the client's lungs and prevent noisy respirations. -The nurse should administer antiemetics for clients who are experiencing nausea or vomiting. However, this is not the correct action to take when assisting a client who is experiencing respiratory difficulty at the end of life. -The nurse should provide frequent oral care in order to keep the client's mouth moist and provide comfort. -Keeping the air temperature cool by allowing air to circulate with the use of a fan or opening windows is more comfortable for a client who is dying and will decrease air hunger.
A nurse on a medical surgical unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse take?
Pad the client's wrist before applying the restraints Explanation: The use of restraints without padding can abrade the client's skin resulting in client injury
A nurse is reviewing evidence-based practice principles about administration of oxygen therapy with newly licensed nurse. Which of the following actions should the nurse include? Regulate the flow rate by aligning the rate with the top of the ball inside the flow meter. Regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min. Make sure the reservoir bag of a partial rebreathing mask remains deflated. Use petroleum jelly to lubricate the client's nares, face, and lips.
regulate oxygen via nasal cannula at a flow rate no more than 6 L/min explanation: Evidence-based practice supports a flow rate of 1 to 6 L/min via nasal cannula. Rates above 6 L/min have a drying effect and force clients to swallow air excessively without increasing their fraction of inspired oxygen (FiO2). -The nurse should regulate the oxygen flow rate by aligning the rate on the flow meter with the middle of the silver ball inside the meter. -The reservoir bag should inflate by one-third to one-half with inspiration. If it remains deflated, it indicates that clients are breathing in too much of the carbon dioxide they exhale. -Evidence-based practice supports the use of a water-soluble lubricant to protect the client's skin from the drying effects of oxygen.
A nurse in a long-term care facility is caring for a client who dies during the nurse's shift. Identify the sequence in which the nurse should perform the following steps.
The first step is to obtain the death pronouncement from the provider. Next, the nurse should remove tubes and indwelling lines prior to cleansing the client's body. After cleansing, the nurse should ask the family members if they wish to view the body. Finally, the nurse should place a name tag on the body before transfer.
The nurse is caring for a client with a respiratory infection. Which of the following techniques should the nurse use when performing nasotracheal suctioning for the client Insert the suction catheter while the client is swallowing. Apply intermittent suction when withdrawing the catheter. Place the catheter in a location that is clean and dry for later use. Hold the suction catheter with her clean, nondominant hand.
apply intermittent suction when withdrawing the catheter Explanation: This is to prevent injury to the mucosa. However, suctioning continuously for more than 10 seconds can cause cardiopulmonary compromise. -The nurse should insert the suction catheter while the client is inhaling to avoid inserting the catheter into the esophagus. -The nurse should discard the suction catheter after use to eliminate the risk of reintroducing pathogens into the respiratory tract. -Hold the suction catheter with her clean, nondominant hand.
A nurse is preparing to administer 750 mL of 0.9% sodium chloride IV to infuse over 7 hr. The nurse should set the infusion pump to deliver how many mL/hr? (Round to the nearest whole number.
750 mL/7 hr = 107.1 mL/hr = 107 mL/hr Volume (mL)X mL/hr = Time (hr) 750 mLX mL/hr = 7 hr X mL/hr = 107.14 mL/hr
A nurse is performing a skin assessment for a client who expresses concern about skin cancer. Which of the following findings should the nurse identify as potential indication of a skin malignancy? A lesion with uniform pigmentation New appearance of petechiae A mole with an asymmetrical appearance The presence of a papule
A mole with an asymmetrical appearance Explanation: An uneven or asymmetrical shape is a potential indication of a skin malignancy. This is manifested when part of a lesion or mole looks different from the other part. -Variations in pigmentation are a possible indication of a skin malignancy. A lesion with uniform pigmentation is not an expected indication of a skin malignancy. -Petechiae are capillaries that have burst under the skin and appear as small spots on the skin. Although they can be indications of other conditions, petechiae are not an expected indication of a skin malignancy. -Papules are solid elevations that are palpable in the skin and are less than 1 cm (0.39 in) in size. They are not an expected indication of a skin malignancy.
A nurse is preparing to apply a dressing for a pt who has a stage 2 pressure injury. Which of the following types of dressing should the nurse use?
Hydrocolloid Hydrocolloid dressings promote healing in stage 2 pressure injuries by creating a moist wound bed. -Alginate dressings are used to treat stage 3 and 4 pressure injuries to absorb drainage. Alginate forms a soft gel when it comes in contact with drainage. -Moistened gauze promotes healing in stage 4 or unstageable pressure injuries by causing debridement and allowing granulation of the wound bed. -Transparent dressings promote healing in stage 1 pressure injuries by preventing further friction and shearing.
A nurse is assessing a client who reports increased pain following physical therapy. Which of the following questions should the nurse ask when assessing the quality of the client's pain.
Is your pain sharp or dull Explanation: This helps determine the quality of the pain. QRSTU
A nurse is caring for a group of clients. Which of the following actions should the nurse take to prevent the spread of infection? Carry a client's soiled linens out of the room in a mesh linen bag. Place a client who has tuberculosis in a room with negative-pressure airflow. Provide disposable plates and utensils for a client who is HIV-positive. Dispose of a client's blood-saturated dressing in a trash bag inside a second trash bag.
Place a client who has tuberculosis in a room with negative-pressure airflow. A client who has tuberculosis requires airborne precautions, which include placing the client in a room that has negative-pressure airflow to reduce the risk of infection transmission.
A nurse is assessing a client's electrolyte status. Which of the following finding should the nurse report to the provider? BUN 15 mg/dL Creatinine 0.8 mg/dL Sodium 143 mEq/L Potassium 5.4 mEq/L
Potassium 5.4 mEq/L This value is above the expected reference range of 3.5 to 5 mEq/L, so the nurse should report this finding to the provider. This client is at risk for dysrhythmias. -BUN 15 mg/dL: This value is within the expected reference range of 10 to 20 mg/dL. -Creatinine 0.8 mg/dL: This value is within the expected reference range of 0.5 to 1.1 mg/dL for women 41 to 60 years of age and 0.6 to 1.3 mg/dL for men 41 to 60 years of age. Even for clients within younger and older age ranges (with the exception of newborn through 9 years of age), 0.8 mg/dL is within the expected reference range for creatinine. -Sodium 143 mEq/L: This value is within the expected reference range of 136 to 145 mEq/L.
A nurse is caring for a client who is expressing anger about his diagnosis of colorectal cancer. Which of the following actions should the nurse take?
Reassure the client that this is an expected response. Explanation: During the anger stage of the psychosocial adaptation to illness, the nurse should support the client and explain that this is an expected reaction to a cancer diagnosis
A nurse is talking with the partner of a client who has dementia. The client's partner expresses frustration about finding time to manage household responsibilities while caring for his partner. Role ambiguity Sick role Role overload Role conflict
Role overload The partner's expression of frustration is an example of role overload, which refers to having more responsibilities within a role than one person can manage. -Role ambiguity occurs when people are unclear about the expectations of their role in a given situation. -Sick role refers to the expectations placed on the individual who has the alteration in health, rather than the caregiver. -Role conflict develops when a person must assume multiple roles that have opposing expectations.
A home health nurse is performing a follow up visit for a client who has a gastrostomy tube through which they receive intermittent feedings and medications. The client has recently developed diarrhea. Which of the following findings should the nurse identify as a possible cause of the diarrhea ?
The client's caregiver washes out the feeding bag with warm water every 24 hrs. Explanation: Feeding bags should be washed out after every feeding to prevent bacterial contamination
A nurse is preparing to administer enoxaparin subcutaneously to a client. Which of the following actions should the nurse take? Administer the medication with the needle at a 45° angle. Administer the medication into the client's nondominant arm. Pull the client's skin laterally or downward prior to administration. Massage the injection site after administration
administer the medication with the needle at a 45º angle Explanation: The nurse should insert the needle at a 45° to 90° angle for a subcutaneous injection. -The nurse should administer enoxaparin into the abdomen, at least 5 cm (2 in) from the umbilicus. -The Z-track technique involves displacing the skin laterally or downward prior to administration of an IM injection. -The nurse should not massage the injection site following the injection of an anticoagulant due to the risk for bruising.
A nurse is caring for a client who asks about the purpose of the advance directives. Which of the following statements should the nurse make? They allow the court to overrule an adult client's refusal of medical treatment." "They indicate the form of treatment a client is willing to accept in the event of a serious illness." "They permit a client to withhold medical information from health care personnel." "They allow health care personnel in the emergency department to stabilize a client's condition."
"They indicate the form of treatment a client is willing to accept in the event of a serious illness." Explanation: Advance directives include a living will, which permits clients to direct the treatment they will receive in the event of a medical emergency or serious illness. -A court can only overrule an adult client's refusal of medical treatment if the client is legally incompetent. -The Americans with Disabilities Act, not advance directives, protects the privacy of a client who chooses not to disclose a medical disability. -The Emergency Medical Treatment and Active Labor Act, not advance directives, directs emergency personnel to provide screening and stabilizing care before discharging or transferring clients to another facility.
a nurse is assessing an older adult client's risk for falls. Which of the following assessments should the nurse use to identify client's safety needs? Lacrimal apparatus Pupil clarity Appearance of bulbar conjunctivae Visual fields Visual acuity
- pupil clarity - visual fields - visual acuity Explanation: Cloudy pupils mean that the client has cataracts. This makes vision cloudy and creates halos around lights, which can increase the risk for falls because clients cannot see items in their path clearly. The nurse should use a finger to test the client's peripheral vision by moving the finger out of range and then back into the visual field to determine when the client sees the finger. Clients who have a visual field impairment are at an increased risk for falls because they might not see objects outside of their central vision and trip over them or bump into them and fall. The nurse should use a Snellen chart to assess distance vision and a handheld card to assess near vision. Clients who wear eyeglasses should wear them during the assessments. Clients who have impaired visual acuity are at an increased risk for falls because they might not see objects in their path and trip over them or bump into them and fall.
A nurse is preparing an education program for staff about advocacy. Which of the following should the nurse include? Advocacy ensures clients' safety, health, and rights. Advocacy ensures that nurses are able to explain their own actions. Advocacy ensures that nurses follow through on their promises to clients. Advocacy ensures fairness in client care delivery and use of resources.
Advocacy ensures clients' safety, health, and rights. Explanation: As a client advocate, the nurse ensures clients' safety, health, and rights, including the right to privacy, confidentiality, and refusal of care. -Accountability, not advocacy, is the responsibility of nurses to explain their own actions to their clients and employer. -Fidelity, not advocacy, is an agreement by nurses to follow through with promises made to clients. -Justice, not advocacy, is fairness in client care delivery, including the distribution of resources and care
A nurse is assessing a client who has required bed rest for the past month. Which of the following findings should the nurse identify as an indication that the client has developed thrombophlebitis? Bladder distention Decreased blood pressure Calf swelling Diminished bowel sounds
Calf Swelling Explanation: Swelling, redness, and tenderness in a calf muscle are manifestations of thrombophlebitis, a common complication of immobility. -Urinary retention, which causes bladder distention, is a common complication of bed rest due to a loss of muscle tone in the bladder and detrusor muscles. -A client who requires bed rest can develop postural hypotension, which is a drop in blood pressure when the client moves from a lying to a sitting position. The nurse should also assess the client for an increase in pulse rate and dizziness. -A decrease in bowel sounds reflects slowed peristalsis. Constipation is a common complication of immobility
A nurse is assessing four adult clients. Which of the following physical assessment techniques should the nurse use? Use the Face, Legs, Activity, Cry, and Consolability (FLACC) pain rating scale for a client who is experiencing pain. Ensure the bladder of the blood pressure cuff surrounds 80% of the client's arm. Obtain an apical heart rate by auscultating at the third intercostal space left of the sternum. Palpate the client's abdomen before auscultating bowel sounds.
Ensure the bladder of the blood pressure cuff surrounds 80% of the client's arm. The nurse should use a blood pressure cuff with a bladder that surrounds 80% of the client's arm circumference to give an accurate reading. -The nurse should use an age-appropriate pain-rating scale, such as the visual analog or numerical scale, when assessing the pain level of an adult. The FLACC pain rating scale is used for clients aged from 2 months to 7 years old -The nurse should place the stethoscope at the point of maximal impulse, which is at the fifth intercostal space at the midclavicular line left of the sternum. -When assessing an adult client's abdomen, the nurse should auscultate bowel sounds before performing palpation in order not to change the character of the sounds.
A nurse is caring for a client who requires an NG tube for stomach decompression. Which of the following actions should the nurse take when inserting the NG tube? osition the client with the head of the bed elevated to 30° prior to insertion of the NG tube. Remove the NG tube if the client begins to gag or choke. Apply suction to the NG tube prior to insertion. Have the client take sips of water to promote insertion of the NG tube into the esophagus.
Have the client take sips of water to promote insertion of the NG tube into the esophagus. Explanation: Taking sips of water as the NG tube passes through the oropharynx will close the epiglottis over the trachea and prevent the tube from passing into the trachea. -The nurse should not apply suction until the NG tube is in place with x-ray verification of its position in order to reduce the risk of injury to the client. -The nurse should withdraw the NG tube slightly, not remove it, if the client gags or chokes to reduce the risk of injury to the client. -The client should be sitting in high-Fowler's position with the head of the bed elevated to 90° to reduce the risk for aspiration.
A nurse is providing discharge instructions to a client who will be using a walker. Which of the following client statements indicates an understanding of the teaching? "I can place an extension cord across my living room to plug in my television." "I will hire someone to trim the tree that hangs low over the stairs of my front porch." "I will place my alarm clock on my bedroom dresser across the room." "I will replace the old throw rug in my kitchen with a new one."
I will hire someone to trim the tree that hangs low over the stairs of my front porch. Explanation: Clearing stairs of any object that could cause the client to trip or require them to bend over while walking will decrease the risk for falls. -Extension cords should be securely fastened to the floor and should be run along the edge of the wall, if possible, to avoid the risk for tripping. -Frequently used items like an alarm clock, glasses, or disposable tissues should be placed within reach, such as on the client's night stand. This helps to prevent the client from needing to get up and potentially falling in the night. -Using throw rugs increases the client's risk for falls because they create a tripping and slipping hazard for the client.
A nurse is caring for a client who is post-operative following knee arthroplasty and requires the use of thigh length sequential compression sleeves. Which of the following actions should the nurse take? Assist the client into a prone position. Place a sleeve over the top of each leg with the opening at the knee. Make sure two fingers can fit under the sleeves. Set the ankle pressure at 65 mm Hg.
Make sure two fingers can fit under the sleeves. The nurse should ensure that there is enough space for two fingers to fit under the sleeve because any less space between the sleeves and the legs can inhibit circulation when the sleeves inflate. -The nurse should place the client in a dorsal recumbent or semi-Fowler's position to facilitate application of the sleeves. -The nurse should place the sleeve under each leg with the opening at the knee and then wrap the sleeve around the leg so that it is secure. -The nurse should set the ankle pressure between 35 and 55 mm Hg to achieve a therapeutic effect while also preventing damage to the client's skin and circulatory impairment.
A nurse is preparing a change of shift report. Which of the following tools or documents should the nurse use to communicate continuity of care Critical pathway Situation, background, assessment, and recommendation (SBAR) Transfer report Medication administration record (MAR)
Situation, background, assessment, and recommendation (SBAR) Explanation: SBAR is a communication tool nurses use to relate a client's status during a change-of-shift report. -A critical pathway is an interprofessional approach to planning all phases of client care. -The nurse should use a transfer report when the client is moving from one health care area or facility to another. -The nurse should use the MAR to document medication administration.
A nurse is lifting a bedside cabinet to move it closer to a client who is sitting in a chair. To prevent self-injury, which of the following actions should the nurse take when lifting this object? Bend at the waist. Keep his feet close together. Use his back muscles for lifting. Stand close to the cabinet when lifting it.
Stand close to the cabinet when lifting it. This action keeps the cabinet close to the nurse's center of gravity and decreases back strain from horizontal reaching. -The nurse should bend the knees when lifting the cabinet. -The nurse should spread the feet wide apart to create a broad base of support. This promotes stability while lifting the cabinet. -The nurse should use the arm and leg muscles when lifting the cabinet because they are generally stronger than back muscles.
A nurse in a provider's office is assessing the deep tendon reflexes of a client. Which of the following images should the nurse identify as indicating the correct technique for eliciting the client's patellar reflex?
Tap below the knee cap The nurse should identify this image as assessing the client's patellar reflex. To elicit the expected response of lower leg extension, the nurse should allow the client's legs to hang freely over the side of the examination table while seated and quickly tap the patellar tendon just below the kneecap using a reflex hammer.
A nurse is performing a home safety assessment for a client who is receiving supplemental oxygen. Which of the following observations should the nurse identify as proper protocol. The client uses a wool blanket on their bed. The client identifies the location of a fire extinguisher. The client stores an extra oxygen tank on its side under their bed. The client has a weekly inspection checklist for oxygen equipment.
The client identifies the location of a fire extinguisher. Explanation: The client should be able to identify the location of fire extinguishers in the home and be aware of how to use them
A nurse is caring for a client who has dementia. Which of the following interventions should the nurse take to minimize the risk for injury to the client? Use a bed exit alarm system. Raise four side rails while the client is in bed. Apply one soft wrist restraint. Dim the lights in the client's room.
Use a bed exit alarm system. Explanation: The nurse should identify that a client who has dementia requires assistance when exiting their bed and might be unable to remember to ask for help. The client's condition places them at a risk for falling. A bed alarm system can alert staff members that the client is trying to get out of bed and requires assistance. -Raising four side rails when the client is in bed is a form of restraint and increases the risk for falls and injury. -Applying one soft wrist restraint is a physical restraint requiring a prescription. Other forms of distraction or intervention to maintain client safety should be attempted for clients who have dementia. -Dimming the lights in the room for a client who has dementia can reduce visibility and increase the risk for injury.
nurse is caring for a client who has pharyngeal diphtheria. Which of the following types of transmission precautions should the nurse initiate? Contact Droplet Airborne Protective
droplet Droplet precautions are a requirement for clients who have infections that spread via droplet nuclei that are larger than 5 microns in diameter, including rubella, meningococcal pneumonia, and streptococcal pharyngitis. The nurse should wear a mask when providing care or when within 1 m (3 feet) of the client who has a disorder requiring droplet precautions. -Contact precautions are a requirement for clients who have infections that spread via direct contact or from environmental contact. Examples are vancomycin-resistant enterococci and herpes simplex infections. -Airborne precautions are a requirement for clients who have infections that spread via droplet nuclei that are smaller than 5 microns in diameter, including varicella, tuberculosis, and measles. -Clients who have a compromised immune system, such as those who have received an allogeneic stem cell transplant, require a protective environment. This precaution keeps them from acquiring infections from others.
A nurse is planning strategies to manage time effectively for client care. Which of the following strategies should the nurse implement? Combine client care tasks when caring for multiple clients. Wait until the end of the shift to document client care. Use the planning step of the nursing process to prioritize client care delivery. Allow for interruptions in tasks to discuss client care issues with colleagues.
Use the planning step of the nursing process to prioritize client care delivery. Explanation: Setting up a list of goals and tasks to perform for clients can help the nurse set care priorities and plan tasks accordingly. The priority to-do list is an efficient tool for optimal time management. -The nurse should complete the tasks for one client before beginning the tasks for another client to reduce fragmentation of care and avoid potential errors. -Documentation should be completed in a timely manner after care is performed to reduce errors and unsafe client care. Performing documentation at the end of the shift is not effective time management. -An important principle of time management is controlling interruptions to reduce errors and loss of care delivery time.
A nurse is caring for a client who has diarrhea due to shigella. Which of the following precautions should the nurse take? Have the client wear a mask when receiving visitors. Limit the client's time with visitors to no more than 30 min per day. Assign the client to a room with negative-pressure airflow exchange. Wear a gown when caring for the client.
Wear a gown The nurse should implement contact precautions for a client who has shigella to prevent the transmission of the bacteria. The nurse should wear a gown when providing care for a client who requires contact precautions due to the risk of contact with bodily fluids and contaminated surfaces. -The client does not need to wear a mask to prevent the spread of the infection because shigella does not require airborne or droplet precautions. -Limiting the client's time with visitors will not decrease the risk of spreading shigella. Clients who require isolation precautions are at risk for depression and loneliness; therefore, the nurse should encourage visitation. -The nurse should assign a client who has shigella to a private room; however, negative-pressure airflow is not necessary because shigella is not airborne.
A nurse is caring for a client who has a sodium level of 125 mEq/L. Which of the following findings should the nurse expect? Numbness of the extremities Bradycardia Positive Chvostek's sign Abdominal cramping
Abdominal cramping Explanation: This client has hyponatremia, which is a low sodium level. Manifestations include abdominal cramping, weakness, confusion, lethargy, headache, and nausea. -Numbness of the extremities is a manifestation of hyperkalemia. -Tachycardia is a manifestation of hyponatremia along with hypovolemia. -A positive Chvostek's sign is a manifestation of hypomagnesemia and hypocalcemia.
A nurse is administering 1L of 0.9% sodium chloride to a client who is postoperative and has fluid-volume deficit. Which of the following changes should the nurse identify as an indication that the treatment was successful? Increase in hematocrit Increase in respiratory rate Decrease in heart rate Decrease in capillary refill time
Decrease in heart rate explanation: Fluid volume deficit causes tachycardia. With correction of the imbalance, the heart rate should return to the expected range. -Fluid volume deficit causes an increase in hematocrit level due to depletion of extracellular fluid. With correction of the imbalance, the hematocrit level should decrease. -Fluid volume deficit causes an increase in respiratory rate. With correction of the imbalance, the respiratory rate should return to the expected range. -Fluid volume deficit slows capillary refill. With correction of the imbalance, capillary refill time should return to the expected range.
A nurse is administering an otic medication to an older adult client. Which of the following actions should the nurse take to ensure that the medication reaches the inner ear? Press gently on the tragus of the client's ear. Pack a small piece of cotton deep into the client's ear canal. Move the client's auricle down and back toward her head. Tilt the client's head backward for 5 min.
Press gently on the tragus of the client's ear. Explanation: Pressing gently on the tragus of the ear will help the medication get into the inner ear. -Inserting a piece of cotton into the meatus of the canal could damage the ear. If cotton is necessary, the nurse should place it into the outer portion of the ear canal and not push it inward. -Move the client's auricle down and back toward her head. Move the client's auricle down and back toward her head.
A nurse is auscultating the anterior chest of a client newly admitted to a medical-surgical unit. Listen to the audio and identify the breath sounds.
normal breath sounds explanation: These are normal bronchovesicular breath sounds, characteristically of moderate intensity and sounding like blowing as air moves through the larger airways on inspiration and expiration.
A nurse is caring for a client who has an aggressive form of prostate cancer. The provider briefly discusses treatment options and leaves the client's room. When the nurse asks if the client would like to discuss any concerns, the client declines. Which of the following statements should the nurse make? "I will return shortly after I document this in your record." "Most men live a long time with prostate cancer." "I am available to talk if you should change your mind." "I will make a referral to a cancer support group for you."
"I am available to talk if you should change your mind." -Although it is helpful to assure the client that the nurse will return, reminding him about the nurse's need to perform certain tasks is likely to sound dismissive of his profound needs at this time. -This statement provides false reassurance. The nurse cannot predict what this client's outcome might be. -Dismissing the client's concerns by referring him elsewhere without specific intervention by the nurse is a nontherapeutic response.
A client who is postop is verbalizing pain as a 2 on a pain scale of 0-10. The nurse understands that the preop teaching regarding pain control has been effective when the client states which of the following? "I think I should take my pain medication more often, since it is not controlling my pain." "Breathing faster will help me keep my mind off of the pain." "It might help me to listen to music while I'm lying in bed." "I don't want to walk today because I have some pain."
"It might help me to listen to music while I'm lying in bed." Listening to music is an effective nonpharmacological intervention for the management of mild pain. -As a 2 on a scale of 0 to 10, this client's pain is mild. Additional analgesic medication is unnecessary at this time. -Rapid breathing can lead to hyperventilation, while slow, focused breathing helps induce relaxation, which can help with managing pain. -Postoperative clients need to ambulate even if they are having mild pain.
A nurse is educating a client who has a terminal illness about declining resuscitation in a living will. The client asks, What would happen if I arrived at the emergency department and I had difficulty breathing? Which of the following responses should the nurse make? "We would consult the person appointed by your health care proxy to make decisions." "We would give you oxygen through a tube in your nose." "You would be unable to change your previous wishes about your care." "We would insert a breathing tube while we evaluate your condition."
"We would give you oxygen through a tube in your nose." Explanation: Oxygen can provide comfort and is not considered a resuscitative measure when the nurse delivers it via nasal cannula. -The staff must honor the client's wishes as stated in their living will; therefore, it would not be necessary to consult the person appointed by the client's health care proxy to make decisions about the client's care. -Clients determine advance directives ahead of time to guide decision-making at the time of an emergency event. If the client initiates a change, the staff must honor it. Otherwise, staff must honor the decisions the client has documented in the advance directives. -Intubation is a resuscitative measure. The staff should not implement this intervention for a client who declines resuscitation in their living will.
A nurse is caring for a client who has herpes zoster and asks the nurse about the use of complementary and alternative therapies for pain control. The nurse should inform the client that his condition is a contraindication for which of the following therapies? Biofeedback Aloe Feverfew Acupuncture
Acupuncture The nurse should inform the client that herpes zoster, or any skin infection, is a contraindication for the use of acupuncture. An open portal on the skin's surface could increase the risk of further infection. -Biofeedback is a complementary and alternative therapy to assist clients with stroke recovery, smoking cessation, headaches, and many other disorders. Herpes zoster is not a contraindication for the use of this mind-body technique. -Aloe is a complementary and alternative therapy that can help improve disorders and can have wound healing effects. Herpes zoster is not a contraindication for the use of this type of therapy. -Feverfew is a complementary and alternative therapy that helps promote wound healing. Anticoagulant therapy is a contraindication for taking feverfew. However, herpes zoster is not a contraindication for the use of this type of therapy.
A nurse is caring for a client who is post-operative. When the nurse prepares to change her dressings, she says, Everytime you change my bandage, it hurts so much. Which of the following interventions is the nurse's priority actions. Encourage the client to relax and take deep breaths during the dressing change. Educate the client about the importance of the dressing change to prevent infection. Assist the client to a comfortable position for the dressing change. Administer pain medication 45 min before changing the client's dressing.
Administer pain medication 45 min before changing the client's dressing. The priority action the nurse should take when using Maslow's hierarchy of needs is to meet the client's physiological need for comfort and pain relief. Therefore, the priority intervention is to administer an analgesic 30 to 60 min before changing the client's dressing. -Encouraging the client to relax and take deep breaths during the postoperative period is important because relaxation can help reduce the client's anxiety about the procedure. However, there is another intervention that is the priority. -Educating the client about the importance of the dressing change is important because understanding the rationale for the procedure can help the client relax. However, there is another intervention that is the priority. -Moving the client to a comfortable position for the dressing change is important because it can help the client relax and can also reduce strain on the wound. However, there is another intervention that is the priority.
The nurse is providing discharge teaching to a client about self administering heparin. Which of the following instructions should the nurse include in the teaching. Insert the needle at a 15° angle. Aspirate for blood return prior to administration. Administer the medication into the abdomen. Massage the site following the injection.
Administer the medication into the abdomen. Explanation: The nurse should instruct the client to administer the medication into the abdomen at least 5.08 cm (2 in) from the umbilicus. The client should pinch or spread the skin at the injection site to administer the medication into the subcutaneous tissue. -The nurse should instruct the client to insert the needle at a 45° to 90° angle to administer the medication into the subcutaneous tissue. -The nurse should instruct the client not to aspirate for blood return because this can cause tissue damage and bruising. -The nurse should instruct the client not to massage the site because this can cause tissue damage and bruising.
a nurse is preparing to administer an injection of an opioid medication to a client. The nurse draws out 1 mL of the medication from a 2 mL vial. Which of the following actions should the nurse take? Ask another nurse to observe the medication wastage. Notify the pharmacy when wasting the medication. Lock the remaining medication in the controlled substances cabinet. Dispose of the vial with the remaining medication in a sharps container
Ask another nurse to observe the medication wastage. Explanation: A second nurse must witness the disposal of any portion of a dose of a controlled substance. -Pharmacies do not require notification of the disposal of a portion of a dose of a controlled substance. -The nurse should not lock the remaining controlled substance in the cabinet because this is a violation of the Controlled Substances Act. -The nurse should not dispose of the remaining controlled substance in the sharps container because this is a violation of the Controlled Substances Act.
A nurse is planning care for a client who has had a stroke with severe aphasia and dysphagia. Which of the following tasks should the nurse assign to an assistive personnel? Assist the client with a partial bed bath. Measure the client's BP after the nurse administers an antihypertensive medication. Test the client's swallowing ability by providing thickened liquids. Use a communication board to ask what the client wants for lunch. Irrigate the client's indwelling urinary catheter.
Assist the client with a partial bed bath. Measure the client's BP after the nurse administers an antihypertensive medication. Use a communication board to ask what the client wants for lunch. -Assisting a client with a bed bath poses minimal risk to the client and is within the AP's range of function. -Measuring a client's BP poses minimal risk to the client and is within the AP's range of function. - Assessing the client's swallowing ability places the client at risk for aspiration and is not within the AP's range of function. Nurses perform tasks that require assessment. -Using a communication board poses minimal risk to the client and is within the AP's range of function. -Irrigating the client's indwelling urinary catheter is an invasive procedure and is not within the AP's range of function.
A nurse is admitting a new client. Which of the following actions should the nurse take while performing medication reconciliation. Verify the client's name on their identification bracelet with the medication administration record. Call the pharmacy to determine whether the client's medications are available. Compare the client's home medications with the provider's prescriptions. Place the client's home medication bottles in a secure location.
Compare the client's home medications with the provider's prescriptions. The nurse should compare the client's home medications with the provider's prescriptions when performing medication reconciliation. -The nurse should verify the client's name on their identification bracelet when administering medication; however, this action is not a part of performing medication reconciliation -The nurse should call the pharmacy if the client's medications are not available to administer at the appropriate time; however, this action is not a part of performing medication reconciliation. -The nurse should place the client's home medications in a secure location to ensure safe handling of prescribed medications; however, this action is not a part of performing medication reconciliation.
A nurse is caring for a postoperative adult client who refuses to use an incentive spirometer following major abdominal surgery. Which of the following is the nurse's priority action? Request that a respiratory therapist discuss the technique for incentive spirometry with the client. Determine the reasons why the client is refusing to use the incentive spirometer. Document the client's refusal to participate in health restorative activities. Administer a pain medication to the client.
Determine the reasons why the client is refusing to use the incentive spirometer. The first action the nurse should take when using the nursing process is to assess the client; therefore, the priority action for the nurse to take is to determine why the client is refusing the treatment. -The nurse can request that another team member discuss the use of the incentive spirometer with the client to encourage the client to use it; however, this is not the priority action for the nurse to take. -If other interventions to promote the client's use of the incentive spirometer are unsuccessful, the nurse must document the client's refusal; however, this is not the priority action for the nurse to take.
A nurse is admitting a client who is having an exacerbation of heart failure. In planning this client's care, when should the nurse initiate discharge planning During the admission process As soon as the client's condition is stable During the initial team conference After consulting with the client's family
During the admission process Explanation: Discharge planning should begin as soon as the client is undergoing the admission process. The nurse should begin to assess the client's needs and plan for care both during and after the client's time in the facility. -Although it is appropriate to defer client teaching until the client is stable and receptive to learning, the initiation of discharge planning does not depend on the client's physiological stability. -Team conferences facilitate discharge planning, but they are not essential for initiating the planning process. -The nurse should only consult with the client's family if the client gives the nurse permission to share that information. In the case of a client who has an exacerbation of heart failure, delaying discharge planning until this time could result in overlooking essential care needs.
A nurse is planning to insert a peripheral IV catheter for an older adult client. Which of the following actions should the nurse plan to take? Insert the catheter at a 45° angle. Place the client's arm in a dependent position. Shave excess hair from the insertion site. Initiate IV therapy in the veins of the hand.
Place the client's arm in a dependent position. Explanation: The nurse should place the client's arm in a dependent position because the veins will dilate due to gravity. -Generally, the nurse should insert the catheter at a 10° to 30° angle. However, for an older adult client, an angle of 10° to 15° is preferable because veins are closer to the skin surface as aging diminishes subcutaneous tissue. -The nurse should clip excess hair from the IV insertion site and avoid shaving the area because shaving can cause breaks and cuts in the skin that could place the client at risk for infection. -The nurse should avoid using the fragile veins of an older adult's hands because the loss of subcutaneous tissue can allow those veins to roll away from the needle. Also, having an IV catheter in the client's hand can interfere with the client's performance of activities of daily living and can diminish an older adult's sense of independence and mobility.
A nurse is teaching a client and his family how to care for the client's tracheostomy at home. Which of the following instructions should the nurse include in the teaching?
Use tracheostomy covers when outdoors Explanation: The cover protects the client's airway from air, dust, and airborne particles
A nurse is administering 1 L of 0.9% sodium chloride to a client who is postoperative and has fluid-volume deficit. Which of the following changes should the nurse identify as an indication that the treatment was successful? Reposition the client. Document the client's IV intake in the medical record. Request a new IV fluid prescription. Check the IV tubing for obstruction.
check the IV tubing for obstruction. The first action the nurse should take using the nursing process is to assess the client. If checking the IV tubing and verifying an obstruction, the nurse might be able to facilitate the flow of fluid through the tubing. This could re-establish the infusion rate the provider prescribed. -The nurse should reposition the client to help improve the flow rate; however, there is another action the nurse should take first. -The nurse should document the client's IV intake in the medical record accurately to help the team prevent or correct fluid imbalances; however, there is another action the nurse should take first. -The nurse should request a new IV fluid prescription to compensate for lost fluid intake; however, there is another action the nurse should take first.
A nurse is caring for a child who has a prescription for a blood transfusion. The parents have refused the treatment due to religious beliefs. Which of the following actions should the nurse take? Examine personal values about the issue. Tell the parents that this is a necessary procedure. Inform the parents that the staff does not require their consent. Contact a spiritual support person to explain the importance of the procedure.
examine personal values about the issue Explanation: Nurses should examine their own personal values about the issue in question in order to provide care that is without bias. -The nurse should provide the parents with information about the procedure. However, telling the parents that this is a necessary procedure disregards the parents' religious beliefs and their right to refuse treatments. -Parents must give consent for a child to receive a blood transfusion. -The nurse or the provider should provide information about the procedure. Spiritual support people attend to clients' and families' spiritual needs, not their physiological needs.