hesi test 5

2. a nurse is caring for a client who is having difficulty breathing. the client is laying in bed with a nasal cannula delivering oxygen. which of the followingintervention should the nurse take first? A. suction the client's airway B. administer a bronchodilator C. increase the humidity in the client's room D. assist the client to an upright position

D. assist the client to an upright position When providing client care, the nurse should first use the least invasive intervention. Therefore, the nurse should elevate the head of the client's bed tothe semi-Fowler's or high Fowler's position to facilitate maximal chest expansion. Sitting upright improves gas exchange and prevents pressure on thediaphragm from abdominal organs.

61. 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? A) Increase in hematocrit B) Increase in respiratory rate C) Decrease in heart rate D) Decrease in capillary refill time

Decrease in heart rate Fluid-volume deficit causes tachycardia. With correction of the imbalance, theheart rate should return to the expected range.

17. a nurse is caring for a client who is postoperative and refused to use anincentive spirometer following major abdominal surgery. which of the following is the nurse's priority action? A. request that a respiratory therapist discuss the technique for incentive spirometer B. determine the reasons why the client is refusing to use the onetime spirometer C. document the client's refusal to participate in health restorative activities D. 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 assessthe client; therefore, the priority action is for the nurse to determine why the client is refusing the treatment.

54. a nurse is admitting a client who has influenza. which of the following typesof transmission precautions hold the nurse initiate? A. airborne B. droplet C. contact D. protective environment

Droplet Droplet precautions are a requirement for clients who have infections that spreadvia droplet nuclei that are larger than 5 microns in diameter, including influenza,rubella, meningococcal pneumonia, and streptococcal pharyngitis.

116. A nurse is caring for a client who has pharyngeal diphtheria. Which of thefollowing types of transmission precautions should the nurse initiate? A) Contact B) Droplet C) Airborne D) Protective

Droplet Droplet precautions are a requirement for clients who have infections that spreadvia 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 ft) of the client who has a disorder requiring droplet precautions.

117. 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? A) During the admission process B) As soon as the client's condition is stable C) During the initial team conference D) After consulting with the client's family

During the admission process Discharge planning should begin as soon as the client is undergoing admission.The nurse should begin to assess the client's needs and plan for care during andafter hospitalization.

78. A nurse is caring for a client who has a terminal illness and is approaching death. The client's respirations are noisy from secretions in her airway and she is short of breath. Which of the following actions should the nurse take? A) Turn the client every 4 hr. B) Elevate the head of the client's bed. C) Hold oral care. D) Increase the room's temperature.

Elevate the head of the client's bed. This action promotes postural drainage and also allows maximal chest expansion, which makes it easier for the client to breathe and decreases noisyrespirations.

10. a nurse is assessing an adult client who has been immobile for the past 3 week. the nurse should identify that which of the following findings requiresfurther intervention? A. erythema on pressure points B. lower-extremity pulse strength on 2+ C. fluid intake of 3,000 mLper day D. a bowel movement every other day

Erythema on pressure points Erythema on pressure points requires prompt relief of pressure and additionalmeasures to protect the skin from further breakdown.

86. A client who is nonambulatory notifies the nurse that his trash can is on fire.After the nurse confirms the fire, which of the following actions should the nurse take next? A) Activate the emergency fire alarm. B) Extinguish the fire. C) Evacuate the client. D) Confine the fire.

Evacuate the client. According to the RACE mnemonic, the first action in response to a fire is torescue the clients, moving them to a safe area.

75. A nurse is planning care for a client who has fluid overload. Which of the following actions should the nurse plan to take first? A) Reduce dietary sodium B) Administer a loop diuretic C) Evaluate electrolytes D) Restrict intake of oral fluids

Evaluate electrolytes. The first action the nurse should take when using the nursing process is to assessthe client's electrolytes; therefore, the nurse should evaluate the client's laboratory results, including sodium, potassium, BUN, Hgb, Hct, and protein, toguide the planning of interventions to correct the imbalances.

94. 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 thefollowing actions should the nurse take? A) Examine personal values about the issue. B) Tell the parents that this is a necessary procedure. C) Inform the parents that the staff does not require their consent. D) Contact a spiritual support person to explain the importance of the procedure.

Examine personal values about the issue. The nurse should examine her own personal values about the issue to help herprovide care that is without bias.

22. a nurse is preparing to administer multiple medications to a client who has an enteral feeding tube. which of the following actions should the nurse planto take? A. dissolve each medication in 5 mL of sterile water B. draw up medication together in the syringe C. push the syringe plunger gently when feeling resistance D. flush the tube with 15 mL of sterile water

Flush the tube with 15 mL of sterile water. The nurse should flush the feeding tube with 15 to 30 mL of sterile water before administration and between each medication. The nurse should flush the feedingtube with 30 to 60 mL of sterile water following the administration of the last medication.

3. a nurse is preparing to administer 0.5 mL of oral single-dose liquid medication to a client. which of the following actions should the nurse take? A. gently shake the container of medication prior to administration B. transfer the medication to a medicine cup C. place the client in a semi-fowlers position to medication administration D. verify the dosage by measuring the liquid before administering it

Gently shake the container of medication prior to administration. The nurse should gently shake the liquid medication to ensure the medication ismixed.

31. a charge nurse is discussing the responsibility of nurses caring for clients who have a clostridium difficile infection. which of the following informationshould the nurse include in the teaching? A. assign the client to a room with a negative air-flow system B. use alcohol-based hand sanitizer when leaving he client's room C. clean contaminated surfaces in the client's room with a phone solution D. have family members wear gown and gloves when visiting

Have family members wear a gown and gloves when visiting. Nurses are responsible for ensuring that family members wear a gown and gloves to prevent the transmission of Clostridium difficile spores. Caregiversmust also wear gowns and gloves.

59. a nurse is performing a Romberg's test during the physical assessment of aclient. which of the following techniques should the nurse use? A. touch the face with a cotton ball B. apply a vibrating tuning fork to the clients forehead C. have the client stand with her arms at her side and her feet together D. perform direct percussion over the area of the kidneys

Have the client stand with her arms at her side and her feet together. Romberg's test helps identify alterations in balance. The nurse should have theclient stand with her arms at her sides and her feet together to observe her forswaying and a loss of balance.

39. a nurse is caring for a client who requires an NG tube for stomach decompression. which of the following actions should the nurse take wheninserting the NG tube? A. position the client with the head of the bed elevated to 30o prior toinsertion of the NG tube B. remove the NG tube if the client begins to gag of choke C. apply suction to the NG tube prior to insertion D. have the client take sips of water to promote insertion of the NG tube intothe esophagus

Have the client take sips of water to promote insertion of the NG tube into theesophagus. Taking sips of water as the NG tube passes through the oropharynx will close theepiglottis over the trachea and prevent the tube's passage into the trachea.

19. a nurse is caring for a client who has limited mobility in his lower extremities. which of the following actions should the nurse take to preventskin breakdown? A. place the client in high-flowers position B. increase the client's intake of carbohydrates C. massage the reddened areas with unscented lotion D. have the client use a trapeze bar when changing positions

Have the client use a trapeze bar when changing position. By using a trapeze bar to assist with repositioning and transferring, the clientavoids the friction and shearing that result from sliding up and down in bed. Shearing is a risk factor for pressure- ulcer development.

56. a nurse is reviewing practice guidelines with a group of newly licensed nurses. which of the following interventions should the nurse include that iswithin the RN scope of practice? A. insert an implanted port B. close a laceration with sutures C. place an endotracheal tube D. initiate an enteral feeding though a gastrostomy tube

Initiate an enteral feeding through a gastrostomy tube. It is within the RN scope of practice for nurses to initiate enteral feedingsthrough nasoenteric, gastrostomy, and jejunostomy tubes.

76. A nurse is planning to initiate IV therapy for an older adult client who requires IV fluids. Which of the following actions should the nurse take? A) Insert the IV catheter into the back of the client's hand. B) Massage the area of the venipuncture site vigorously. C) Insert the IV catheter without using a tourniquet. D) Apply traction to the skin proximal to the insertion site to stabilize thevein.

Insert the IV catheter without using a tourniquet. The nurse should insert the IV catheter using the tourniquet minimally or not atall to avoid injury of fragile skin or veins.

112. 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? A) Back of foot (heel) B) Knee cap C) Elbow D) Back of elbow

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.

92. A nurse is initiating a protective environment for a client who has had anallogeneic stem cell transplant. Which of the following precautions shouldthe nurse plan for this client? A) Make sure the client's room has at least 6 air exchanges per hour. B) Make sure the client wears a mask when outside her room if there is construction in the area. C) Place the client in a private room with negative-pressure airflow. D) Wear an N95 respirator when giving the client direct care.

Make sure the client wears a mask when outside her room if there is constructionin the area. An allogeneic stem cell transplant compromises the client's immune system,putting her at high risk for infection. The client will need protection from breathing in any pathogens in the environment.

90. A nurse is caring for a client who is postoperative following knee arthroplasty and requires the use of a thigh-length sequential compressiondevice. Which of the following actions should the nurse take? A) Assist the client into a prone position. B) Place a sleeve over the top of each leg with the opening at the knee. C) Make sure two fingers can fit under the sleeves. D) Set the ankle pressure at 65 mm Hg.

Make sure two fingers can fit under the sleeves. Less space than two fingers between the sleeves and the legs can inhibitcirculation when the sleeves inflate.

48. a nurse is performing a peripheral vascular assessment for a client. whenplacing the bell on the stethoscope on the client's neck, she heads the following sound: audible vascular sound associated with turbulent bloodflow. this sound indicates which of the following? A. narrowed arterial lumen B. distended jugular veins C. impaired ventricular contraction D. asynchronous closure of the aortic and pulmonic valve

Narrowed arterial lumen Arterial bruits are blowing sounds resulting from blood flowing through occludedor narrowed arteries.

107. A nurse is auscultating the anterior chest of a client newly admitted to a medical- surgical unit. Listen to the audio clip of what the nurse auscultatesthrough his stethoscope and identify the type of breath sounds he hears. A) Crackles B) Rhonchi C) Friction rub D) Normal breath sounds

Normal breath sounds These are normal bronchovesicular breath sounds, characteristically of moderate intensity and sounding like blowing as air moves through the largerairways on inspiration and expiration.

84. A nurse is caring for a client who is postoperative and has signs of hemorrhagic shock. When the nurse notifies the surgeon, he directs her to continue to measure the client's vital signs every 15 min and call him back in1 hr. From a legal perspective, which of the following actions should the nurse take next? A) Document the provider's statement in the medical record. B) Notify the nursing manager. C) Consult the facility's risk manager. D) Complete an incident report.

Notify the nursing manager. The greatest risk to the client is not receiving timely intervention for his deterioration in physiological status; therefore, the next action the nurse should take is to activate the chain of command to ensure the necessary care is providedto the client.

89. 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 thenurse take? A) Pad the client's wrist before applying the restraints. B) Evaluate the client's circulation once per shift after application. C) Remove the restraints every 4 hr to evaluate the client's status. D) Secure the restraint ties to the client's bed side rails.

Pad the client's wrist before applying the restraints. Restraints without padding can abrade the client's skin.

66. A nurse is caring for a group of clients. Which of the following actions should the nurse take to prevent the spread of infection? A) Carry a client's soiled linens out of the room in a mesh linen bag. B) Place a client who has tuberculosis in a room with negative-pressureairflow. C) Provide disposable plates and utensils for a client who is HIV-positive. D) Dispose of a client's blood-saturated dressing in a trash bag inside asecond 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 riskof infection transmission.

53. a nurse is reviewing a client's fluid and electrolyte status. which of thefollowing findings should the nurse report to the provider? A. BUN 15 mg/dL B. Creatinine 0.8 mg/dL C. Sodium 143 mg/dL D. Potassium 5.4 mg/dL

Potassium 5.4 mEq/L The value is above the expected reference range and the nurse should report thisfinding. This client is at risk for dysrhythmias.

96. A nurse is planning teaching for a group of adolescents who each recentlyhad surgical placement of an ostomy. Which of the following methods should the nurse use as a psychomotor approach to learning? A) Role play B) Group discussions C) Question-answer meetings D) Practice sessions

Practice sessions Practice sessions require psychomotor skills when learning.

29. a nurse is administering an otic medication to an older adult client. which ofthe following actions should the nurse take to ensure that the medication reaches the inner ear? A. press gently on the tarsus of the client's ear B. pack a small piece of cotton deep into the cent's ear canal C. move the client's auricle down and back toward her head D. tilt the client's head backward for 5 min

Press gently on the tragus of the client's ear. Pressing gently on the tragus of the ear will help the medication get into theinner ear.

49. a nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. which of the following assessment findings should the nurse expect? A. neck vein distention B. urine specific gravity 1.010 C. rapid heart rate D. blood pressure 144/82 mm Hg

Rapid heart rate Tachycardia indicates fluid-volume deficit, which is an expected finding for aclient who has had vomiting and diarrhea for 3 days.

33. a nurse is caring for a client who is expressing anger over his diagnosis ofcolorectal cancer. which of the following actions should the nurse take? A. discuss the risk factors for colon cancer B. focus teaching on what the client will need to do in the future to managehis illness C. provide the client with written information about the phases of loss andgrief D. reassure the client that this is an expected response to grief

Reassure the client that this is an expected response to grief. During the anger stage of the client's psychosocial adaptation to illness, the nurse should support the client and ensure him that this is an expected reactionto a cancer diagnosis.

99. A nurse is reviewing evidence-based practice principles about administration of oxygen therapy with a newly licensed nurse. Which of thefollowing actions should the nurse include? A) Regulate the flow rate by aligning the rate with the top of the ball inside the flow meter. B) Regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min. C) Make sure the reservoir bag of a partial rebreathing mask remainsdeflated. D) Use petroleum jelly to lubricate the client's nares, face, and lips.

Regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min. Evidence-based practice supports a flow rate of 1 to 6 L/min via nasal cannula. Rates above 6 L/min force clients to swallow air excessively without increasing their fraction of inspired oxygen (FiO2).

42. a nurse is caring for a client who requires bed rest and has a prescription foranti embolic stocking. which of the following actions should the nurse take? A. apply the stockings so the creases are on the front of the leg B. apply the stockings while the client's legs are in a dependent position C. remove the stockings at least once per shift D. remove the stockings while the client is sitting in a reclining chair

Remove the stockings at least once per shift. The nurse should remove the stocking once per shift to check the client'scirculation and skin integrity.

46. a nurse is talking with the partner of an older adult male client who has dementia. the client's partner expresses frustration about finding time to manage household responsibilities while caring for his partner. the nurse should identify that he is going through which of the following types of role-performing stress? A. role ambiguity B. sick role C. role overload D. 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 perform.

77. A nurse is caring for a client who has a heart murmur. The nurse is preparing to auscultate the pulmonary valve. Over which of the followinglocations should the nurse place the bell of the stethoscope? A) Second intercostal space at the left sternal border B) Fourth intercostal space at the right sternal border C) Fourth intercostal space at the left sternal border D) Second intercostal space at the right sternal border

Second intercostal space at the left sternal border This is the area over the pulmonary valve. The nurse should listen over this, theapex, and the other valve areas for rate and rhythm, as well as gallops and murmurs.

58. a nurse is reviewing protocol in preparation for suctioning secretions from client who has a new tracheostomy. which of the following actions should thenurse plan to take? A. use a resuscitation bag with 80% oxygen prior to the procedure B. select a suction catheter that is half of the size of the lumen C. place the end of the function catheter in water-soluble lubricant D. adjust the wall suction apparatus to a pressure of 170 mm Hg

Select a suction catheter that is half the size of the lumen. The nurse should select a suction catheter that is half the size of the lumen toprevent hypoxemia and trauma to the mucosa.

9. a nurse is assisting a client who is postoperative with the use of an incentivespirometer. into which of the following positions should the nurse place theclient? A. side-lying B. supine C. semi-fowlers D. trendelenburg

Semi-Fowler's Positioning the client in semi-Fowler's or high-Fowler's position allows formaximum expansion of the lungs.

60. a nurse is preparing a change-of-shift report. which of the of the following tools or documents should the nurse use to communicate continuity of care? A. critical pathway B. SBAR C. transfer report D. medication administration record (MAR)

Situation, background, assessment, and recommendation (SBAR) SBAR is a communication tool used to relate a client's status during a change-of-shift report.

21. a nurse is caring for a client receiving fluid through a peripheral IV catheter.which of the following filings at the IV site should the nurse identify as infiltration? A. purulent exudate B. warmth C. skin blanching D. bleeding

Skin blanching Skin blanching, edema, and coolness at the IV site indicate infiltration.

35. a nurse is lifting a bedside cabinet to move it closer to a client who is sittingin a chair. to prevent self-injury, which of the following actions should the nurse take when lifting this object? A. bend at the waist B. keep his feet close together C. use his back muscles for lifting D. stand close to the banner 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.

51. a nurse is using an open irrigation technique to irrigate a client's indwellingurinary catheter. which of the following actions should the nurse take? A. place the client in a side-lying position B. instill 15 mL of irrigation fluid into the catheter with each flush C. subtract the amount of irritant used from the client's urine output D. 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 theclient's total urinary output.

85. A nurse is caring for a client who is receiving parenteral fluid therapy via a peripheral IV catheter. After which of the following observations should the nurse remove the IV catheter? A) Small air bubbles are in the IV tubing. B) IV flow stops when the client bends her arm. C) Swelling and coolness are observed at the IV site. D) Blood is visible in the IV catheter and tubing.

Swelling and coolness are observed at the IV site. Swelling and coolness are indications of IV infiltration, which warrant removingthe catheter and restarting the IV infusion with a new catheter at a different site.

67. A nurse is caring for a client who does not speak the same language as the nurse. When working with the client through an interpreter, which of thefollowing actions should the nurse take? A) Talk directly to the client, instead of the interpreter, when speaking. B) Use a family member as the client's interpreter. C) Make sure that the interpreter has a college degree. D) Avoid asking the client personal questions through the interpreter.

Talk directly to the client, instead of the interpreter, when speaking. When using an interpreter, the nurse should speak directly to the client andobserve the client when the interpreter is translating.

43. a nurse is caring for a client who has an NG tube and is receiving intermittent feedings through an open system. which of the following actionsshould the nurse take first? A. rinse the feeding bag with water between feedings B. tell the client to keep the head of the bed elevated at least 30o C. make sure the enteral formula is at room temperature D. wipe the top of the formula can with alcohol

Tell the client to keep the head of the bed elevated at least 30°. The first action the nurse should take when using the airway, breathing, circulation approach to client care is to prevent aspiration of the enteralformula; therefore, the priority intervention is to keep the head of the bedelevated at least 30° to prevent reflux of the formula backward into the esophagus.

24. a nurse is evaluating a client's use of a cane. which of the following actionsshould the nurse identify as an indication of correct use? A. the top of the cane is parallel to the client's waist B. when walking, the client move the cane 46 cm (18 in) forward C. the client holds the cane on the stronger side of her body D. the client moves her stronger limb forward with the cane

The client holds the cane on the stronger side of her body. The client should hold the cane on the stronger side of her body to increasesupport and maintain alignment.

18. a nurse is reviewing a client's medication prescription, which reads, "digoxin 0.25 by mouth every day." which of the following components ofthe prescription should the runs question? A. the medication B. the route C. the dose D. the frequency

The dose The dose is not complete. The number 0.25 should be followed by a unit of measurement, such as mg, to clarify the amount the nurse should administer.

108. A nurse is providing home care for a client who is receiving tube feedings and medication through a gastrostomy tube. The family member providing the feedings reports that the client has begun to have diarrhea. For which ofthe following practices should the nurse intervene? A) The client is receiving formula at room temperature. B) The feedings infuse at a slow, continuous drip over 8 hr each night. C) The family member washes out the feeding bag with warm water onceevery 24 hr. D) The family member flushes the tubing with water before and after giving medications.

The family member washes out the feeding bag with warm water once every 24hr. The family member should wash out the feeding bag at each refilling throughoutthe day (every 4 to 8 hr) and replace it with a new feeding bag every 24 hr to prevent bacterial contamination. Therefore, the nurse should reinforce this information with the family member.

101. A charge nurse is observing a newly licensed nurse prepare a sterile field.Which of the following actions should the charge nurse identify as contaminating the sterile field? A) The nurse opens the sterile field on a wet surface. B) The nurse opens the first fold away from his body. C) The nurse holds sterile objects above the waist. D) The outer edge of the sterile field is touching a bottle.

The nurse opens the sterile field on a wet surface. Opening a sterile field on a wet surface contaminates it because capillary action can wick bacteria through the sterile drape.

71. A nurse is preparing to insert an IV catheter into a client's arm prior to initiating IV fluid therapy. Which of the following interventions should thenurse implement to prevent infection? A) Thread the IV catheter so that the hub rests at the insertion site. B) Shave excess hair from around the insertion site. C) Cleanse the site with hydrogen peroxide before IV catheter insertion. D) Palpate the site carefully just before inserting the IV catheter.

Thread the IV catheter so that the hub rests at the insertion site. Inserting the catheter up to the hub reduces the risk of contamination along thelength of the catheter.

4. a nurse is planning care to improve self-feeding for a client who has visionloss. which of the following interventions should the nurse include in the plan of care? A. tell the client which food she should eat first B. provide small-handle utensils for the client C. thicken liquids on the client's tray D. use a clock pattern to describe food on the client's plate

Use a clock pattern to describe food on the client's plate. Use a clock pattern to describe food on the client's plate.MY ANSWERDescribing the location of the food on the plate by using a clock patternallows the client to have greater independence during meals.

8. a nurse is caring for a client who is reporting difficulty falling asleep. whichof the following measures should the nurse recommend? A. drink a cup of hot cocoa before bedtime B. exercise 1 hr before going to bed C. use progressive relaxation techniques at bedtime D. reflect on the day's activities before going to bed

Use progressive relaxation techniques at bedtime. Progressive relaxation promotes sleep by decreasing stress and reducing muscletension.

97. 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 nurseinclude in the teaching? A) Remove the outer cannula cautiously for routine cleaning. B) Use tracheostomy covers when outdoors. C) Use sterile technique when performing tracheostomy care at home. D) Cleanse irritated skin with full-strength hydrogen peroxide.

Use tracheostomy covers when outdoors. Tracheostomy covers protect the client's airway from cold air, dust, and otherairborne particles.

69. A nurse is caring for a client who has diarrhea due to shigella. Which of thefollowing precautions should the nurse take? A) Have the client wear a mask when receiving visitors. B) Wash her hands before and after contact with the client. C) Assign the client to a room with negative-pressure airflow exchange. D) Instruct all visitors to limit their time with the client.

Wash her hands before and after contact with the client. Shigella requires the nurse to perform contact precautions to prevent the transmission of the bacteria. The nurse should also use standard precautions, which require the nurse to perform hand hygiene before and after direct contactwith every client, regardless of their diagnosis.

52. a nurse is caring for a client who is refusing a blood transfusion for religiousreasons. the client's partner wants the client to have the blood transfusion. which of the following actions should the nurse take? A. ask the client to consider a direct donation B. withhold the blood transfusion C. request a consolation with the ethics committee D. ask the client's family to intervene

Withhold the blood transfusion. The principle of autonomy ensures that a client who is competent has the right to refuse treatment.

104. A nurse is admitting a client who has been having frequent tonic-clonic seizures. Which of the following actions should the nurse add to the client'splan of care? A) Wrap blankets around all four sides of the bed. B) Apply restraints during seizure activity. C) Place the client in a supine position during seizure activity. D) Have a tongue depressor at the client's bedside.

Wrap blankets around all four sides of the bed. The nurse should affix linens or blankets around the head, foot, and side rails ofthe bed to pad them and prevent injury for a client who has been having frequenttonic-clonic seizures.

38. a nurse in a surgical suite notes documentation on a client's medical record that he has a latex allergy. in preparation for the client's procedure, which ofthe following precautions should the nurse take? A. ensure sterilization of non disposable items with ethylene oxide B. wrap monitoring cords with stockinette and tape them in place C. cleanse latex pots on IV tubing with chlorohexidine before injection medication D. wear hypoallergenic latex gloves that contain powder

Wrap monitoring cords with stockinette and tape them in place. Many monitoring devices and cords contain latex. The nurse should prevent anycontact of these cords and devices with the client's skin by covering them with a nonlatex barrier material, such as stockinette, and using nonlatex tape to secure them.

30. a nurse in a long-term care facility is planning to perform hygiene care for anew resident. which of the following assessment questions is the nurse's priority before beginning this procedure? A. "when do you usually bathe, in the morning or evening?" B. "do you prefer a bath or a shower?" C. "at what temperature do you prefer your bath water?" D. "are you able to help with you hygiene care?"

"Are you able to help with your hygiene care?" The greatest risk to the client's safety is an injury resulting from an overestimation of the client's ability to help with hygiene care; therefore, thenurse's priority is to assess the client's ability to assist with her hygiene care.

119. A nurse enters a client's room and finds her on the floor. The client's roommate reports that the client was trying to get out of bed and fell overthe bedrail onto the floor. Which of the following statements should the nurse document about this incident? A) "Incident report completed." B) "Client climbed over the bedrails." C) "Client found lying on floor." D) "Client was trying to get out of bed."

"Client found lying on floor." The nurse should include documentation that is descriptive, objective information about what she actually observed, without any opinions or judgmentabout motive or cause.

103. 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? A) "I will return shortly after I document this in your record." B) "Most men live a long time with prostate cancer." C) "I am available to talk if you should change your mind." D) "I will make a referral to a cancer support group for you."

"I am available to talk if you should change your mind." When a client does not wish to share his feelings with the nurse, it is importantfor the nurse to convey a willingness to be available when he needs her.

6. a nurse is assessing a client's readiness to learn about insulin administration.which of the following statements should the nurse identify as an indication that the client is ready to learn? A. "I can concentrate best in the morning." B. "it is difficult to read the instructions because my glasses are at home." C. "I'm wondering why I need to learn this." D. "you will have to talk to my wife about this."

"I can concentrate best in the morning." The client's statement indicates a readiness to learn because he is verbalizing thebest time for him to learn.

11. a nurse is caring for a client who requires a 24-hour urine collection. which of the following statement by the client indicates an understanding of the teaching? A. "I had a bowel movement, but I was able to save the urine." B. "I have a specimen in the bathroom from about 30 minutes ago." C. "I flushes what I urinated at 7 am and have saved all urine since." D. "I drink a lot, so I will fill up the bottle and complete the txt quickly."

"I flushed what I urinated at 7:00 a.m. and have saved all urine since." For a 24-hr urine collection, the client should discard the first voiding and saveall subsequent voidings.

120. A nurse is caring for a client who has recently started using a behind-the-earhearing aid. Which of the following statements should the nurse identify as an indication that she understands the use of this assistive device? A) "This type of hearing aid does not allow for fine tuning of volume." B) "I shouldn't have trouble keeping the hearing aid in place during exercise." C) "I expect to hear a whistling sound when I first insert the hearing aid." D) "I will be sure to remove my hearing aid before taking a shower."

"I will be sure to remove my hearing aid before taking a shower." The client should remove any hearing device before showering because exposureto water can damage the hearing aid.

7. a nurse is giving discharge instructions to a client who will require oxygen therapy at home. which of the following statements should the nurse identifyas an indication that the client understands how to manage this therapy at home? A. "I'll make sure that, when my friend comes by, she smokes at least 6 feetaway from my oxygen tank." B. "I'll use a woolen blanket if I get chilly while I'm using my oxygen." C. "I'll check the wires and cables on my TV to make sure they are in goodworking order." D. "I'll lay my oxygen tank down on the floor when the grandchildren visit so they don't knock it over."

"I'll check the wires and cables on my TV to make sure they are in good workingorder." Oxygen is a highly flammable gas. The client should make sure any electricalequipment in the room where she is using supplemental oxygen is functioningproperly so it does not create any electrical sparks.

80. A nurse is assessing a client who reports increased pain following physicaltherapy. Which of the following questions should the nurse ask when assessing the quality of the client's pain? A) "Is your pain constant or intermittent?" B) "What would you rate your pain on a scale of 0 to 10?" C) "Does the pain radiate?" D) "Is your pain sharp or dull?"

"Is your pain sharp or dull?" Asking the client whether the pain is sharp, dull, crushing, throbbing, aching,burning, electric- like, or shooting helps determine the quality of the pain.

115. A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0 to 10. Which of the following statements should the nurse identify as an indication that the client understands the preoperative teaching she receivedabout pain management? A) "I think I should take my pain medication more often, since it is not controlling my pain." B) "Breathing faster will help me keep my mind off of the pain." C) "It might help me to listen to music while I'm lying in bed." D) "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.

118. A middle adult client tells the nurse, "I feel so useless now that my childrendo not need me anymore." Which of the following responses should the nurse make? A) "Most people are happy when their children grow up and leave home." B) "You should be proud that your children are becoming independent." C) "Maybe you should consider why you are feeling useless." D) "People in middle adulthood often find satisfaction in nurturing andguiding young people."

"People in middle adulthood often find satisfaction in nurturing and guidingyoung people." According to Erik Erikson, the task of middle adulthood is generativity versus self- absorption and stagnation. The focus of this task is on offering support andguidance to future generations. The nurse should explore with the client opportunities for mastering the developmental tasks of this stage, such as volunteering and mentoring young people.

28. a nurse is caring for a client who report pain. when documenting the qualityof the client's pain on an initial pain assessment, the nurse should record which of the following client statements? A. "I'm having mild pain." B. "the pain is like a dull ache in my stomach." C. "I notice that the pain gets worse after I eat." D. "the pain makes me feel nauseous."

"The pain is like a dull ache in my stomach." The client is describing the quality of the pain, which is how the pain feels in herown words.

26. a nurse is caring for a client who asks about the purpose of advance directives. which of the following statements should the nurse make? A. "they allow the court to overrule an adult client's refusal of medical treatment." B. "they indicate the form of treatment a client is willing to accept in theevent of a serious illness." C. "the permit a client to withhold medical information from heath care personnel." D. "they allow heath care personnel in the emergency department tostabilize a client's condition."

"They indicate the form of treatment a client is willing to accept in the event of aserious illness." Advance directives include a living will, which permits the client to directtreatment in the event of a terminal illness.

55. a nurse is caring for a client who is terminally ill. which of the following statements should the nurse identify as an indication that the client's familymember is coping effectively with the situation? A. "we are not worried. we still have hope that everything will be ok." B. "this is a difficult time, but we are helping each other though this." C. "after he comes home, we can plan out family reunion." D. "we don't need to talk about funeral arraignments at this time."

"This is a difficult time, but we are helping each other through this." An effective coping strategy is talking with others in the family and supportingeach other. This statement displays effective coping skills because the family isusing social supports to assist them throughout the grief process.

37. a nurse manager is preparing to review medication documentation with a group of newly licensed nurses. which of the following statements should thenurse manger plan to include in the teaching? A. "use the complete name of the medication magnesium sulfate." B. "delete the space between the numerical dose and the unit of measure." C. "write the letter U when noting the dosage of insulin." D. "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 providerswrite the complete medication name magnesium sulfate when documenting medications to avoid any misinterpretation of MgSO4 as MSO4 , which means morphine sulfate

79. A nurse is caring for a client who has a terminal diagnosis and whose healthis declining. The client requests information about advance directives. Which of the following responses should the nurse make? A) "We can talk about advance directives, and I can also give you some brochures about them." B) "You should set up a time to talk with your provider about that." C) "Let's discuss how you are feeling today, and we'll save the planning forwhen you are feeling a little better." D) "Why do you want to discuss this without your partner here to plan thiswith you?"

"We can talk about advance directives, and I can also give you some brochuresabout them." With this statement, the nurse offers to provide the information the client needs ina direct and simple way.

87. A nurse in a provider's office is obtaining the health and medication history of a client who has a respiratory infection. The client tells the nurse that she is not aware of any allergies, but that she did develop a rash the last time shewas taking an antibiotic. Which of the following information should the nurse give the client? A) "Rashes are very common, especially if you have dry skin. Did it go awayon its own?" B) "Virtually all medications have adverse effects. It sounds like this couldhave been an adverse effect of the antibiotic." C) "It's unlikely that your doctor will prescribe an antibiotic for what seemsto be a minor viral infection, so we shouldn't be concerned about that rash." D) "We need to document the exact medication you were taking because youmight be allergic to it."

"We need to document the exact medication you were taking because you mightbe allergic to it." If there is any possibility that a client had an allergic reaction to a medication, itis imperative that the provider be aware and does not prescribe that same medication again. Subsequent allergic reactions could be life-threatening.

98. A nurse is educating a client who has a terminal illness about her request todecline resuscitation in her living will. The client asks what would happen ifshe arrived at the emergency department and had difficulty breathing. Which of the following responses should the nurse provide? A) "We will determine who the durable power of attorney for health careform has designated." B) "We will apply oxygen through a tube in your nose." C) "We will ask if you have changed your mind." D) "We will insert a breathing tube while we evaluate your condition."

"We will apply oxygen through a tube in your nose." Oxygen can provide comfort and is not resuscitative when the nurse delivers itvia nasal cannula.

50. a nurse is caring for a client who has terminal live cancer. which of thefollowing statements should the nurse identify as an indication that the client is experiencing spiritual distress? A. "what could I have done to deserve this illness?" B. "I blame medical science for not curing me." C. "where is my daughter at a time like this?" D. "will I ever begin to feel in charge of my life again?"

"What could I have done to deserve this illness?" The client's terminal illness might prompt him to review his life and question itsmeaning. A manifestation of the client's spiritual distress is asking why this illness is happening to him.

114. A nurse is teaching a client whose left leg is in a cast about using crutches. Which of the following statements should the nurse identify as an indicationthat the client understands the teaching? A) "When descending stairs, I will first shift my weight to my right leg." B) "I should place my crutches 12 inches in front and to the side of eachfoot." C) "As I sit down, I will hold one crutch in each hand." D) "I will make sure the shoulder rests are snug against my armpits.

"When descending stairs, I will first shift my weight to my right leg." To descend stairs, the client should first shift his body weight to his right(unaffected) leg.

20. a nurse has accepted a verbal prescription for three tenths of a milligram of levothyroxine IV STAT for a client who has myxedema coma. how should the nurse transcribe the dosage of this medication on the client's medical record? A. .3 mg B. 0.3 mg C. 0.30 mg D. 3/10 mg

0.3 mg The use and placement of a decimal point can cause a medication error. A zero should precede a decimal point (0.3 mg), but should not follow a decimal point unless a whole number follows the zero, as in 2.05 mg.

13. a nurse is preparing to transfer a client who has right-sided weakness fromthe bed to a chair. in what order should the nurse take the following actionsto assist the client? 1. ask the client is he can bear weight 2. use the stand-pivot technique to move the client to the chair 3. position the chair on the left side of the bed 4. have the client sit and dangle his feet at the bedside

1. ask the client is he can bear weight 3. position the chair on the left side of the bed 4. have the client sit and dangle his feet at the bedside 2. use the stand-pivot technique to move the client to the chair

91. A nurse is preparing to administer 750 mLof 0.9% sodium chloride IV toinfuse over 7 hr. The nurse should set the infusion pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

107 mL/hr

111. A nurse in a long-term care facility is caring for a client who dies during thenurse's shift. Identify the sequence in which the nurse should perform the following steps. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) 1) Place a name tag on the body 2) Obtain the pronouncement of death from the provider 3) Remove tubes and indwelling lines 4) Wash the client's body 5) Ask the client's family members if they would like to view the body

2) Obtain the pronouncement of death from the provider 3) Remove tubes and indwelling lines 4) Wash the client's body 5) Ask the client's family members if they would like to view the body 1) Place a name tag on the body The first step is to obtain the death pronouncement from the provider. Next, thenurse 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.

16. a nurse is caring for a client who has a prescription for 5 units of regularinsulin and 10 units of NPH insulin to mix together and administer subcutaneously. determine the correct order of steps for this procedure. 1. inject 5 units of air into the bottle of regular insulin 2. withdraw the correct dose of NPH insulin from the bottle 3. inject 10 units of air into the bottle of NPH insulin 4. withdraw the correct dose of regular insulin from the bottle

3. inject 10 units of air into the bottle of NPH insulin 1. inject 5 units of air into the bottle of regular insulin 4. withdraw the correct dose of regular insulin from the bottle 2. withdraw the correct dose of NPH insulin from the bottle

95. A nurse is calculating a client's fluid intake over the past 8 hr. Which of the following items should the nurse plan to document on the client's intake andoutput record as 120 mL of fluid? A) 2 cups of soup B) 1 quart of water C) 8 oz of ice chips D) 6 oz of tea

8 oz of ice chips The nurse should document half of the volume of ice chips when calculating fluid intake to account for the air in between the chips. Four oz of liquid water equals120 mL of fluid.

15. a nurse is preparing a herparing infusion for a client who was hospitalizedwith deep- vein thrombosis. the orders read: 25,000 units of heparin in 250mL of 0.9% sodium chloride to infuse at 800 units/hr. at what rate should the nurse set the infusion pump? (round to the nearest whole number)

8mL/hr

62. A nurse working in the emergency department is witnessing the signing ofinformed consent forms for the treatment of multiple clients during her shift. Which of the following individuals' signatures may the nurse legallywitness? (Select all that apply.) A) A teacher who brings in a 7-year-old student B) A 16-year-old client who is married C) A 27-year-old client who has schizophrenia D) An adoptive parent who brings in his 8-year-old son E) A 17-year-old mother who brings in her toddler

A 16-year-old client who is married is correct. A minor who is married is emancipated and can give consent for his own treatment. A 27-year-old client who has schizophrenia is correct. An adult client who requires psychiatric care can give consent for her own care unless the court hasdetermined the client to be incompetent. An adoptive parent who brings in his 8-year-old son is correct. The adoptiveparent of a child is a parent and legal guardian and can sign to give consent for the child's care. A 17-year-old mother who brings in her toddler is correct. A custodial parent who is a minor can legally give consent for the medical treatment of her child.

106. A nurse is caring for a group of clients on a medical-surgical unit. In which of the following situations does the nurse demonstrate the ethical principleof veracity? A) A client unaware of her recent cancer diagnosis asks the nurse if she hascancer, and the nurse responds affirmatively. B) A client who has a prescription for a nasogastric tube refuses it, and thenurse complies with the client's wishes. C) A client with a do-not-resuscitate (DNR) status has a cardiac arrest, andthe nurse does not perform CPR despite requests from the client's family. D) A client who is about to undergo a painful procedure receives pain medication 30 min before the procedure that the nurse promised she wouldgive her.

A client unaware of her recent cancer diagnosis asks the nurse if she has cancer,and the nurse responds affirmatively. Following the ethical principle of veracity, the nurse must tell the truth at alltimes and never deceive others.

36. a nurse is providing care to four clients. which of the following situationsrequires the nurse to complete an incident report? A. a nurse tied a client's restraints straps to the moveable part of the bedframe B. an assuétude personnel placed a surgical mask on a client who has TBbefore transporting her to radiology C. a nurse administer a medication to a client 30 min before the dose is due D. a client who has an IV infusion pump receives an additional 250 mL of IVfluid

A client who has an IV infusion pump receives an additional 250 mL of IV fluid. The nurse should complete an incident report if an IV infusion pump malfunctions to assist in compiling information for risk management todetermine actions to take to prevent further similar incidents.

88. A home health nurse who has attended a training session for the therapeutic use of aromatherapy with essential oils is planning to use this modality with some of her clients. For which of the following clients should the nurseconsult the provider before using this complementary therapy? A) A client who has a history of physical abuse B) A client who has a permanent pacemaker C) A client who has ulcerative colitis D) A client who has asthma

A client who has asthma Some essential oils can cause bronchospasm; therefore, the nurse should consultthe client's provider before using this therapy.

57. a nurse manager is overseeing the care on a unit. which of the followingshould the nurse manager identify as a violation of HIPAA guidelines? A. a nurse who is caring for a client reviews the client's medical chart withthe nursing student who is working with the nurse B. a nurse asks a nurse from another unit to assist with her documentation C. a nurse who is caring for a client returns a call to the client's durablepower of attorney for health care designee to discuss the client's care D. a nurse discusses a client's status with the physical therapies that iscaring for the client's bedside

A nurse asks a nurse from another unit to assist with her documentation. Only health care professionals directly caring for a client may access medicalinformation; therefore, this is a violation of HIPAA guidelines.

44. a nurse is caring for a client who has tuberculosis. which of the followingactions should the nurse take? (Select all that apply) A. place the client in a rom with negative pressure airflow B. wear gloves the assisting the client with oral care C. limit each visitor to 2 hour increments D. wear a surgical mask when providing client care E. use antimicrobial sanitizer for hand hygiene

A. place the client in a rom with negative pressure airflow B. wear gloves the assisting the client with oral care E. use antimicrobial sanitizer for hand hygiene

105. A nurse is caring for a client who has a sodium level of 125 mEq/L. Which ofthe following findings should the nurse expect? A) Numbness of the extremities B) Bradycardia C) Positive Chvostek's sign D) Abdominal cramping

Abdominal cramping The client has hyponatremia, a low sodium level. Manifestations includeabdominal cramping, weakness, headache, and nausea.

12. a nurse is caring for a client who has herpes zoster and asks the runs about the use of complementary and alternative therapies for pain control. the nurse should inform inform the client that his condition is a contraindication for which of the following therapies? A. biofeedback B. aloe C. feverfew D. acupuncture

Acupuncture The nurse should inform the client that the use of acupuncture is contraindicatedfor a client who has herpes zoster, or any skin infection, to prevent an open portal on the skin's surface, which could increase the risk of further infection.

113. A nurse is caring for a client who is postoperative. When the nurse preparesto change her dressing, she says, "Every time you change my bandage, it hurts so much." Which of the following interventions is the nurse's priorityaction? A) Encourage the client to relax and take deep breaths during the dressingchange. B) Educate the client about the importance of the dressing change to prevent infection. C) Assist the client to a comfortable position for the dressing change. D) 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 minbefore changing the client's dressing.

93. A nurse is preparing to administer enoxaparin subcutaneously to a client.Which of the following actions should the nurse take? A) Administer the medication with the needle at a 45° angle. B) Administer the medication into the client's nondominant arm. C) Pull the client's skin laterally or downward prior to administration. D) Massage the injection site after administration.

Administer the medication with the needle at a 45° angle. The nurse should insert the needle for a subcutaneous injection at a 45° to 90°angle.

82. A nurse is reviewing the medical records of a client who has a pressure ulcer.Which of the following findings should the nurse expect? A) Albumin level of 3 g/dL B) HDL level of 90 mg/dL C) Norton scale score of 18 D) Braden scale score of 20

Albumin level of 3 g/dL An albumin level below 3.5 g/dL indicates protein deficiency, placing the client atrisk for pressure ulcer formation and poor wound healing.

a nurse is planning an education session for an older adult client who hasjust learned that she has type 2 diabetes mellitus. which of the following strategies should the nurse plan to use with this client? A. allow extra time for the client to respond to questions B. expect the client to have difficulty understanding the information C. avoid references to the lento's past experiences D. keeping the learning session private and one-on-one

Allow extra time for the client to respond to questions. Older adult clients often process information at a slower rate than younger clients; therefore, the nurse should plan for extra time to allow the client to askquestions and absorb the information.

102. A nurse is performing a skin assessment of a client who has a lesion on hisanterior thigh and expresses concern about skin cancer. Which of the following findings should the nurse report to the provider as a possible indication of a skin malignancy? A) Uniform pigmentation B) A regular border C) An uneven shape D) A diameter smaller than 6 mm

An uneven shape An uneven shape is a possible indication of a cutaneous malignancy. Each half ofthe lesion looks different from the other half.

109. A nurse has just inserted an NG tube for a client. Which of the followingassessment findings should the nurse expect to confirm correct tube placement? A) The tube aspirate has a pH of 7. B) An x-ray shows the end of the tube above the pylorus. C) Bowel sounds are present on auscultation. D) The client reports relief of nausea.

An x-ray shows the end of the tube above the pylorus. An abdominal x-ray showing the end of the tube above the pylorus indicatesgastric placement.

63. A nurse is caring for a client who has a respiratory infection. Which of thefollowing techniques should the nurse use when performing nasotracheal suctioning for the client? A) Insert the suction catheter while the client is swallowing. B) Apply intermittent suction when withdrawing the catheter. C) Place the catheter in a location that is clean and dry for later use. D) Hold the suction catheter with her clean, nondominant hand.

Apply intermittent suction when withdrawing the catheter. The nurse should apply intermittent suction during the withdrawal of the catheterto prevent injury to the mucosa. Suctioning continuously for more than 10 seconds can cause cardiopulmonary compromise.

14. a nurse is preparing to administer an injection of an opioid medication to aclient. the nurse draws out 1 mL of the medication from a 2 mL vial. which of the following actions should the nurse take? A. ask another nurse to observe the medication wastage B. notify the pharmacy when eating the medication C. lock the remaining medication in the controlled substance cabinet D. dispose of the vial with the remaining medication in a sharps container

Ask another nurse to observe the medication wastage. A second nurse must witness the disposal of any portion of a dose of a controlledsubstance.

65. A nurse is preparing to transfer a client who can bear weight on one legfrom the bed to a chair. After securing a safe environment, which of the following actions should the nurse take next? A) Rock the client up to a standing position. B) Pivot on the foot that is the farthest from the chair. C) Assess the client for orthostatic hypotension. D) Apply a gait belt to the client.

Assess the client for orthostatic hypotension. The first action the nurse should take using the nursing process is to assess the client. The nurse should determine the client's risk for falling or fainting during the transfer by assisting her to sit and dangle her feet on the side of the bed. Thenurse should assess her for dizziness and a significant drop in blood pressure before assisting her to stand and transfer into the chair.

100. A nurse is planning care for a client who has had a stroke, resulting in aphasia and dysphagia. Which of the following tasks should the nurse assignto an assistive personnel (AP)? (Select all that apply.) A) Assist the client with a partial bed bath. B) Measure the client's BP after the nurse administers an antihypertensive medication. C) Test the client's swallowing ability by providing thickened liquids. D) Use a communication board to ask what the client wants for lunch. E) Irrigate the client's indwelling urinary catheter.

Assist the client with a partial bed bath is correct. Assisting a client with abed bath poses minimal risk to the client and fits within the AP's range of function. Measure the client's BP after the nurse administers an antihypertensive medication is correct. Measuring a client's BP poses minimal risk to the clientand fits within the AP's range of function. Use a communication board to ask what the client wants for lunch is correct.Using a communication board poses minimal risk to the client and fits within the AP's range of function.

47. a nurse is administering IV fluid to an older adult client. the nurse shouldperform which priority assessment to monitor for adverse effects? A. auscultate lung sounds B. masure urine output C. monitor blood pressure readings D. monitor serum electrolyte levels

Auscultate lung sounds. The priority assessment the nurse should make when using the airway, breathing,circulation approach to client care is auscultating lung sounds to monitor for fluid-volume excess, a complication of IV therapy. Manifestations of fluid volumeexcess include moist crackles heard in lung fields, dyspnea, and shortness of breath.

64. A nurse is teaching a client about dietary management of hypercholesterolemia. Which of the following foods should the nurse suggestthat the client add to his diet? A) Beef liver B) Shellfish C) Egg yolks D) Avocados

Avocados Avocados contain no cholesterol. Plant foods contain no cholesterol; foods fromanimals contain cholesterol.

32. a nurse is assessing an older adult client's risk for falls. which of the following assessments would the nurse use to identify the cent's safety needs? (Select all that apply). A. lacrimal apparatus B. pupil clarity C. appearance of bulbul conjuctivae D. visual fields E. visual acuity

B. pupil clarity D. visual fields E. visual acuity

68. A nurse is caring for a client who has an indwelling urinary catheter. Whichof the following assessment findings indicates that the catheter requires irrigation? A) Urine has an unusual odor. B) Urine specific gravity is 1.035. C) Bladder scan shows 525 mL of urine. D) Urine is positive for ketones.

Bladder scan shows 525 mL of urine. A client who has an indwelling urinary catheter should have continuous urine flow without an accumulation of urine in the bladder; therefore, the nurse shouldirrigate the catheter to resolve a blockage.

81. A nurse is giving a change-of-shift report about a client he admitted earlier that day who has pneumonia. Which of the following pieces of information isthe priority for the nurse to provide? A) Admitting diagnosis B) Breath sounds C) Body temperature D) Diagnostic test results

Breath sounds When using the airway, breathing, circulation approach to client care, the nurse should determine that the priority information to provide is the current status ofthe client's breath sounds.

83. A nurse is completing an admission assessment of an older adult client.Which of the following findings should the nurse identify as a potentialindication of abuse? A) Loss of skin turgor on the back of the hands B) Varicosities on the lower extremities C) Thick, discolored nails with ridges D) Bruises on the arms in various stages of healing

Bruises on the arms in various stages of healing Bruises in various stages of healing is an indicator of abuse. Other indicators include burns, abrasions, fractures, bite marks, dried blood, and pressure ulcers.

a nurse in a clinical is caring for a middle age adult who states, "the doctor says that since I am at an average risk for colon cancer, I should have a routine screening. what does that involve?" which of the following responsesshould the nurse make? A. "I'll get a blood sample from you and send it for a screening test." B. "beginning at age 60, you should have a colonoscopy." C. "you should have a decal occult blood test every year." D. "the recommendation is to have a sigmoidoscopy every 10 years."

C. "you should have a decal occult blood test every year." Colorectal cancer screening for clients at average risk begins at age 50. Oneoption for screening is a fecal occult blood test annually.

27. a nurse is assessing a client who has been on bed rest for the past month.which of the following findings should the nurse identify as an indicationthat the client has developed thrombophlebitis? A. bladder distention B. decreased blood pressure C. calf swelling D. diminished bowel sounds

Calf swelling Swelling, redness, and tenderness in a calf muscle are manifestations ofthrombophlebitis, a common complication of immobility.

74. A nurse receives report about a client who has 0.9% sodium chloride infusing IV at 125 mL/hr. When the nurse performs the initial assessment, he notes that the client has received only 80 mLover the last 2 hr. Which ofthe following actions should the nurse take first? A) Reposition the client. B) Document the client's IV intake in the medical record. C) Request a new IV fluid prescription. D) 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. By checking the IV tubing for obstruction, the nurse might be able to facilitate the flow of fluid through the tubing. This could re-establish the infusionrate the provider prescribed.

45. a nurse is responding to a call light and finds a client lying on the bathroomfloor. which of the following actions should the nurse take first? A. check the client for injuries B. move hazardous objects away from the client C. notify the provider D. ask the client to describe how she felt prior to the fall

Check the client for injuries. The first action the nurse should take when using the nursing process is to assess the client for injuries.

73. A nurse is providing discharge teaching to a client who has a new prescription for a home oxygen concentrator. Which of the following instructions should the nurse provide to the client and his family? (Select all that apply.) A) Check the cord routinely for frays or tearing. B) Keep the unit at least 4 feet away from a gas stove. C) Consider purchasing a generator for power backup. D) Observe for signs of hypoxia. E) Select synthetic clothing and bedding.

Check the cord routinely for frays or tearing is correct. Oxygen concentrators require electrical power. Safe use of this delivery system includes assessing the electrical function of the device; therefore, the nurse should instruct the client to routinely check the condition of the cord. Consider purchasing a generator for power backup is correct. Loss of electricity prevents the oxygen concentrator from functioning and could deprive the client of the oxygen he needs. The nurse should also instruct the family to explore getting the client on their municipality's priority list for restoring power after an outage occurs. Observe for signs of hypoxia is correct. The nurse should instruct the family to observe for and report signs of hypoxia, such as anxiety, worsening fatigue, dizziness, rapid pulse and respirations, pallor, and cyanosis. Even with supplemental oxygen, the client's status can worsen, and he can develop hypoxia.

72. A nurse is caring for a client who needs to maintain a positive nitrogen balance for wound healing. Which of the following food items should thenurse recommend as a good source of complete protein? A) Oat cereal B) Refried beans C) Peanut butter D) Cheddar cheese

Cheddar cheese Complete proteins contain enough of all nine of the essential amino acids that help maintain and promote nitrogen balance. Cheese, poultry, and fish are examples of foods that are good sources of complete protein.

110. A nurse has an order to remove sutures from a client. After retrieving thesuture remover kit and applying sterile gloves, which of the following actions should the nurse take next? A) Clean sutures along the incision site. B) Grasp at the knot of the sutures with forceps. C) Cut the sutures close to the skin on one side. D) Pull out the sutures with forceps in one piece.

Clean sutures along the incision site. The greatest risk to this client is injury from infection; therefore, the first actionthe nurse should take is to clean the incision to minimize the risk of infection.

41. a nurse is caring for a client who has a prescription for wound irrigation.which of the following actions should the nurse take? A. wear sterile gloves when removing the old dressing B. warm the irrigation solution of 40.5oc (105oF) C. cleanse the wound from the center outward D. use a 20 mL syringe to irrigate the wound

Cleanse the wound from the center outward. The nurse should clean the wound from the center outward to preventintroduction of micro- organisms from the outer skin surface.

70. A nurse on a medical unit is preparing to discharge a client to home. Whichof the following actions should the nurse take as part of the medication reconciliation process? A) Seal unused hospital medications in a plastic bag. B) Evaluate the client's ability to self-administer medications. C) Report an identified discrepancy to The Joint Commission. D) Compare prescriptions with medications the client received during hospitalization.

Compare prescriptions with medications the client received during hospitalization. When performing medication reconciliation, the nurse should create a current, accurate list of every medication the client is or should be taking. Part of the process is comparing the medications the client received at the facility with thosethe provider has prescribed for the client to take after discharge.

40. a nurse is admitting a client who has an abdominal wound with a largeamount of purulent drainage. which of the following types of transitionprecautions hold the nurse initiate? A. protective environment B. airborne precautions C. droplet precautions D. contact precautions

Contact precautions Major wound infections require contact precautions, which mean the nurse should admit the client to a private room. All caregivers should wear a gown andgloves during direct contact with this client.

34. a nurse is planning to insert a peripheral IV catheter for an older adultclient. which of the following actions should the nurse plan to take? A. insert the other at a 45o angle B. place the client's arm in a dependent position C. shave excess hair from the insertion site D. initiative IV therapy in the veins of the hand

place the client's arm in a dependent position The nurse should place the client's arm in a dependent position because the veinswill dilate due to gravity.

25. a nurse is caring for a client who has had his diet prescription changed to amechanical soft diet. which of the following food items should the nurse remove from the client's breakfast tray? A. smoothie B. sliced banana C. pancakes D. sunny side up (fired) eggs

sunny side up (fired) eggs Evidence-based practice indicates the nurse should remove fried eggs from theclient's tray. Fried eggs are not a part of a mechanical soft diet. Eggs that are poached or scrambled are an acceptable replacement for this item.

5. a nurse is teaching an older adult client who is at risk for osteoporosis aboutbeginning a program of regular physical activity. which of the following types of activity should the nurse recommend? A. walking briskly B. riding a bicycle C. performing isometric exercises D. engaging in high-impact aerobics

walking briskly Weight-bearing exercises are essential for maintaining bone mass, which helps toprevent osteoporosis. Walking engages older adult clients in this preventive and therapeutic strategy.