NURS 230 - TEST 1: Ch. 32, 33, 29, 30, 44, 31, 36, 47, 48, 49

The client has a hearing aid with an earpiece that is connected by a cord to a receiver that the client keeps in a shirt pocket. The nurse would document this as which type of hearing aid? 1. Body hearing aid 2. In-the-canal aid 3. Completely-in-the-canal aid 4. Eyeglasses aid

Body hearing aid

The continuous quality improvement team is monitoring the nursing care of clean-contaminated wounds. Which operative wound would be excluded from this study? 1. Gastric resection 2. Uncomplicated abdominal hysterectomy 3. Breast biopsy 4. Lung resection

Breast biopsy

The nurse is planning care for an older client. Which safety hazard should the nurse take into consideration when planning this care? 1. Burns 2. Drowning 3. Poisoning 4. Suffocation

Burns

Nitrogen balance testing is planned for a client. What instruction to the staff caring for this client is essential? 1. Remove the clients oxygen cannula 10 minutes prior to the test. 2. Accurate measurement of food intake is very important. 3. All urine output should be collected for 48 hours. 4. Keep the client NPO beginning at midnight before the test.

Accurate measurement of food intake is very important

The nurse is making an occupied bed. Which step will provide comfort for the client during this linen change? 1. Allow for a toe pleat. 2. Place a bath blanket over the client. 3. Slide the mattress to the head of the bed. 4. Raise the side rail.

Allow for a toe pleat.

A connection on a clients intravenous solution was dislodged and solution saturated the clients gown and bed linens. The nurse will provide which type of hygienic care to the client? 1. Hour-of-sleep care 2. As-needed care 3. Early morning care 4. Morning care

As-needed care

A client has hard contact lenses. What should the nurse do to assist the client in the care of the lenses? 1. Pinch the lenses out of the clients eyes to remove. 2. Remove both of the clients lenses before storing in the appropriate storage cup. 3. Document when the lenses need to be removed and cleaned every 2 weeks. 4. Ask the client how many hours the lenses are worn each day.

Ask the client how many hours the lenses are worn each day.

The nurse is caring for the stoma of a client who has a colostomy. Which action is the most appropriate? 1. Apply pressure over the stoma. 2. Clean the stoma and pat dry. 3. Dilate the stoma. 4. Scrub the stoma.

Clean the stoma and pat dry.

A clients hearing aid needs to be cleaned. What action should the nurse take to complete this task? 1. Clean with a dry, soft cloth. 2. Leave the battery in place when not in use. 3. Store the aid in the bathroom cabinet. 4. Use alcohol to remove any earwax.

Clean with a dry, soft cloth.

The nurse is caring for a client with diabetes. What should the nurse include as foot care for this client? 1. Cut toenails in a rounded shape and file. 2. Dry toes thoroughly. 3. Wash feet with water at a temperature of 90F to 98.6F. 4. Inspect feet thoroughly once a week.

Dry toes thoroughly.

The nurse is assessing the peripheral vascular status of an older client. Which finding should the nurse consider as being normal for this client? 1. Easy to palpate upper extremity arteries 2. Easy to palpate lower extremity arteries 3. Reduction in the number of varicosities 4. Increase in diastolic blood pressure

Easy to palpate upper extremity arteries

A client asks the nurse for help in selecting foods, as some are good and others are bad. How should the nurse respond to the client? Select all that apply. 1. Eat a wide variety of foods to furnish adequate nutrients. 2. Avoid starchy foods. 3. Limit foods with high-fructose corn syrup. 4. Eat three meals a day to reduce calories. 5. Eat moderately to maintain correct body weight.

Eat a wide variety of foods to furnish adequate nutrients. Eat moderately to maintain correct body weight.

A client has a spinal cord injury at the cervical spine area. The nurse realizes that this injury will affect which aspect of urinary elimination in the client? 1. Elimination of urine from the bladder 2. Ability of the kidneys to absorb solutes 3. Ureteral function 4. Urethra function

Elimination of urine from the bladder

The RN has just been stuck with a syringe while dropping it into a sharps container that was too full in a clients room. What action should the nurse take first for this puncture wound? 1. Complete an injury report. 2. Encourage bleeding. 3. Initiate first aid. 4. Wash the area with soap and water.

Encourage bleeding

A client reports following the food pyramid to guide nutritional intake. How should the nurse evaluate this information? 1. Because this food pyramid is produced by the U.S. Department of Agriculture, the client is likely consuming necessary levels of all essential nutrients. 2. The food pyramid is most useful when applied to the nutritional intake of children. 3. The food pyramid is not very useful because it does not take fluid intake and combination foods into consideration. 4. Following the appropriate food pyramid is helpful, but there are additional factors to consider in a balanced diet.

Following the appropriate food pyramid is helpful, but there are additional factors to consider in a balanced diet

The nurse is preparing to apply a bandage to a client using the spiral reverse turn. For which body parts should the nurse use this technique when bandaging? Select all that apply. 1. Finger 2. Forearm 3. Upper leg 4. Lower leg 5. Upper arm

Forearm Lower leg

A client has a history of an inconsistent fecal elimination pattern. What should the nurse instruct this client to improve this health problem? 1. Drink two to four glasses of water daily. 2. Include more spicy foods and sugar in the diet. 3. Include more whole grains in the diet. 4. Use enemas as desired.

Include more whole grains in the diet.

The nurse is considering using the NANDA nursing diagnosis Impaired Physical Mobility in the care plan of a newly admitted client. In order to make this problem statement more individual, the nurse should take which action? 1. Include what mobility is impaired. 2. Use Level 1, 2, 3, or 4 to describe immobility. 3. Describe what happens when the client attempts mobility. 4. Add strength assessment data.

Include what mobility is impaired

The nurse is caring for a client with a urinary diversion. For which type of diversion should the nurse plan care for this client? 1. Incontinent urinary diversion 2. The kock pouch. 3. Neobladder 4. Nephrostomy

Incontinent urinary diversion

While waiting for the physician to respond regarding a clients elevated temperature, what can the nurse do to assist the client? 1. Bathe the client with ice water. 2. Give the client an antipyretic. 3. Increase fluid intake. 4. Lower the room temperature.

Increase fluid intake

The nurse should incorporate which instructions into the teaching plan for a client with a urinary diversion? 1. Change the appliance several times a day. 2. Increase fluid intake. 3. Notify the physician if the stoma is deep pink and shiny. 4. Strands of blood may appear in the urine.

Increase fluid intake.

The nurse is assessing a clients pressure ulcer. To determine the depth of the ulcer, the nurse should take which action? 1. Measure the width. 2. Measure the length. 3. Insert a sterile swab into the deepest part of the wound. 4. Identify where on the face of a clock the ulcer is located

Insert a sterile swab into the deepest part of the wound

A client has been admitted with incontinence. What should the nurse expect to assess in this client? 1. Client is wearing cotton undergarments. 2. Leakage of urine occurs when client laughs. 3. Leakage of urine occurs when talking with the client. 4. The skin of the client is clear without discoloration.

Leakage of urine occurs when client laughs.

After eating dinner, a client asks for help to get to the bathroom because of an extreme urge to defecate. The nurse realizes that the client has experienced which physiological function of the colon? 1. Flatus 2. Mass peristalsis 3. Haustral churning 4. Peristalsis

Mass peristalsis

The nurse is selecting dressings for a clean abdominal incision that will be allowed to heal by secondary intention. What principles should the nurse use in choosing this dressing? 1. Materials used in dressing this wound should keep the wound bed moist. 2. The dressing should allow good air circulation through the wound. 3. Dressings should be simple as they will be changed at least every 4 hours. 4. Absorbent material to wick exudates away and support drying should be used.

Materials used in dressing this wound should keep the wound bed moist

A client has several dark, thick scars on body locations from previous surgeries and injuries. The nurse realizes this occurs during which phase of wound healing? 1. Exudative 2. Proliferative 3. Inflammatory 4. Maturation

Maturation

Which nursing intervention is appropriate when caring for a client with a retention catheter? 1. Don sterile gloves. 2. Gently retract the labia majora away from the urinary meatus. 3. Observe urine in the drainage bag. 4. Retape the catheter to the thigh.

Retape the catheter to the thigh.

The client who is bed-bound complains of abdominal pain. Bowel sounds are present. What action should be taken by the nurse? 1. Percuss for flatness over the liver. 2. Palpate for bladder fullness. 3. Use the p.r.n. order to medicate the client with an antacid. 4. Inspect the sacral area for edema.

Palpate for bladder fullness

An older client diagnosed with Alzheimers disease continually tries to get out of bed at night. Which safety measure should the nurse consider using with this client? 1. Explain all procedures and treatments. 2. Place a bed safety monitoring device on the bed. 3. Orient the client to surroundings. 4. Use relaxation techniques.

Place a bed safety monitoring device on the bed.

The mother of a 2-year-old expresses concern to the nurse that her child continually climbs out of the crib at home. What should the nurse advise the mother to do? 1. Omit the afternoon nap. 2. Place a crib net over the top of the crib. 3. Remove all objects from around the crib. 4. Restrain the child if he gets up more than once.

Place a crib net over the top of the crib.

The nurse is caring for a client who is confused and wanders. Which alternative to a restraint can the nurse use for this client? 1. Assign this client to the farthest room from the nurses station. 2. Place a rocking chair in the clients room. 3. Pull up all of the side rails on the bed. 4. Wedge pillows against the side rails on the bed.

Place a rocking chair in the clients room.

The nurse is planning care for a client who has limited bed mobility. What instruction should be given to the assistive personnel who will be caring for this client? Select all that apply. 1. Place a turn sheet on the bed. 2. Always use two personnel to move the client. 3. Stand at the head of the bed to pull the client up. 4. Slide the client toward the head of the bed. 5. Encourage the client to assist as possible

Place a turn sheet on the bed. Always use two personnel to move the client Encourage the client to assist as possible

The nurse is preparing to provide a client with mouth care. What should the nurse do to ensure safe handling of the clients dentures? 1. Clean biting surfaces. 2. Place a washcloth in the bowl of the sink. 3. Replace the upper dentures first. 4. Rinse dentures thoroughly with hot water.

Place a washcloth in the bowl of the sink.

The clients lab studies reveal a normal serum albumin with a prealbumin of 10. How should the nurse interpret the significance of these readings? 1. The client has had recent protein malnutrition. 2. The client is now relatively well nourished with malnutrition 6 to 8 months ago. 3. The client is at risk for development of malabsorption syndromes. 4. Carbohydrate malnutrition has occurred over the last 6 months.

The client has had recent protein malnutrition

The nurse is reviewing laboratory data for a client who is receiving total parenteral nutrition. Which laboratory value should be immediately brought to the physicians attention? 1. BUN of 60 2. Prealbumin of 15 3. Serum glucose of 328 4. Potassium of 3.5

Serum glucose of 328

Prior to assessing a clients blood pressure, the nurse reviews factors that could affect the reading. Which factors could impact blood pressure? Select all that apply. 1. Stress 2. Race 3. Obesity 4. Medications 5. Employment

Stress, Race, Obesity, Medications

The nurse is reviewing safety hazards with a pregnant client. What should the nurse include when instructing this client about safety and the developing fetus? 1. Banging into objects 2. Bicycle rides 3. Recreational activities 4. X-rays

X-rays

On admission, the client weighs 165 lb (75 kg). The client reports that this is a weight loss from 180 lb (82 kg). What is this clients percent weight loss? 1. 4.5% 2. 6.25% 3. 8.3% 4. 10.0%

8.3%

When documenting a clients axillary temperature on the graphic sheet, how should the nurse identify the method of assessing the temperature? 1. AX 2. O 3. R 4. SL

AX

A client has received an oil retention enema. The nurse should instruct the client that the enema will take effect within 1. 1 to 3 hours. 2. 10 to 20 minutes. 3. 5 to 10 minutes. 4. 10 to 15 minutes.

1 to 3 hours

The nurse completes triceps skinfold measurement on a client. In order to obtain the most meaningful data, how soon should the nurse repeat this measurement? 1. 2 days 2. 10 days to 2 weeks 3. 1 month 4. 1 year

1 year

A client is prescribed to have wrist restraints applied. Place in order the steps the nurse will take to apply these restraints. Choice 1. Pad bony prominences on the wrist. Choice 2. Apply the padded portion of the restraint around the wrist. Choice 3. Pull the tie of the restraint through the slit in the wrist restraint and ensure that it is not too tight. Choice 4. Attach the other end of the restraint to the movable portion of the bed frame using a half-bow knot.

1, 2, 3, 4

The nurse assesses phase 1 Korotkoffs sound occurring at 136 and phase 5 Korotkoffs sound occurring at 72. How should the nurse document this clients blood pressure reading? 1. 136/72 2. 72/136 3. 136 72 4. 72 136

136/72

The nurse is preparing to insert a nasogastric tube into a client. In what order will the nurse conduct the following steps? Standard Text: Click and drag the options below to move them up or down. Choice 1. Ask the client to tilt the head forward. Choice 2. Insert the tube with its natural curve toward the client. Choice 3. Ask the client to hyperextend the neck. Choice 4. Have the client swallow a small amount of liquid. Choice 5. Employ a slight twisting motion on the tube.

2, 3, 5, 1, 4

A client is prescribed a 1600-calorie diet. Of this diet, 30% of the intake should be protein, 20% fat, and 50% carbohydrates. How many grams of carbohydrates should the client ingest every day?

200 grams

The nurse is performing ostomy care for a client. Place in order the steps the nurse will perform to do this care. Choice 1. Clean and dry the peristomal skin and stoma. Choice 2. Prepare and apply the skin barrier. Choice 3. Empty the pouch and remove the ostomy barrier. Choice 4. Assess the stoma and peristomal skin. Choice 5. Apply the pouch. Choice 6. Place a piece of tissue or gauze over the stoma and change it as needed.

3, 1, 4, 6, 2, 5

The nurse is assisting a client in removing soft contact lenses. Place in order the steps the nurse should take to help this client. Choice 1. Using the pad of the index finger of the other hand, move the lens down to the sclera. Choice 2. Have the client look forward. Choice 3. Apply gloves. Choice 4. Gently pinch the lens between the pads of the thumb and index finger. Choice 5. Retract the lower lid with one hand.

3, 2, 5, 1, 4

While performing a health assessment, in which position should the nurse place the client for inspection of the jugular veins? 1. 90-degree angle 2. 30- to 45-degree angle 3. 15-degree angle 4. 60-degree angle

30- to 45-degree angle

The nurse has established an expected outcome that the client will demonstrate healing of a stage II pressure ulcer over the coccyx. Which finding, discovered by the nurse during evaluation, might be implicated in the failure to achieve this outcome? 1. The rubber doughnut pressure relief device was not delivered by central supply. 2. The clients serum albumin increased over the last month. 3. Nurses did not document disinfection of the wound with alcohol with each dressing change. 4. Unlicensed assistive personnel (UAP) followed a right sidebackleft sideback turning schedule.

4. Unlicensed assistive personnel (UAP) followed a right sidebackleft sideback turning schedule.

A clients nasogastric tube has been discontinued and needs to be removed. Place in order the steps the nurse will perform to remove this tube. Choice 1. Place the tube in a plastic bag. Choice 2. Ask the client to take a deep breath and to hold it. Choice 3. Smoothly withdraw the tube. Choice 4. Pinch the tube with the gloved hand. Choice 5. Observe the intactness of the tube. Choice 6. Apply clean gloves.

6, 2, 4, 3, 1, 5

A client with an indwelling urinary catheter is prescribed to receive sterile normal saline bladder irrigation at 100 mL/hr. After an 8-hour shift the nurse measures the clients output as being 1425 mL. What is the clients urine output for the 8-hour shift? Calculate to the nearest whole number.

625 mL

The nurse is reviewing assigned clients for morning care needs. Which situation could pose a threat to one clients personal hygiene? 1. A client has a newly formed ileostomy. 2. A client performs meticulous foot care. 3. A German client refuses to bathe everyday. 4. The room temperature is set at 72F.

A client has a newly formed ileostomy.

The nurse is assessing a clients blood pressure. What should the nurse hear during phase 2 of Korotkoffs sounds? 1. A muffled, whooshing, or swishing sound 2. Disappearance of sound 3. Faint, clear tapping sound 4. Increased intensity of sound

A muffled, whooshing, or swishing sound

The postoperative client is ambulating for the first time since surgery. The client has been able to tolerate sitting up on the side of the bed and has stood at the bedside without difficulty on two occasions. Which staff member should ambulate this client? 1. The UAP 2. A licensed practical (vocational) nurse 3. A registered nurse 4. It makes no difference

A registered nurse

The nurse has completed closed irrigation of a clients retention catheter. What specific information should the nurse document about this procedure? 1. Number of ml of solution used to inflate the balloon of the catheter 2. Abnormal drainage, such as blood clots, pus, or mucous shreds 3. Location of the draining bag 4. Technique used to conduct the irrigation

Abnormal drainage, such as blood clots, pus, or mucous shreds

The nurse has applied an aquathermia pad to a clients back. After 15 minutes of treatment, the client says that the pack no longer is warm and asks the nurse to increase the temperature. How should the nurse evaluate this request? 1. Because this clients thermal tolerance is higher than normal, increasing the temperature is necessary. 2. This client may be experiencing a rebound effect from the application of moist heat. 3. Adaptation of the thermal receptors often results in the decreased sensation of warmth. 4. The aquathermia pad should be replaced with a standard hot pack.

Adaptation of the thermal receptors often results in the decreased sensation of warmth

Multiple severely injured clients have arrived in the emergency department. On rapid assessment, the nurse notes that a leg wound dressing has a 4-cm by 6-cm blood spot that has soaked through the bandage. The client is otherwise stable. What action should the nurse take? 1. Place a tourniquet above the wound. 2. Remove the dressing and place direct pressure on the wound. 3. Add an additional dressing to the wound without removing the original. 4. Remove the dressing and replace it with a new sterile dressing

Add an additional dressing to the wound without removing the original

The nurse is assessing a clients urinary elimination. Which factor should the nurse keep in mind as influencing this elimination? 1. Age 2. Body image 3. Knowledge 4. Socioeconomic status

Age

The nurse is determining a clients risk for injury. What should the nurse assess in this client? Select all that apply. 1. Age 2. Mobility 3. Hearing 4. Vision 5. Dietary intake

Age Mobility Hearing Vision

The nurse is reviewing safety with a home-care client. What should the nurse include in this teaching? 1. Always pull a plug at the plug-in from the wall outlet. 2. Keep plants in the home. 3. Use overloaded outlets when necessary. 4. Remove labels from containers and refill for recycling.

Always pull a plug at the plug-in from the wall outlet.

The nurse realizes that which client is at risk for difficulty in urinary elimination? 1. A client who had bladder cancer and now has a newly created ileal conduit 2. A 25-year-old female client with low self-esteem 3. An 80-year-old male reporting frequent urination at night 4. The client with hypertension who takes a diuretic every day for blood pressure

An 80-year-old male reporting frequent urination at night

The nurse is reviewing the care needs for a group of assigned clients. Which client should the nurse recognize as being most at risk for a nosocomial infection? 1. A client in the emergency department with abdominal pain 2. A 19-year-old woman in her first trimester of pregnancy 3. A 72-year-old male client with COPD 4. An 86-year-old female client on steroid therapy

An 86-year-old female client on steroid therapy

The home care nurse is reviewing a list of clients prior to making visits. For which client should the nurse plan interventions to decrease the risk of developing constipation? 1. An adult who is on bed rest 2. An infant who is breast-fed 3. A school-age child at recess 4. A toddler who is now walking

An adult who is on bed rest

A client was bitten by a rabid raccoon. What care should the nurse prepare to provide to this client? 1. A tetanus toxoid injection 2. An immunization for rabies 3. An injection of immunoglobulin 4. Mothers breast milk with antibodies in it

An immunization for rabies

A client tells the nurse that the newly diagnosed communicable disease is negatively impacting employment and causing a stressful situation at home. What diagnosis should the nurse select as a priority for this client? 1. Anxiety 2. Acute Pain 3. Social Isolation 4. Low Self-Esteem

Anxiety

The nurse has completed care with a client who has a new ostomy. What should the nurse document about the care provided? Select all that apply. 1. Any change in stoma size 2. Condition of the skin around the stoma 3. Amount and type of drainage 4. Clients response to the procedure 5. Degree of bowel sounds after care provided

Any change in stoma size Condition of the skin around the stoma Amount and type of drainage Clients response to the procedure

The nurse is preparing to conduct an assessment of the heart. Where should the nurse place the stethoscope to auscultate heart sounds? Select all that apply. 1. Aortic region 2. Pulmonic region 3. Tricuspid valve region 4. Abdomen 5. Mitral valve region

Aortic region Pulmonic region Tricuspid valve region Mitral valve region

The nurse is preparing to administer a cardiotonic drug to a client. Which assessment should the nurse perform before administering the medication? 1. Respiratory rate 2. Apical pulse 3. Popliteal pulse 4. Capillary blanch test

Apical pulse

A client has a yellow wound with purulent drainage. The nurse identifies what type of wound care as appropriate for this clients wound? Select all that apply. 1. Cover it with transparent film. 2. Apply a damp-to-damp normal saline dressing. 3. Cover it with a dry dressing. 4. Irrigate the wound. 5. Apply impregnated hydrogel.

Apply a damp-to-damp normal saline dressing. Irrigate the wound. Apply impregnated hydrogel.

The nurse is identifying activities and skills to delegate to unlicensed assistive personnel (UAP). Which action can the nurse safely delegate? 1. Provide oral fluids to a newly extubated client. 2. Irrigate the indwelling urinary catheter of a client recovering from prostate surgery. 3. Apply a wrist restraint to a client. 4. Administer oral pain medication to a client before the client attends physical therapy.

Apply a wrist restraint to a client.

The nurse is preparing to irrigate a clients abdominal wound. In which order should the nurse perform this irrigation? Standard Text: Click and drag the options below to move them up or down. Choice 1. Dry the area around the wound. Choice 2. Insert the catheter into the wound until resistance is met. Choice 3. Remove and discard clean gloves. Choice 4. Apply clean gloves. Choice 5. Irrigate until the solution flows clear. Choice 6. Select a syringe with a catheter attached or with an irrigating tip.

Apply clean gloves, Select a syringe with a catheter attached or with an irrigating tip, Insert the catheter into the wound until resistance is met, Irrigate until the solution flows clear, Dry area around the wound, Remove and discard clean gloves (4, 6, 2, 5, 1, 3)

A client tells the nurse that she does not want to get into the tub for a morning bath. The client has not been bathed for several days. What should the nurse do? 1. Assign UAP the task of giving the client a bath. 2. Skip the clients bath and document refused in the medical record. 3. Ask the client the usual way bathing occurs at home. 4. Tell the client that a bath is needed and ignore the clients comment.

Ask the client the usual way bathing occurs at home.

The nurse is preparing a client for an abdominal examination. What should the nurse done before beginning the examination? 1. Ask the client to urinate. 2. Ask the client to drink 8 ounces of water. 3. Assess vital signs. 4. Assess heart rate.

Ask the client to urinate

While eating in a restaurant, a nurse notices that a customer at the next table begins to clutch his throat while eating a steak. What should the nurse do first? 1. Ask the customer if he is choking. 2. Attempt to give five back blows. 3. Perform the Heimlich maneuver. 4. Start chest compressions.

Ask the customer if he is choking.

The nurse is caring for a client with a fecal incontinence pouch. What should the nurse do when caring for this client? Select all that apply. 1. Assess perianal skin. 2. Irrigate the pouch every shift. 3. Maintain the drainage system. 4. Change the bag every 72 hours. 5. Explain the purpose of the system to the client.

Assess perianal skin. Maintain the drainage system. Change the bag every 72 hours. Explain the purpose of the system to the client.

The nurse is preparing to measure a clients temperature. What is the first thing that the nurse should do to ensure an accurate temperature reading? 1. Assess that the equipment used is working properly. 2. Place the client in a position that is most comfortable for the health care provider. 3. Take the temperature with a chemical disposable thermometer when the client is perspiring. 4. Wait at least 10 minutes before taking the temperature after a client has been smoking.

Assess that the equipment used is working properly.

The nurse is preparing to administer a feeding to a client with a gastrostomy tube. What should the nurse do before providing this feeding? 1. Assess tube placement. 2. Measure vital signs. 3. Assist the client to a prone position. 4. Lower the head of the bed.

Assess tube placement

The nurse wants to delegate the application of a condom catheter to unlicensed assistive personnel (UAP). What must the nurse assess prior to delegating this task? 1. Assess whether the client has unique needs. 2. Measure the clients intake. 3. Assist the client out of bed to a chair. 4. Assess changes in the clients mobility status.

Assess whether the client has unique needs.

During an assessment, the nurse learns a client has soft contact lenses that have not been removed or cleaned for weeks. What should the nurse do? 1. Nothing, because these types of lenses can be worn for months. 2. Remove the clients lenses, wrap in tissue, and place in the bedside table. 3. Assist the client to remove and clean the contacts. 4. Ask the physician for ophthalmology consult because the client will need help removing the lenses.

Assist the client to remove and clean the contacts.

A hospitalized client tells the nurse of the inability to have a bowel movement because too many people are around. What should the nurse do to promote normal fecal elimination for this client? 1. Provide a laxative. 2. Assist the client to the bathroom to ensure privacy. 3. Restrict fluids. 4. Assist the client with ambulation.

Assist the client to the bathroom to ensure privacy.

A client in isolation ambulates with assistance to the bathroom. After toileting, what should the unlicensed assistive personnel do? 1. Assist the client with hand washing. 2. Assist the client back to bed. 3. Change the clients bed. 4. Leave the clients room.

Assist the client with hand washing

A clients hearing aid needs to be removed. What action should the nurse perform? 1. Assist the client with removal when necessary. 2. Instruct the client to remove the aid in the sunroom. 3. Leave the aid in place when bathing. 4. Send the aid home with the family.

Assist the client with removal when necessary.

The nurse is assisting a newly delivered mother in ambulating to the nursery to see the baby. The client complains of light-headedness and begins to faint. What is the nurses most important action? 1. Ensure the clients modesty as she falls. 2. Be certain the client does not hit the head on anything. 3. Call for immediate assistance. 4. Check the vital signs and for excessive vaginal bleeding.

Be certain the client does not hit the head on anything

Upon assessing a pressure ulcer, the nurse notes the presence of red, yellow, and black tissue. Using the RYB color code, which wound care should the nurse plan? 1. Red 2. Yellow 3. Black 4. A combination of all three

Black

A client is rushed to the emergency department with what the physicians suspect to be necrosis of the urinary diversion stoma. What evidence presented by the client leads to this conclusion? 1. Black with sloughing 2. Moist stoma 3. Pink and shiny 4. Slight bleeding from stoma

Black with sloughing

The nurse has delegated the making of unoccupied beds to unlicensed assistive personnel. What should the nurse assess regarding client safety once the beds are completed? 1. Folding of the top sheet 2. Direction of the pillow 3. Call light being readily available 4. Presence of mitered corners

Call light being readily available

The RN needs vital signs assessed for four clients. Which client should the nurse address and not assign to the UAP? 1. Cardiac catheterization client returning to the nursing unit 2. COPD client on 2 Lpm oxygen via nasal cannula 3. Pneumonia client nearing discharge 4. Post-op client of 2 days from gallbladder surgery

Cardiac catheterization client returning to the nursing unit

The nurse is documenting the insertion of a retention catheter for a client. What should be included in this documentation? Select all that apply. 1. Catheter size 2. Location of the drainage bag 3. Amount of urine that drained after insertion 4. Name of the physician who prescribed the insertion of the catheter 5. Client tolerance of the procedure

Catheter size Amount of urine that drained after insertion Client tolerance of the procedure

The nurse has delegated administration of tube feeding to a specially trained UAP. What action should be taken by the nurse in regard to this delegation? 1. Order the equipment to give the feeding. 2. Check the tube for placement. 3. Set up the equipment and mix the feeding. 4. Regulate the rate of the feeding.

Check the tube for placement

A client who has undergone a gastrointestinal surgery is permitted to have a clear liquid diet on the second postoperative day. Which fluid should the nurse order from the diet kitchen for this client? 1. Apricot nectar 2. Cranberry juice 3. Chicken broth 4. Cherry ice pop

Chicken broth

While administering an enema, the client complains of abdominal cramping. What should the nurse do? 1. Raise the height of the solution container. 2. Clamp the flow for 30 seconds, and restart at a slower rate. 3. Discontinue the enema infusion. 4. Assist the client to a supine position.

Clamp the flow for 30 seconds, and restart at a slower rate.

The nurse is collecting a specimen from an infected wound. From which portion of the wound should the specimen be collected? 1. Clean areas of granulation tissue 2. Exudate in the bottom of the wound 3. A pus-coated area on the side of the wound 4. Intact skin at the edge of the wound

Clean areas of granulation tissue

The UAP reports a small skin tear on the clients forearm that occurred during a routine turn. After assessing the wound the nurse should take which action? 1. Obtain a transparent dressing for the UAP to place on the wound. 2. Request a consult with the wound care nurse. 3. Cleanse the wound and apply a dressing. 4. Tell the UAP to reevaluate the wound in 20 minutes.

Cleanse the wound and apply a dressing

After ambulating a client to the bathroom, the unlicensed assistive personnel did not reattach the clients bed safety-monitoring device, and the client fell out of bed. What should the nurse document? 1. Client fell out of bed; bed safety-monitoring device malfunctioning. 2. Client fell out of bed; client removed leg band of bed safety-monitoring device. 3. Client fell out of bed; no observable injuries. 4. Client fell out of bed; bed safety-monitoring device not activated.

Client fell out of bed; bed safety-monitoring device not activated.

The nurse is considering the use of restraints for a client. In which situation can the nurse apply restraints to a client? 1. Client wanders around the care area. 2. Client is picking at the access site for intravenous infusion of chemotherapy. 3. Client needed to use the bathroom and waited for help but didnt want to soil the bed and fell while attempting to walk to the bathroom. 4. Client does not want to stay in bed but wants to sit in the lounge with others.

Client is picking at the access site for intravenous infusion of chemotherapy.

The nurse is concerned that a client is at risk for a nosocomial infection. What did the nurse assess to make this clinical decision? Select all that apply. 1. Client is receiving intravenous fluids. 2. Client has an indwelling urinary catheter. 3. Client is recovering from surgery. 4. Client is receiving pain medication. 5. Client is ambulating twice a day with assistance

Client is receiving intravenous fluids Client has an indwelling urinary catheter Client is recovering from surgery

Even though a UAP is available to assist with vital sign assessment, the nurse is going to conduct these assessments independently in which situations? Select all that apply. 1. Client who complains of chest pain 2. Client returning from surgery 3. Prior to administering a medication that affects blood pressure 4. Client who complains of dizziness after ambulating. 5. Client being admitted to the care area

Client who complains of chest pain Client returning from surgery Prior to administering a medication that affects blood pressure Client who complains of dizziness after ambulating.

The nurse is identifying goals for a client experiencing diarrhea. What goal should the nurse select for this client? 1. Client will defecate regularly. 2. Client will increase the amount of sugar in the diet. 3. Client will limit fluid intake. 4. Client will regain normal stool consistency.

Client will regain normal stool consistency.

A client recovering from acute illness has just received a tub bath. When documenting the bath, what should the nurse include? Select all that apply. 1. Clients ability to maintain a conversation during the procedure 2. Clients tolerance of the procedure 3. Condition and integrity of the skin 4. Client strength 5. Percentage of bath done without assistance

Clients tolerance of the procedure Condition and integrity of the skin Client strength Percentage of bath done without assistance

The nurse is preparing to conduct a mental status assessment. What should the nurse include in this assessment? 1. Cognitive and affective functions 2. Cognitive and effective functions 3. Affective and memory functions 4. Affective and knowledge functions

Cognitive and affective functions

The surgical report of a newly transferred client indicates that there was a great deal of intestinal spillage into the abdominal cavity during the clients bowel resection. For which category of wound should the receiving nurse plan care for this client? 1. Clean-contaminated 2. Contaminated 3. Dirty 4. Infected

Contaminated

The parent of a newborn infant reports that the baby wakes up every 2 hours and only takes about 2 ounces of formula before going back to sleep. What instruction should the nurse give this parent? 1. Make the baby wait at least 3 hours between feedings. 2. Continue to feed the baby with this on-demand schedule. 3. When the baby gets sleepy during feeding, use techniques such as moving around and tickling to encourage wakefulness. 4. Offer the baby less formula to prevent waste.

Continue to feed the baby with this on-demand schedule

On the fourth postoperative day, the client has a sudden coughing episode and tells the nurse that something popped in the abdominal incision. Upon inspection, the nurse finds that evisceration has occurred. What nursing action should be taken first? 1. Notify the clients surgeon. 2. Cover the area with a large saline-soaked dressing. 3. Position the client in bed with knees bent. 4. Pack the wound with nonadherent gauze.

Cover the area with a large saline-soaked dressing

The nurse wants to protect a client from developing an infection. Which action should the nurse take to break a link in the chain of infection? 1. Cover the mouth and nose when sneezing. 2. Place contaminated linens in a paper bag. 3. Use personal protective equipment (PPE) sparingly. 4. Wear gloves at all times.

Cover the mouth and nose when sneezing

The nurse determines that an adult clients feces are normal. What did the nurse assess to come to this conclusion? 1. Black in color 2. Cylindrical in shape 3. Pungent in odor 4. Yellow in color

Cylindrical in shape

A client tells the nurse about the need to get up several times throughout the night to void. The nurse suspects the client is experiencing nocturia due to which factor? 1. Decrease in bladder tone 2. Decrease in blood supply 3. Decrease in number of nephrons 4. Decrease in cardiac output

Decrease in bladder tone

The nurse has documented that the client has orthostatic hypotension. Which assessment finding would support this assessment? 1. Decrease in blood pressure when moving from supine to standing 2. Decrease in heart rate when moving from supine to sitting 3. Pale color in the legs when lying in bed 4. Complaints of dizziness when first sitting up

Decrease in blood pressure when moving from supine to standing

A client is diagnosed with an elevated aldosterone level. The nurse realizes that this finding will affect what aspect of urinary elimination? 1. Increased urine output 2. Urinary incontinence 3. Decreased urine output 4. Urinary retention

Decreased urine output

A client comes to the emergency department with a temperature of 104F. Which assessment findings should the nurse use to determine if this client is experiencing heat stroke? Select all that apply. 1. Delirious 2. Pale and dizzy 3. Skin warm and flushed 4. No evidence of sweating 5. Had been playing tennis in the sun

Delirious Skin warm and flushed No evidence of sweating Had been playing tennis in the sun

The nurse is planning instruction for a client who is underweight. What should be included in this teaching? Select all that apply. 1. Discuss factors contributing to inadequate nutrition and weight loss. 2. Discuss ways to manage, minimize, or alter the factors contributing to malnourishment. 3. Discuss principles of a well-balanced diet and high- and low-calorie foods. 4. Provide information about community agencies that can assist in providing food. 5. Provide information about ways to increase calorie intake.

Discuss factors contributing to inadequate nutrition and weight loss. Discuss ways to manage, minimize, or alter the factors contributing to malnourishment. Provide information about community agencies that can assist in providing food. Provide information about ways to increase calorie intake.

A client is diagnosed as having a negative nitrogen balance. What should the nurse instruct the client about this finding? 1. Discuss ways to reduce protein in the diet. 2. Review how to limit carbohydrates in the diet. 3. Discuss ways to increase protein in the diet. 4. Analyze reasons why fats should be limited in the diet.

Discuss ways to increase protein in the diet

The nurse is preparing a presentation on standard precautions. Which statement should the nurse include in the presentation? 1. Cut the needle off a syringe after using it to give a client an injection. 2. Dispose of blood-contaminated materials in a biohazard container. 3. Gloves should not be worn for client care unless body fluids are seen. 4. Wear a mask when in direct contact with all clients.

Dispose of blood-contaminated materials in a biohazard container

During the assessment of a clients breasts, the nurse finds both breasts rounded, slightly unequal in size, skin smooth and intact, and nipples without discharge. What should the nurse do next? 1. Notify the charge nurse. 2. Notify the physician. 3. Document the findings in the nurses notes as normal. 4. Document the findings in the nurses notes as abnormal.

Document the findings in the nurses notes as normal

A client is having issues with urinary elimination. What should the nurse instruct this client to promote urinary elimination? 1. Dont interrupt your day by going to the bathroom; wait until youre at a good stopping place. 2. Drink 8 to 10 glasses of water daily. 3. Urine color changes are not important. 4. Wash with soap and water every other day.

Drink 8 to 10 glasses of water daily.

Unlicensed assistive personnel are assigned the task of feeding breakfast to older clients with alterations in mobility and orientation. What instruction should the nurse include in this delegation? 1. Breakfast should be completed quickly so that baths may begin. 2. Give fluids before and after each bite of solid foods. 3. Stand to the left of right-handed clients during feeding. 4. Engage the client in conversation during the meal.

Engage the client in conversation during the meal

The nurse is applying an external urinary device to a client. Before attaching the device to the drainage bag, what should the nurse do? 1. Wash his or her hands. 2. Document the clients tolerance of the procedure. 3. Instruct the client about the drainage system. 4. Ensure that the condom is not twisted.

Ensure that the condom is not twisted.

The nurse is planning an educational program for community members on ways to improve nutritional intake. What information should the nurse include about carbohydrate digestion and metabolism? Select all that apply. 1. Enzymes are needed to digest carbohydrates. 2. The breakdown of carbohydrates results in simple sugars. 3. Carbohydrates are a major source of body energy. 4. The simple sugar glucose provides a readily available source of energy. 5. Pancreatic amylase enhances the use of glucose by the body cells.

Enzymes are needed to digest carbohydrates. The breakdown of carbohydrates results in simple sugars. Carbohydrates are a major source of body energy. The simple sugar glucose provides a readily available source of energy.

A client has occasional bouts of constipation, and asks the nurse what can be done to prevent these episodes in the future. What should the nurse instruct the client to do? Select all that apply. 1. Establish a regular exercise regimen. 2. Include high-fiber foods, such as vegetables, fruits, and whole grains, in the diet. 3. Maintain fluid intake of 2000 to 3000 mL a day. 4. Do not ignore the urge to defecate. 5. Use over-the-counter medications to treat constipation.

Establish a regular exercise regimen. Include high-fiber foods, such as vegetables, fruits, and whole grains, in the diet. Maintain fluid intake of 2000 to 3000 mL a day. Do not ignore the urge to defecate.

A client is prescribed a saline enema. Because this solution is hypertonic, the nurse would expect the enema to cause which action? 1. Exerts osmotic pressure and draws fluid from the interstitial space into the colon 2. Exerts a lower osmotic pressure than the surrounding interstitial fluid 3. Exerts the same osmotic pressure as the interstitial fluid surrounding the colon 4. Stimulates peristalsis by increasing the volume in the colon and irritating the colon

Exerts osmotic pressure and draws fluid from the interstitial space into the colon

The nurse is caring for a client following a cerebrovascular accident (stroke). The client is able to comprehend what is being said to him; however, he is unable to respond by speech or writing. What type of aphasia should the nurse realize this patient is demonstrating? 1. Auditory aphasia 2. Acoustic aphasia 3. Sensory aphasia 4. Expressive aphasia

Expressive aphasia

The nurse is preparing to assess a client with the Glasgow Coma Scale. Which areas is the nurse assessing in this patient? Select all that apply. 1. Eye response 2. Motor response 3. Verbal response 4. Orientation 5. Musculoskeletal response

Eye response Motor response Verbal response

A patient is diagnosed with a systemic infection. What will the nurse most likely assess in this client? 1. Edema, rubor, heat, and pain 2. Fever, malaise, anorexia, nausea, and vomiting 3. Palpitations, irritability, and heat intolerance 4. Tingling, numbness, and cramping of the extremities

Fever, malaise, anorexia, nausea, and vomiting

The nurse is preparing to apply a moist aquathermia pack to a clients left upper leg. In which order should the nurse prepare and apply this treatment? 1. Use tape or gauze ties to hold the pad in place. 2. Set the desired temperature according to the manufacturers instructions. 3. Apply the pad to the body part. The treatment is usually continued for 30 minutes. 4. Fill the reservoir of the unit two-thirds full of water as specified by the manufacturer. 5. Cover the pad and plug in the unit. Check for any leaks or malfunctions of the pad before use.

Fill the reservoir of the unit two-thirds full of water as specified by the manufacturer, Set the desired temperature according to the manufacturers instructions, Cover the pad and plug in the unit. Check for any leaks or malfunctions of the pad before use, Apply the pad to the body part. The treatment is usually continued for 30 minutes, Use tape or gauze ties to hold the pad in place

While providing a complete bed bath to a client, the nurse discovers abrasions along the clients back and upper buttock area. What should the nurse do to help this client? 1. Apply antiseptic spray to the abrasions. 2. Do not wash the client with soap. 3. Find assistance to help with the remainder of the bath. 4. Apply alcohol-free lotion to the abrasions.

Find assistance to help with the remainder of the bath.

While irrigating a clients abdominal wound, the irrigate splashes into the nurses nose and eyes. What should the nurse do? 1. Flush the nose and eyes for 5 to 10 minutes with water or normal saline. 2. Begin HIV high-risk exposure prophylaxis within 24 hours. 3. Wash the areas with soap and water. 4. Have blood drawn for hepatitis B antibodies.

Flush the nose and eyes for 5 to 10 minutes with water or normal saline

A client needs to have soft contact lenses removed. What should the nurse do when removing the lenses? 1. Gently pinch the lens and lift it out. 2. Have the client look up. 3. Pull the lower eyelid upward. 4. Use the pad of the ring finger.

Gently pinch the lens and lift it out.

As the nasogastric tube is passed into the oropharynx, the client begins to gag and cough. What is the correct nursing action? 1. Remove the tube and attempt reinsertion. 2. Give the client a few sips of water. 3. Use firm pressure to pass the tube through the glottis. 4. Have the client tilt the head back to open the passage.

Give the client a few sips of water

The nurse is performing a musculoskeletal assessment on a client admitted with a possible stroke. When testing for muscle grip strength, the nurse should ask the client to perform which action? 1. Grasp the nurses index and middle fingers while the nurse tries to pull the fingers out. 2. Hold an arm up and resist while the nurse tries to push it down. 3. Flex each arm and then try to extend it against the nurses attempt to keep the arm in flexion. 4. Shrug the shoulders against the resistance of the nurses hands.

Grasp the nurses index and middle fingers while the nurse tries to pull the fingers out

The nurse is preparing to remove soiled gloves. What action should the nurse take first? 1. Drop the gloves into the appropriate waste receptacle. 2. Ease the fingers into the gloves. 3. Grasp the outside of the nondominant glove. 4. Hook the bare thumb inside the other glove.

Grasp the outside of the nondominant glove

The nurse is preparing to remove ticks from a clients scalp. Which actions should the nurse perform to safely remove these pathogens from the client? Select all that apply. 1. Grasp the tick with blunt tweezers. 2. Apply heat to the tick with a match. 3. Wash the area with antibacterial soap. 4. Pull the tick away in a perpendicular movement. 5. Apply petroleum jelly to the surface of the tick.

Grasp the tick with blunt tweezers. Wash the area with antibacterial soap. Pull the tick away in a perpendicular movement.

A client is being discharged after a surgical procedure. On what should the nurse instruct the client to reduce the risk of infection? Select all that apply. 1. Hand-washing technique 2. The importance of adequate nutrition 3. Covering the mouth and nose when coughing or sneezing 4. Increasing contact with others 5. Restricting rest period

Hand-washing technique The importance of adequate nutrition Covering the mouth and nose when coughing or sneezing

While assisting the client with a bath, the nurse encourages full range of motion in all the clients joints. Which activity would best support range of motion in the hand and arm? 1. Give the client a washcloth to wash the face. 2. Move the wash basin farther toward the foot of the bed so the client must reach for it. 3. Have the client brush the hair and teeth. 4. Move each of the clients hand and arm joints through passive range of motion.

Have the client brush the hair and teeth

A client diagnosed with tuberculosis is being admitted to a care area. Which nursing action prevents the transmission of the disease? 1. Have the client wear a mask when coming from admission. 2. Stock the supply cart at the beginning of each shift. 3. Wash the hands only after leaving the room. 4. Wear a mask when exiting the room

Have the client wear a mask when coming from admission

The nurse determines that a client has active immunity to a microorganism. What did the nurse assess that caused the client to develop this type of immunity? 1. Becoming ill with tetanus and receiving tetanus toxoid 2. Having chickenpox 3. Receiving a rabies shot after being bitten by a rabid dog 4. Receiving an injection of gamma globulin

Having chickenpox

The nurse is planning a physical examination of a client following a head-to-toe format. In which order should the nurse conduct this assessment? 1. Head, upper extremities, abdomen, lower extremities 2. Neck, head, vital signs, chest and back 3. Lower extremities, abdomen, upper extremities, chest and back 4. Head, neck, lower extremities, abdomen

Head, upper extremities, abdomen, lower extremities

A client has a wound that is going to heal through secondary intention. When instructing the client about this wound, the nurse would include which statements? Select all that apply. 1. Minimal tissue loss. 2. Closure of the wound will occur within 5 days. 3. Healing time will be longer. 4. Potential for scarring is greater. 5. Susceptibility to infection is greater.

Healing time will be longer. Potential for scarring is greater. Susceptibility to infection is greater.

During a prenatal visit, the nurse is instructing a newly pregnant client in regard to exercise. What advice is best for the nurse to give this client? 1. Pregnant clients can exercise if exercise was a part of their life prior to pregnancy. 2. Due to the stress of a growing fetus, exercise should be limited to no more than 10 minutes per day. 3. Healthy pregnant women should exercise at least 30 minutes on most if not all days. 4. The pregnant womans exercise should actually increase above normal recommended levels to prevent water weight gain.

Healthy pregnant women should exercise at least 30 minutes on most if not all days

The nurse must lift a 15-pound box of supplies from a low shelf on the supply cart to a table. Which technique should the nurse use to protect the back? 1. Place the feet together to provide a strong base of support. 2. Flex the knees to lower the center of gravity. 3. Face the box, pick it up, and rotate the upper body toward the table. 4. Hold the box as close to the body as possible.

Hold the box as close to the body as possible

The client has a history of postural hypotension. Which activities should the nurse advise this client as likely to cause postural hypotension? Select all that apply. 1. Hot baths 2. Heavy meals 3. Use of a rocking chair 4. Moving in bed 5. Bending down to the floor

Hot baths Heavy meals Bending down to the floor

A client experiencing hard, dry feces is scheduled for an enema. The nurse recognizes that what type of solution would be best for the client? Select all that apply. 1. Hypertonic 2. Hypotonic 3. Soapsuds 4. Oil retention 5. Isotonic

Hypotonic Isotonic

The client has a documented stage III pressure ulcer on the right hip. What NANDA nursing diagnosis problem statement is most appropriate for use with this client? 1. Altered Tissue Perfusion 2. Impaired Skin Integrity 3. Impaired Tissue Integrity 4. Risk for Injury

Impaired Tissue Integrity

What criteria should the nurse use to evaluate to determine if an infants regurgitation, or spitting up, should be further investigated? 1. How often the baby spits up 2. How much the baby spits up at a time 3. If the baby is gaining weight adequately 4. The consistency of the regurgitated matter

If the baby is gaining weight adequately

The nurse is taking care of a client who states that he ignores the urge to defecate when he is at work. Which response should the nurse make to explain why this practice should be changed? 1. If you continue to ignore the urge to defecate, the urge is ultimately lost. 2. It is best to suppress the urge rather than suffer embarrassment at work. 3. This is a common practice, and it will strengthen the reflex later. 4. You will get the urge later; dont worry.

If you continue to ignore the urge to defecate, the urge is ultimately lost.

A client sustained several wounds on the legs caused by a fall. On the day after the injuries, the wounds appear red and edematous. The nurse identifies the stage of healing of these wounds as being in which phase? 1. Inflammatory 2. Proliferative 3. Maturation 4. Remodeling

Inflammatory

A client is being transferred from an acute care facility to a long-term care facility. What information should the nurse provide to the long-term care facility about the clients medications? 1. Nothing, as the medications all need to be reordered at the long-term care facility. 2. Have the clients medication prescriptions filled before going to long-term care facility. 3. Instruct the client to tell the nurses at the long-term care facility what medications are prescribed. 4. Inform the nurse at the long-term care facility what medications the client is prescribed, and document that this information was provided.

Inform the nurse at the long-term care facility what medications the client is prescribed, and document that this information was provided.

The nurse is determining tasks to delegate to unlicensed assistive personnel (UAP). Which task should the nurse question before delegating to this level of health care provider? 1. Measuring intake and output 2. Assessing vital signs for clients who are clinically stable 3. Performing complete morning care for a client recovering from a stroke 4. Inserting a urinary catheter into a client

Inserting a urinary catheter into a client

A client is experiencing abdominal pain. What assessments should the nurse perform to assess this complaint? Select all that apply. 1. Inspect the abdomen. 2. Auscultate the abdomen. 3. Palpate the abdomen. 4. Assess vital signs. 5. Assess peripheral pulses.

Inspect the abdomen. Auscultate the abdomen. Palpate the abdomen. Assess vital signs.

The nurse is preparing to perform a health assessment of the abdomen. In which order should the nurse perform the assessment? 1. Auscultate, percuss, palpate, inspect 2. Inspect, auscultate, palpate, percuss 3. Inspect, auscultate, percuss, palpate 4. Palpate, percuss, auscultate, inspect

Inspect, auscultate, percuss, palpate

The nurse is caring for a client diagnosed with early osteoporosis. Which intervention is most applicable for this client? 1. Institute an exercise plan that includes weight-bearing activities. 2. Increase the amount of calcium in the clients diet. 3. Protect the clients bones with strict bed rest. 4. Provide the client with assisted range-of-motion exercising twice daily.

Institute an exercise plan that includes weight-bearing activities

Which intervention would the nurse plan to help a client prevent a urinary tract infection? 1. Encourage the use of bubble baths. 2. Have the client increase sugar in the diet. 3. Instruct the client to empty the bladder completely. 4. Wipe from back to front.

Instruct the client to empty the bladder completely.

The nurse determines that a client has adequate physiological barriers to defend the body against infection. What did the nurse assess in this client? Select all that apply. 1. Intact and dry skin 2. Intact oral mucous membranes 3. Bowel sounds present in all four quadrants 4. Nasal congestion 5. Urinary retention

Intact and dry skin Intact oral mucous membranes Bowel sounds present in all four quadrants

A clients urine pH is 8.0. What further assessments would be indicated for this client? Select all that apply. 1. Intake of fruits and vegetables 2. Intake of cranberries 3. Intake of high-protein foods 4. Symptoms of diarrhea 5. Symptoms of a urinary tract infection

Intake of fruits and vegetables Symptoms of a urinary tract infection

During an assessment, the nurse notes that a clients stool is black. Which medication should the nurse consider as causing this clients change in stool color? Select All that apply. 1. Iron 2. Aspirin 3. Antacids 4. Antibiotics 5. Pepto-Bismol

Iron Aspirin Pepto-Bismol

A client recovering from a transurethral resection of the prostate (TURP) with a three-way indwelling catheter expresses the need to urinate. Which action should the nurse take to help this client? 1. Deflate and then reinflate the balloon. 2. Irrigate the catheter. 3. Reposition the catheter. 4. Retape the catheter to the abdomen.

Irrigate the catheter

A client diagnosed with an infectious disease asks the nurse how the infection got inside her body. Which responses would be appropriate for the nurse to make? Select all that apply. 1. It depends on the number of organisms present to cause a disease. 2. It depends on how aggressive the organisms are to cause a disease. 3. It depends upon how the organisms get inside the body to cause a disease. 4. It depends upon where the person is at the time the disease is present. 5. It depends upon where the person works.

It depends on the number of organisms present to cause a disease It depends on how aggressive the organisms are to cause a disease It depends upon how the organisms get inside the body to cause a disease It depends upon where the person is at the time the disease is present

A client has the nursing diagnosis Risk for Impaired Skin Integrity related to immobility. Which nursing intervention should be identified for this clients problem? 1. Encourage the client to eat at least 40% of meals. 2. Keep linens dry and wrinkle-free. 3. Restrict fluid intake. 4. Turn client every 3 hours.

Keep linens dry and wrinkle-free.

A client is prescribed to receive a cleansing enema. What should the nurse instruct the client prior to administering this enema? 1. Hold the solution for a short time. 2. Lie in the left lateral position. 3. Lie in the right lateral position. 4. Take fast breaths through the nose.

Lie in the left lateral position.

The nurse is appointed to be a member of committee whose focus is to identify and address workplace safety issues. Which issues should the nurse recommend for analysis by this committee? Select all that apply. 1. Lifting clients 2. Inadequate lighting 3. Bending and walking 4. Exposure to infectious agents 5. Exposure to hazardous medications

Lifting clients Bending and walking Exposure to infectious agents Exposure to hazardous medications

The nurse is instructing a client on ways to manage stress urinary incontinence. What should be included in this clients teaching? Select all that apply. 1. Limit intake of caffeine. 2. Limit intake of alcohol. 3. Increase intake of citrus juices. 4. Limit evening fluid intake. 5. Increase intake of beverages with artificial sweeteners.

Limit intake of caffeine. Limit intake of alcohol. Limit evening fluid intake.

A client who is on seizure precautions experiences a seizure while ambulating in the room. What should the nurse include in this clients documentation? Select all that apply. 1. Who assisted the client back to bed 2. Location of the seizure 3. Duration of the seizure 4. Status of airway and use of oxygen 5. Who discovered the client

Location of the seizure Duration of the seizure Status of airway and use of oxygen

What is the priority action of the nurse prior to transferring a client from bed to wheelchair? 1. Place the bed in its lowest position. 2. Place the wheelchair parallel to the bed. 3. Lock the brakes on the bed. 4. Place a transfer belt on the client.

Lock the brakes on the bed

While the nurse is performing morning care, a client begins to have a seizure. What should the nurse do to help this client? 1. Insert a tongue blade into the clients mouth. 2. Loosen any clothing around the neck and chest. 3. Restrain the client. 4. Turn the client to the supine position if possible.

Loosen any clothing around the neck and chest.

The nurse is assessing the musculoskeletal status of a 4-year-old child. What findings should the nurse consider as being expected in this client? Select all that apply. 1. Lordosis 2. Genu valgus 3. Genu varum 4. Pronation of the feet 5. Asymmetric leg abduction

Lordosis Genu valgus

An older client has an oral temperature reading of 97.2 degrees F. The nurse realizes that this clients low temperature could be due to which observation? 1. The anxiety level of the client has increased. 2. Hormones have fluctuated in this client. 3. Muscle activity has increased during the clients therapy session. 4. Loss of subcutaneous fat is noted.

Loss of subcutaneous fat is noted.

An older female client with a history of urinary tract infections has an indwelling urinary catheter. What should the nurse do to reduce this clients risk of developing an infection because of the catheter? Select all that apply. 1. Maintain a sterile closed drainage system. 2. Clean the peri-urethral area with antiseptics. 3. Ensure the catheter and tubing are not kinked. 4. Wash his or her hands before manipulating the catheter. 5. Keep the collection bag below the level of the bladder.

Maintain a sterile closed drainage system. Ensure the catheter and tubing are not kinked. Wash his or her hands before manipulating the catheter. Keep the collection bag below the level of the bladder.

The bed-bound client complains of pain and burning in the right calf area. What action should be taken by the nurse? 1. Deeply palpate the area for rebound tenderness. 2. Percuss over the area for change in tone. 3. Measure the calf and compare to the opposite calf. 4. Medicate the client for pain and reassess in 30 minutes.

Measure the calf and compare to the opposite calf

The nurse is instructing a client on foods that are considered complete proteins. What will the nurse include in these instructions? Select all that apply. 1. Meat 2. Gelatin 3. Eggs 4. Chicken 5. Fish

Meat Eggs Chicken Fish

The client is weighed each month while residing in the long-term care facility. This month the client weighs 110 lb (50 kg). The nurse compares this weight to the last 3 months results and discovers the client has lost 22 lb (10 kg). There has been no attempt to lose this weight. How should the nurse interpret this weight loss? 1. No malnutrition 2. Mild malnutrition 3. Moderate malnutrition 4. Severe malnutrition

Mild malnutrition

A client is diagnosed with an elevated cholesterol level. What should the nurse instruct the client regarding foods to avoid? Select all that apply. 1. Fish 2. Milk 3. Liver 4. Chicken 5. Egg yolk

Milk Liver Egg yolk

The nurse is preparing to provide a morning bath to a client diagnosed with dementia. What can the nurse do to ensure a positive bathing experience for the client? Select all that apply. 1. Move slowly. 2. Be flexible. 3. Help the client feel in control. 4. Avoid stopping once the bath is started. 5. Be prepared.

Move slowly. Be flexible. Help the client feel in control. Be prepared.

The nurse is teaching a client on the use of a cane. What should the nurse include in this teaching? Select all that apply. 1. Hold the cane on the weaker side of the body. 2. Move the cane forward while the body weight is between both legs. 3. The length of the cane should permit the elbow to be fully extended. 4. Move the weaker leg forward while the weight is between the cane and the stronger leg. 5. Move the stronger leg forward while the weight is between the cane and the weaker leg.

Move the cane forward while the body weight is between both legs. Move the weaker leg forward while the weight is between the cane and the stronger leg. Move the stronger leg forward while the weight is between the cane and the weaker leg.

The nurse is working on a hospital committee focused on preventing back injury in nurses. Which recommendation by this committee is most likely to result in a decrease in back injuries if followed? 1. Nurses must wear back belts when lifting clients. 2. All nursing personnel must attend annual body mechanics education. 3. In order to prevent injury, nurses must strive to become physically fit. 4. No solo lifting of clients is permitted in the facility

No solo lifting of clients is permitted in the facility

An older client tells the nurse that in order to have a daily bowel movement, the client uses laxatives most days of the week. What should the nurse tell this client? Select all that apply. 1. Normal patterns of elimination are different for everyone. 2. Increase fiber intake to 2035 grams a day. 3. Engage in enjoyable exercise. 4. Ignore the urge to have a bowel movement. 5. Drink six to eight glasses of fluid daily.

Normal patterns of elimination are different for everyone. Increase fiber intake to 2035 grams a day. Engage in enjoyable exercise. Drink six to eight glasses of fluid daily.

The nurse is assessing the nose and sinuses of a client. Which findings should the nurse identify as being within normal limits? Select all that apply. 1. Nose straight 2. Nares symmetrical 3. No tenderness over the bridge 4. Air movement restricted in one nare 5. Clear drainage from one nare

Nose straight Nares symmetrical No tenderness over the bridge

The nurse is caring for a client who experiences frequent bouts of diarrhea. What should the nurse instruct the client to do? 1. Change the daily routine. 2. Decrease fluid consumption. 3. Increase fiber in the diet. 4. Note the precipitating event.

Note the precipitating event.

The nurse has completed foot care for a client as part of routine morning care. What should the nurse document about the procedure? 1. The condition of the skin and nails 2. Nothing unless a problem is noted 3. The amount of time taken on foot care 4. The clients comments about the foot care

Nothing unless a problem is noted

A client is prescribed propranolol (Inderal). What should the nurse instruct the client about this medication? 1. The medication should be discontinued abruptly. 2. Notify the physician if you experience urinary retention. 3. Take a laxative every day. 4. Take the medication on an empty stomach.

Notify the physician if you experience urinary retention.

The nurse is preparing discharge teaching for a client recovering from surgery. What instruction is the most important for the nurse to give this client who has a surgical wound? 1. Adjust the diet so it contains more fruits and vegetables. 2. Apply lubricating lotion to the edges of the wound. 3. Notify the physician of any edema, heat, or tenderness at the wound site. 4. Thoroughly irrigate the wound with hydrogen peroxide.

Notify the physician of any edema, heat, or tenderness at the wound site.

The nurse is preparing to assess a client who has a history of falls. Which methods should the nurse use to assess this clients risk for injury? Select all that apply. 1. Cognitive awareness 2. Mobility 3. Nursing history 4. Physical examination 5. Health status

Nursing history Physical examination

The nurse has instructed an overweight client to follow a 2,000-calorie diet by substituting foods considered low in calories for those higher in calories. How should the client interpret the food label to decide if a food is low in calories? 1. The product label will state lighter or reduced calories. 2. The Nutrition Facts label will have the letter L located in the lower right corner. 3. Nutritional labeling on the product will indicate less than 40 calories per serving. 4. The product will contain no more than 11% fat.

Nutritional labeling on the product will indicate less than 40 calories per serving

The RN assesses a client who is recovering from femoral popliteal bypass surgery and discovers that it is difficult to assess the dorsalis pedis pulses. Which nursing intervention would be most appropriate for the nurse to use? 1. Ask another nurse to assess the pulses. 2. Document the findings. 3. Obtain a Doppler ultrasound stethoscope. 4. Wait and try again later.

Obtain a Doppler ultrasound stethoscope.

The nurse is preparing to assess a clients fecal elimination status. Which activity will the nurse complete during this assessment? 1. Obtain a nursing history. 2. Interpret results of diagnostic tests. 3. Perform a physical examination. 4. Set goals with the client.

Obtain a nursing history.

An older client tells the nurse that showers are not taken because of a previous fall. What can the nurse do to support the clients bathing needs? 1. Obtain a shower chair and assist the client in the shower. 2. Document that the client refused a morning bath in the medical record. 3. Tell the client that shower shoes can be worn to prevent falls. 4. Hold the client during the shower.

Obtain a shower chair and assist the client in the shower.

A client recovering from abdominal surgery is demonstrating abdominal distention from trapped flatus. What can the nurse do to help this client? 1. Assist the client to move in bed. 2. Restrict fluids. 3. Obtain an order for a rectal tube. 4. Provide a diet rich in foods that create flatulence.

Obtain an order for a rectal tube.

The nurse is preparing to complete a physical examination on a client. What should the nurse realize as being the purpose for this examination? Select all that apply. 1. Obtain baseline data. 2. Obtain data to help determine nursing diagnoses. 3. Identify areas for disease prevention. 4. Identify the clients employment status. 5. Obtain data about the clients leisure activities.

Obtain baseline data. Obtain data to help determine nursing diagnoses. Identify areas for disease prevention.

A client has sustained multiple contusions from a motor vehicle accident. What should the nurse do to prepare for this clients care? 1. Obtain ice packs to apply to the wounds. 2. Request gauze to pack the wounds. 3. Organize suture material to close the wounds. 4. Notify the surgical staff that a surgical client will soon be arriving.

Obtain ice packs to apply to the wounds

The nurse has advised the client to consume alcohol only in moderation. What guideline should the nurse provide as a moderate alcohol intake? 1. Two drinks per week for women, three for men 2. Two drinks per day for women, three for men 3. One drink per day for women, two for men 4. One drink per week for women, two for men

One drink per day for women, two for men

The nurse is caring for a client experiencing dyspnea. In which position should the nurse place this client? 1. High Fowlers position with two pillows behind the head 2. Orthopneic position across the overbed table 3. Prone position with knees flexed and arms extended 4. Sims position with both legs flexed

Orthopneic position across the overbed table

The nurse is applying restraints to a client. After securing a health care providers order, what should the nurse do? 1. Assess the restraints every 10 minutes. 2. Pad bony prominences. 3. Secure the restraint to the side rail. 4. Tie the restraint with a square knot.

Pad bony prominences.

A client is prescribed seizure precautions. What can the nurse safely delegate to UAP to complete when implementing the precautions? 1. Placing a tongue blade at the head of the bed 2. Padding the clients bed 3. Installing oxygen 4. Checking the oral suction apparatus

Padding the clients bed

The RN is admitting a client to the medical unit for a urinary disorder. Which physical assessment techniques should the nurse use in assessing this clients urinary system? 1. Auscultation and inspection 2. Inspection and percussion 3. Observation and auscultation 4. Palpation and observation

Palpation and observation

A client needs to be placed in contact isolation. What items should the nurse ensure are included in this clients room? 1. Cabinet stocked with gloves and gowns 2. Cards and records 3. Paper towels, sink, and blood pressure cuff 4. Sign on the door

Paper towels, sink, and blood pressure cuff

The nurse is preparing to perform an eye assessment. What equipment should the nurse have available to complete this assessment? Select all that apply. 1. Penlight 2. Snellens chart 3. Sterile gloves 4. Gauze square 5. Millimeter ruler

Penlight Snellens chart Gauze square Millimeter ruler

The nurse is preparing to assess a clients reflexes. What equipment should the nurse gather before entering the room? 1. Sterile gloves 2. Clean gloves 3. Percussion hammer 4. Penlight

Percussion hammer

The nurse needs to apply personal protective equipment before entering a clients room. In which order should the nurse perform the following actions? Standard Text: Place the steps in the order in which they should be performed. 1. Apply gloves. 2. Apply eyewear. 3. Apply the gown. 4. Apply the face mask. 5. Perform hand hygiene.

Perform hand hygiene, Apply the face mask, Apply the gown, Apply eyewear, Apply gloves

The client who is unconscious is developing foot drop. What nursing action is indicated? 1. Place high-topped shoes on the client while in bed. 2. Keep the linens on the end of the bed turned back to expose the feet. 3. Use only the prone and Sims positions for client positioning. 4. Use a device to elevate the linens off the feet

Place high-topped shoes on the client while in bed

The nurse is installing a bed safety-monitoring device for a client. What should the nurse do after testing the device and alarm sound? 1. Place the leg band on the client with the leg in a straight horizontal position. 2. Place the sensor under the mattress near the shoulder region. 3. Set a time delay for 30 seconds. 4. Connect the sensor pad to the control unit.

Place the leg band on the client with the leg in a straight horizontal position.

The nurse is planning to perform indirect percussion on an area of a clients body during a physical examination. Which actions should the nurse take to use this assessment technique? Select all that apply. 1. Place the middle finger of the nondominant hand on the clients skin. 2. Use the tip of the flexed middle finger of the other hand to strike the middle finger of the nondominant hand. 3. Perform a striking motion by moving the wrist. 4. Perform short, rapid, firm blows. 5. Use a stethoscope to transmit sounds to the ears.

Place the middle finger of the nondominant hand on the clients skin. Use the tip of the flexed middle finger of the other hand to strike the middle finger of the nondominant hand. Perform a striking motion by moving the wrist. Perform short, rapid, firm blows.

The nurse is making a clients bed. What safety measure should the nurse implement at this time? 1. Begin at the head and move toward the foot, loosening bottom linens. 2. Miter corners at the head of the bed. 3. Place the soiled sheet in a laundry bag. 4. Prepare the client.

Place the soiled sheet in a laundry bag.

The nurse identifies an older client as being at risk for impaired skin integrity. What did the nurse assess in this client? Select all that apply. 1. Poor skin turgor. 2. Elevated body temperature. 3. Diminished pain sensation. 4. Thin epidermis. 5. Dry skin.

Poor skin turgor. Diminished pain sensation. Thin epidermis. Dry skin.

Unlicensed assistive personnel are caring for a clients ears. What information should be reported to the nurse? 1. Excessive earwax 2. Loud talking 3. Presence of a hearing aid 4. Presence of any drainage

Presence of any drainage

An older client is observed having difficulty moving from a sitting to standing position, and has an unsteady gait. What should the nurse assess in this client to promote home safety? Select all that apply. 1. Presence of grab bars in the bathroom 2. Absence of scatter rugs on the floors 3. Correct use of cane to ambulate 4. Ability to stand in place for a minute before ambulating 5. Alcohol use with prescribed medications

Presence of grab bars in the bathroom Absence of scatter rugs on the floors Correct use of cane to ambulate

The nurse is delegating activities regarding fecal elimination to unlicensed assistive personnel (UAP). Which activity can UAP safely perform to meet a clients fecal elimination needs? 1. Provide a fracture pan to a client on bed rest. 2. Provide a client who has a fecal impaction and prolapsed rectum with a cleansing enema. 3. Change a clients ostomy device. 4. Irrigate a clients ostomy.

Provide a fracture pan to a client on bed rest.

The nurse is admitting an older client to the care area. What can the nurse do to promote a safe environment for the client? 1. Keep clutter to a minimum in the clients room. 2. Have the client wear terry-cloth slippers. 3. Provide adequate lighting. 4. Turn off alarms to reduce noise.

Provide adequate lighting.

A client who is ambulatory is able to get out of bed for morning care. What should the nurse assess before assisting the client out of the bed to change the linen? Select all that apply. 1. Pulse 2. Respirations 3. Urine output 4. Blood pressure 5. Mobility status

Pulse Respirations Blood pressure Mobility status

While changing a clients dressing, the nurse notes thick yellow-green drainage on the gauze. How should the nurse document this wounds drainage? 1. Purulent 2. Serous 3. Sanguineous 4. Serosanguinous

Purulent

The nurse is preparing to bath a client on the first postoperative day. Which nursing intervention should take priority? 1. Apply lotion to the extremities. 2. Change the water when it becomes cold. 3. Raise side rails when gathering supplies. 4. Remove the soiled dressing during the bath.

Raise side rails when gathering supplies.

The newly admitted client has contractures of both lower extremities. What nursing intervention should be included in this clients plan of care? 1. Frequent position changes to reverse the contractures 2. Exercises to strengthen flexor muscles 3. Range-of-motion exercises to prevent worsening of contractures 4. Weight-bearing activities to stimulate joint relaxation

Range-of-motion exercises to prevent worsening of contractures

After completing a scheduled every-2-hour turn by turning the client to the left side, the nurse notices a reddened area over the coccyx. The area blanches when the nurse compresses it with thumb pressure. One hour later, the nurse reassesses the area and finds the redness has disappeared. How should the nurse document this area? 1. Reactive hyperemia 2. Stage I pressure ulcer 3. Stage II pressure ulcer 4. Stage III pressure ulcer

Reactive hyperemia

The nurse is providing range-of-motion exercising to the clients elbow when the client complains of pain. What action should the nurse take? 1. Stop immediately and report the pain to the clients physician. 2. Discontinue the treatment and document the results in the medical record. 3. Reduce the movement of the joint just until the point of slight resistance. 4. Continue to exercise the joint as before to loosen the stiffness.

Reduce the movement of the joint just until the point of slight resistance

A client is prescribed antiembolic stockings. How should the nurse assess the skin on the clients legs? 1. Defer the assessment because the stockings are in place. 2. Remove the stockings for this assessment. 3. Review the morning assessment, but dont repeat it unless a problem occurs. 4. Assess the skin when the client removes the stockings at bedtime.

Remove the stockings for this assessment

The nurse would like to improve communication among caregivers. How should the nurse use the Joint Commission 2013 National Patient Safety Goals to achieve this objective? 1. Review a list of look-alike/sound-alike drugs used in the organization. 2. Use a verification process to confirm the correct procedure. 3. Report critical results of tests and diagnostic procedures on a timely basis.. 4. Use the clients room number as an identifier.

Report critical results of tests and diagnostic procedures on a timely basis.

During morning care, a UAP notes that thick green drainage is seeping around the appliance of a clients new ostomy. What should the UAP have been instructed to do? 1. Clean around the drainage. 2. Remove the ostomy appliance and cover the stoma with toilet tissue. 3. Perform complete ostomy care. 4. Report the drainage to the nurse.

Report the drainage to the nurse.

During morning care, unlicensed assistive personnel observe a clients abdominal wound dressing become saturated with bright red blood. What should unlicensed assistive personnel do? 1. Reinforce the wound with supplies on the clients bedside table. 2. Document that the bath was completed, and the condition of the dressing. 3. Complete the bath, then report the change to the nurse. 4. Report the dressing changes to the nurse immediately.

Report the dressing changes to the nurse immediately

The nurse is preparing to shave a client. Which action step should the nurse consider when providing this care? 1. Assist the client to a prone position. 2. Pull the skin taut with the dominant hand. 3. Rinse the razor after each stroke. 4. Use long strokes.

Rinse the razor after each stroke.

A client has episodes of bowel and bladder incontinence. When planning care for this client, the nurse would identify which nursing diagnosis as being appropriate? 1. Impaired Skin Integrity 2. Risk for Impaired Skin Integrity 3. Impaired Tissue Integrity 4. Risk for Infection

Risk for Impaired Skin Integrity

What nursing diagnosis is the most important for the nurse to include in the care plan of a client who has just been started on total parenteral nutrition (TPN) therapy? 1. Risk for Infection 2. Imbalanced Nutrition: Less Than Body Requirements 3. Activity Intolerance 4. Fluid Volume Deficit

Risk for Infection

Which nursing diagnosis would be appropriate for a client who has a retention catheter if the drainage bag is found lying on the floor? 1. Risk for Impaired Skin Integrity related to catheter placement 2. Risk for Infection related to improper handling 3. Self-Care Deficit related to presence of a retention catheter 4. Risk for Incontinence related to an obstruction

Risk for Infection related to improper handling

The nurse is planning care for a client who is prone to falling. Which nursing diagnoses should the nurse use for this client? 1. Deficient Knowledge 2. Risk for Injury 3. Risk for Disuse Syndrome 4. Risk for Suffocation

Risk for injury

A client is diagnosed with a communicable disease, and must be placed in isolation. The nurse should identify which diagnosis as a priority for this client? 1. Social Isolation 2. Anxiety 3. Acute Pain 4. Imbalanced Nutrition: Less Than Body Requirements

Social Isolation

The nurse is instructing a client on ostomy care. What should be included in this teaching? 1. Change the drainage pouch daily. 2. Clothing of a special style will be needed now that a pouch is worn. 3. Stick a pin into the drainage pouch to relieve any gas buildup. 4. Secure the faceplate to the drainage pouch so no skin around the stoma is exposed.

Secure the faceplate to the drainage pouch so no skin around the stoma is exposed.

The nurse is planning interventions for a client to improve the appetite. What actions would be appropriate for this client? Select all that apply. 1. Select small portions. 2. Avoid unpleasant treatments immediately before or after a meal. 3. Ensure a clean environment free of unpleasant sights and odors. 4. Encourage oral hygiene before a meal. 5. Provide medication for pain or other symptoms after a meal.

Select small portions. Avoid unpleasant treatments immediately before or after a meal. Ensure a clean environment free of unpleasant sights and odors. Encourage oral hygiene before a meal.

A client is prescribed bed rest with bathroom privileges. Which types of bath would be appropriate for this client? Select all that apply. 1. Shower 2. Tub bath 3. Self-help bed bath 4. Therapeutic bath 5. Partial bath

Self-help bed bath Partial bath

The nurse wants to assess a client during the morning bath. What will the nurse be able to assess during this time? Select all that apply. 1. Skin status 2. Financial status 3. Psychosocial needs 4. Learning needs 5. Physical conditions

Skin status Psychosocial needs Learning needs Physical conditions

The nurse is evaluating teaching provided to a client about home safety. Which observation indicates that teaching has been effective? 1. Smoke alarm functioning with new batteries installed 2. Scatter rugs located in the kitchen and bathroom only 3. Cord for a space heater stretched across a hallway 4. Light bulbs burned out in the bathroom and living room

Smoke alarm functioning with new batteries installed

The nurse is shampooing a clients hair. Which assessment finding should the nurse consider as expected? 1. Dry, dark, thin 2. Smooth, taut, shiny 3. Smooth texture and not oily or dry 4. Tender, warm scalp

Smooth texture and not oily or dry

The nurse has finished providing a tube feeding to a client. What should the nurse document about this procedure? Select all that apply. 1. Name of physician prescribing the feedings 2. Solution provided 3. Amount of fluid 4. Duration of the feeding 5. Client tolerance of the feeding

Solution provided Amount of fluid Duration of the feeding Client tolerance of the feeding

The parents of a 7-month-old child have started offering solid foods to their baby. The baby has enjoyed and tolerated rice cereal, applesauce, and other fruits. Which food should the nurse recommend to be introduced next? 1. Strained beef 2. Green beans 3. Squash 4. Strained chicken

Squash

The nurse is preparing to provide morning care to a client. What should the nurse explain to the client as the reason for a daily bath? 1. Assess skin integrity 2. Develop a nurseclient relationship 3. Moisturize the skin 4. Stimulate circulation

Stimulate circulation

A client is prescribed seizure precautions. The nurse places functioning oral suction equipment in the clients room for what reason? 1. Suctioning might be needed to prevent the aspiration of oral secretions. 2. The client has difficulty swallowing liquids. 3. There was a spare oral suction set up, and the nurse did not want to return it to the engineering department. 4. It helps when the client is brushing her teeth.

Suctioning might be needed to prevent the aspiration of oral secretions.

The nurse is preparing materials to instruct the parents of a newborn. What should the nurse identify as a safety hazard in an infant? 1. Exposure to alcohol consumption 2. Drowning 3. Pedestrian accidents 4. Suffocation in the crib

Suffocation in the crib

The nurse is assisting in logrolling a client recovering from spinal surgery. Why should the nurse place a pillow between the clients legs when turning? Select all that apply. 1. Stabilizes the spine 2. Prevents hip contractures 3. Supports the upper leg 4. Keeps the legs parallel and aligned 5. Prevents adduction of the upper leg

Supports the upper leg Keeps the legs parallel and aligned Prevents adduction of the upper leg

An older client with gallbladder disease has had a cholecystectomy. Which factor should the nurse realize would influence the development of an infection in this client? 1. Active bowel sounds 2. Dry intact skin 3. Intact mucous membranes 4. Susceptibility of the client

Susceptibility of the client

A client asks the nurse why expelled flatus is foul-smelling. What should the nurse respond? 1. The actions of microorganisms within the gastrointestinal tract are responsible for the odor. 2. The clients emotions are causing the gas formation. 3. The sensory nerves in the rectum are being stimulated. 4. The client has swallowed too much air while eating.

The actions of microorganisms within the gastrointestinal tract are responsible for the odor.

A client asks why a cold pack has been prescribed for an arm injury. What should the nurse explain to the client? Select all that apply. 1. The application of cold dilates blood vessels. 2. The application of cold constricts blood vessels. 3. The application of cold decreases inflammation. 4. The application of cold reduces localized pain. 5. The application of cold provides a calming, sedative effect.

The application of cold constricts blood vessels. The application of cold decreases inflammation. The application of cold reduces localized pain.

The client has a body mass index (BMI) of 18. How should the nurse interpret this finding? 1. The client is malnourished. 2. The client is underweight. 3. The client is normal. 4. The client is overweight.

The client is underweight

The nurse is concerned that a client is at risk for the development of urinary tract infections. What did the nurse assess to come to this conclusion? 1. The client is wearing tight clothing. 2. The client is employed as a computer operator. 3. The client drinks 810 8-ounce glasses of water and low-calorie beverages each day. 4. The client exercises for 3060 minutes most days of the week.

The client is wearing tight clothing.

The nurse determines that a clients fecal elimination is pale in color. This finding supports which client behavior obtained during the health history? 1. The client rarely eats animal protein, and ingests milk and cheese at several meals each day. 2. The client rarely eats fruits or vegetables. 3. The client uses laxatives routinely. 4. The client drinks 8 to 10 8-ounce glasses of water each day.

The client rarely eats animal protein, and ingests milk and cheese at several meals each day

A client is instructed on the care of an indwelling urinary catheter. Which returned demonstration by the client indicates that teaching has been effective? 1. The client empties the drainage bag once a day. 2. The client hangs the drainage bag on the towel rod. 3. The client refuses drinks one to two 8-ounce glasses of fluid each day. 4. The client takes a shower each day.

The client takes a shower each day.

The nurse is caring for a client who is experiencing constipation. Which client behavior indicates that teaching was effective? 1. The client continues to ask for his pain medication. 2. The client decreases his fluid consumption. 3. The client refuses to eat the bran flakes on his tray. 4. The client walks around the unit several times a day.

The client walks around the unit several times a day.

The nurse determines that unlicensed assistive personnel (UAP) are not to be delegated client blood pressure measurements. What did the nurse observe to make this clinical decision? 1. The valve on the bulb was closed. 2. The client was sitting with the legs crossed. 3. The arm was below the level of the heart. 4. The UAP waited 2 minutes before re-measuring. 5. The cuff bladder was placed over the brachial artery.

The client was sitting with the legs crossed. The arm was below the level of the heart.

When planning care, the nurse should identify which client as needing logrolling for position changes? 1. A client with documented pneumonia 2. The client who has had abdominal surgery 3. The client who fell from a house, sustaining a fractured tibia 4. A client who has a severe headache from hypertensive crisis

The client who fell from a house, sustaining a fractured tibia

Which goals should the nurse identify as appropriate for a client with the nursing diagnosis Urinary Pattern Alteration related to an enlarged prostate? 1. The client will avoid bladder distention. 2. The client will maintain fluid imbalance. 3. The client will remain free of skin breakdown. 4. The client will voice increased discomfort.

The client will avoid bladder distention.

The nurse is identifying outcomes for an older client prone to injuries. Which outcome should the nurse identify as appropriate for this client? 1. The client will demonstrate an understanding of all limitations. 2. The client will establish a buddy system. 3. The client will make uninformed choices when addressing health issues. 4. The client will take his medication as desired.

The client will establish a buddy system.

The nurse is identifying outcomes for a client with the nursing diagnosis Stress Urinary Incontinence. Which outcome would be related to sphincter incompetence? 1. The client will empty her bladder every time she voids. 2. The client will improve her incontinence within 1 month. 3. The client will perform four to five squeezes for 5 to 10 seconds. 4. The client will stop the flow of urine when voiding.

The client will perform four to five squeezes for 5 to 10 seconds.

The nurse identifies the diagnosis Self-Care Deficit related to cognitive impairment as appropriate for a client. What should the nurse select as an expected outcome for this client? 1. The client will be able to name the staff that works on the day shift. 2. The client will eliminate safety hazards in her environment. 3. The client, with supervision, will brush her teeth. 4. The nurse will stress the importance of adequate fluid intake.

The client, with supervision, will brush her teeth.

The nurse assesses an open area over a clients greater trochanter that is approximately 10 cm in diameter. The tissue around the area is edematous and feels boggy. The edges of the wound cup in toward the center. Which additional finding would indicate to the nurse that this is a stage IV pressure ulcer? 1. There is undermining of adjacent tissues. 2. The crater extends into the subcutaneous tissue. 3. The joint capsule of the hip is visible. 4. The ulcer has thick dark eschar over the top.

The joint capsule of the hip is visible

A client diagnosed with negative nitrogen balance tells the nurse about participating in ritualistic fasts as a part of his culture. The client abstains from all food for several days at a time. What should the nurse discuss with the client regarding this practice? 1. The amount of weight the client will lose during the fasts 2. The need to ingest some carbohydrates for body functions 3. The amount of calories the client will need to ingest after fasting for several days 4. The importance of the practice to the client

The need to ingest some carbohydrates for body functions

A client asks the RN why it is more difficult to use a bedpan for defecating than sitting on the toilet. Which would be the nurses best response? 1. The sitting position decreases the contractions of the muscles of the pelvic floor. 2. The sitting position increases the downward pressure on the rectum, making it easier to pass stool. 3. The sitting position increases the pressure within the abdomen. 4. The sitting position inhibits the urge to urinate, allowing one to defecate.

The sitting position increases the downward pressure on the rectum, making it easier to pass stool

The nurse is going to assess the apical-radial pulse of a client with a cardiovascular disorder. Which rationale did the RN use to make this decision? 1. A forceful radial pulse is much too difficult to count correctly. 2. Both arteriole and venous sounds were heard simultaneously. 3. The pulse was bounding and easily obliterated. 4. The thrust of blood from the heart is too feeble for the wave to be felt at the peripheral pulse site.

The thrust of blood from the heart is too feeble for the wave to be felt at the peripheral pulse site.

The nurse is concerned that an older client is at risk for aspiration. What feeding techniques should the nurse instruct the family to use once the client is discharged? Select all that apply. 1. Thicken all fluids. 2. Use the chin-tuck method. 3. Place the client in a seated position 4. Focus on food preferences. 5. Keep the head of the bed at a 30-degree angle.

Thicken all fluids. Use the chin-tuck method. Place the client in a seated position Focus on food preferences.

A UAP has applied a condom catheter to a client. The nurse should document what information about this procedure? Select all that apply. 1. Number of ml of fluid used to inflate the balloon 2. Location of the drainage bag 3. Name of the UAP who applied the device 4. Time and date that the condom catheter was applied 5. Integrity of the penis

Time and date that the condom catheter was applied Integrity of the penis

A client needs a test to determine the amount of residual urine. The nurse realizes that this assessment is used for which reason(s)? Standard Text: Select all that apply. 1. To evaluate the glomerular filtration rate 2. To determine the extent of renal failure 3. To determine the amount of retained urine after voiding 4. To determine the need for medications 5. To evaluate fluid volume status

To determine the amount of retained urine after voiding To determine the need for medications

Which condition would lead the RN to choose the dorsalis pedis pulse as the site for further assessing the clients status? 1. Altered level of consciousness 2. Decreased urine output 3. Irregular radial pulse 4. Toes cool to touch

Toes cool to touch

A client reports that an adolescent family member has started a vegan diet. Which additions to meals should the nurse recommend to help ensure that the adolescent does not become deficient in calcium? Select all that apply. 1. Tofu 2. Soybeans 3. Brewers yeast 4. Raisins 5. Okra

Tofu Soybeans Raisins

While assessing the dorsalis pedis pulse of a client, the nurse determines that the pulse is absent. However, the extremity is warm and pink with nail beds blanching at 2 to 3 seconds of capillary refilling time. How would the nurse explain these findings? 1. A change in the clients health status has occurred. 2. The client has thrown a blood clot in that extremity. 3. The RNs watch has stopped working. 4. Too much pressure was applied over the pulse site.

Too much pressure was applied over the pulse site.

The nurse is removing personal protective equipment. Which nursing action demonstrates the appropriate technique for removing a mask? 1. Bend the strip at the top of the mask. 2. Loop the ties over the ears. 3. Tie the strings in a bow. 4. Touch the mask by the strings only.

Touch the mask by the strings only

The nurse is setting up a sterile field. Which action by the nurse best exhibits surgical asepsis? 1. Disinfecting an item before adding it to a sterile field 2. Allowing sterile gloved hands to fall below the waist 3. Suctioning the oral cavity of an unconscious client 4. Touching only the inside surface of the first glove while pulling it onto the hand

Touching only the inside surface of the first glove while pulling it onto the hand

The nurse is assisting the client to dangle on the bedside. After raising the head of the bed, in which position should the nurse face? 1. Toward the nearest corner of the head of the bed 2. Toward the side of the bed 3. Toward the far corner of the foot of the bed 4. Directly toward the client

Toward the far corner of the foot of the bed

The nurse is concerned that a break occurred in a sterile field. Which action occurred that caused this break? 1. Grasping the edge of the outermost flap and opening it away from oneself 2. Keeping objects on the field 1 inch from the edge 3. Keeping the sterile field in eyesight 4. Transferring a sterile object to a sterile field with a clean gloved hand

Transferring a sterile object to a sterile field with a clean gloved hand

A client has had Braden scores of 18 and 19 and Norton scores of 15 and 17 over the last 2 months. What does the nurse determine as the significance of the trending of these scores? 1. Trending can only be accurate if the same scale is used. 2. There is a definite trend of low risk for pressure ulcer development. 3. Trending would be more accurate if the same scale was used. 4. The scores indicate opposite risks for pressure ulcer development.

Trending would be more accurate if the same scale was used

The nurse is reviewing the agents available to disinfect the hands after providing client care. Which agents should the nurse consider using? Select all that apply. 1. Triclosan 2. Chlorine (bleach) 3. Isopropyl alcohol 4. Hydrogen peroxide 5. Chlorhexidine gluconate

Triclosan Isopropyl alcohol Chlorhexidine gluconate

The nurse notes that the tube-fed client has shallow breathing and dusky color. The feeding is running at the prescribed rate. What should the nurse do first? 1. Place the client in high Fowlers position. 2. Turn off the tube feeding. 3. Assess the clients lung sounds. 4. Assess the clients bowel sounds.

Turn off the tube feeding

A client has received a return-flow enema. What should the nurse document about this procedure? Select all that apply. 1. Number of times the solution was changed. 2. Type of solution. 3. Length of time the solution was retained. 4. The amount, color, and consistency of the return. 5. Client relief of flatus and abdominal distention.

Type of solution. Length of time the solution was retained. The amount, color, and consistency of the return. Client relief of flatus and abdominal distention.

During a home visit, the nurse determines that a toddler is at risk for injury. What did the nurse assess to identify this clients risk? Select all that apply. 1. Unscreened windows 2. Electrical outlets uncovered 3. Yard with a built-in pool unfenced 4. Cleaning solution in the bottom cabinet 5. Pots on stove with handles turned inward

Unscreened windows Electrical outlets uncovered Yard with a built-in pool unfenced Cleaning solution in the bottom cabinet

The nurse is preparing to leave a clients isolation room. Which action should the nurse take first when removing a grossly soiled gown? 1. Grasp the sleeve of the dominant arm, and remove it with a gloved hand. 2. Release the neck ties of the gown and allow the gown to fall forward. 3. Untie the strings at the neck first. 4. Untie the strings at the waist first.

Untie the strings at the waist first

A client is complaining of pain with urination. The nurse realizes that the client needs to be assessed for which health problems? Select all that apply. 1. Urethral stricture 2. Renal failure 3. Urethral injury 4. Bladder injury 5. Urinary infection

Urethral stricture Urethral injury Bladder injury Urinary infection

A clients results from a urinalysis are as follows: pH 5.2, gross cloudiness, WBC 1015, glucose negative, specific gravity 1.012, and protein negative. How should the nurse interpret the results? 1. Dehydration 2. Diabetic ketoacidosis 3. Trauma 4. Urinary tract infection

Urinary tract infection

The nurse is preparing the morning assignments. Which assessment could the nurse delegate to unlicensed assistive personnel? 1. Neurological assessment 2. Musculoskeletal assessment 3. Vital signs assessment 4. Female genital assessment

Vital signs assessment

The nurse is writing the plan of care for a client who is confined to bed. Which intervention should be included to help reduce the effects of shearing forces on the clients skin? 1. Keep the head of the clients bed at 30 degrees. 2. Coat the clients back and buttocks with baby powder after bathing. 3. Use a turn sheet lifted by two staff members to move the client in bed. 4. Dust the linens with cornstarch each morning to allow for easier movement.

Use a turn sheet lifted by two staff members to move the client in bed

The nurse is caring for a client with hepatitis A. Which technique should the nurse use to promote proper hand-washing technique with this client? 1. Allow the water to splatter forcibly when it is turned on. 2. Clean the faucet after use. 3. Hold the hands upward under the faucet. 4. Use approximately a teaspoon of soap.

Use approximately a teaspoon of soap

The nurse is reviewing collected data from a client. Which information should the nurse identify as a physiological barrier to defend the clients body from microorganisms? 1. Heavy smoking 2. Moisturizing the skin 3. Breakdown of skin 4. Voiding quantity sufficient

Voiding quantity sufficient

The nurse is using medical asepsis when providing client care. Which action did the nurse demonstrate? 1. Administering parenteral medications 2. Changing a dressing 3. Performing a urinary catheterization 4. Using personal protective equipment

Using personal protective equipment

The nurse is utilizing the technique of inspection during a physical examination with a client. When using this technique, the nurse will take which actions? Select all that apply. 1. Visually observe a body area. 2. Obtain information through the sense of smell. 3. Obtain information through the sense of hearing. 4. Examine the body through the use of touch. 5. Strike the body to elicit a sound from a body part.

Visually observe a body area. Obtain information through the sense of smell. Obtain information through the sense of hearing.

The nurse is planning care for a client. Which intervention would be appropriate to reduce the risk of infection? 1. Assess vital signs only once daily. 2. Raise the temperature in the clients room. 3. Wash hands. 4. Wear a mask for all client care.

Wash hands

The nurse notices that the clients continuous open system tube-feeding set is almost empty. What action should the nurse take? 1. Add tube feeding to the set. 2. Discontinue the feeding and hang a closed system bag. 3. Wash out the set and add new feeding. 4. Flush the set with clear carbonated soda and discontinue.

Wash out the set and add new feeding

During the morning bath of a client, the nurse identifies areas of erythema below the clients breasts. What should the nurse do to enhance comfort and healing for the client? 1. Wash the skin carefully. 2. Apply alcohol-free lotion. 3. Wash the area without soap. 4. Remove hair in the area.

Wash the skin carefully.

In the palpatory method of blood pressure determination, instead of listening for the blood flow sounds, light to moderate pressure is used over the artery as the pressure in the cuff is released. When will the nurse read the pressure from the sphygmomanometer? 1. When the cuff is applied 2. When the cuff is being deflated 3. When the first pulsation is felt 4. When the second pulsation is felt

When the first pulsation is felt

The nurse is concerned that an older client has nutritional deficiencies. What did the nurse find when assessing this clients nails to make this clinical decision? Select all that apply. 1. White spots 2. Curved nails 3. Deep purple areas 4. Spoon-shaped nails 5. Bands across the nails

White spots Spoon-shaped nails Bands across the nails

The adult client is incontinent and wears incontinence briefs when using the wheelchair. An irritated rash has developed in the perianal area. What care should the nurse provide? 1. Wash the area with soap and hot water at every brief change. 2. Apply a petroleum-based cream to the area after cleaning. 3. Wipe the skin with an alcohol-free barrier film agent after cleaning. 4. Keep the client in bed on absorbent pads until the area clears

Wipe the skin with an alcohol-free barrier film agent after cleaning

When assessing a clients oxygen saturation reading, the nurse realizes that what will affect this reading? 1. Activity 2. Environmental conditions 3. Nutrition 4. Skin color

activity

The nurse is performing a lung assessment on a client with suspected pneumonia. Which finding should the nurse report to the physician immediately? 1. Chest symmetrical 2. Breath sounds equal bilaterally 3. Asymmetrical chest expansion 4. Bilateral symmetric vocal fremitus

asymmetrical chest expansion

A client tells the nurse that fresh fruit should be eaten only on an empty stomach, as it will cause other foods to ferment in the stomach. The nurse realizes this clients nutritional status is influenced by 1. lifestyle. 2. culture. 3. beliefs about food. 4. religious practices.

beliefs about food

The nurse is preparing to assess a clients blood pressure. Which artery will the nurse use for this assessment? 1. Brachial 2. Femoral 3. Radial 4. Ulnar

brachial

The nurse suspects that a client is experiencing compromised gastrointestinal function. What assessment data did the nurse use to make this clinical decision? 1. Bowel sounds active in all four quadrants 2. Clay-colored stool 3. Increased appetite 4. Semisolid and moist stool

clay-colored stool

The nurse is concerned that an older client with a retention catheter is developing a urinary tract infection. What assessment finding caused this concern? 1. Elevated blood pressure 2. Elevated heart rate 3. Confusion 4. Leg pain

confusion

A client has a bowel movement of hard, dry, but formed stool. The nurse associates these characteristics with 1. bowel incontinence. 2. constipation. 3. diarrhea. 4. fecal impaction.

constipation

What nursing diagnosis should the nurse select as appropriate to address bowel evacuation for a client who is on bed rest? 1. Bowel Incontinence 2. Constipation 3. Diarrhea 4. Disturbed Body Image

constipation

The nurse is performing urinary catheterization for a client. After using the nondominant hand to separate the clients labia for cleansing, the nurse will maintain this hand as being 1. sterile. 2. contaminated. 3. able to evaluate the effectiveness of the catheter balloon. 4. clean.

contaminated

The home care nurse wants to ensure the safety of an older client who lives at home alone. Which intervention should the nurse identify as a way to prevent this client from falling? 1. Check vision every 5 years. 2. Exercise regularly. 3. Place socks on feet. 4. Turn the light on after getting out of bed.

exercise regularly

While performing an assessment of the integument system, the nurse notes the clients eyeballs are protruding and the upper eyelids are elevated. What term should the nurse use to document this finding? 1. Erythema 2. Cyanosis 3. Exophthalmos 4. Normocephalic

exophthalmos

A client with an upper gastrointestinal disorder is experiencing seeping of liquid stool, anorexia, abdominal distention, nausea, and vomiting. The nurse suspects the client is experiencing 1. constipation. 2. diarrhea. 3. trapped flatus. 4. fecal impaction.

fecal impaction

During diet teaching with a client diagnosed with diabetes, the nurse should instruct that the most prevalent monosaccharide is 1. fructose. 2. galactose. 3. corn syrup. 4. glucose.

glucose

The nurse is preparing to provide hygienic care to a client. On what will the nurse focus this care? 1. Clothes 2. Family 3. Hair 4. Nutritional

hair

A client tells the nurse that bathing is done at the sink in the bathroom at home because it is difficult to physically lift the legs to get into the shower. The nurse identifies which factor as influencing this clients hygienic practice? 1. Religion 2. Personal preference 3. Culture 4. Health and energy

health and energy

A client is unconscious and in respiratory distress after being in a motor vehicle crash. Which should the nurse realize as being a factor that caused a change in this clients respiratory rate? 1. Exercise 2. Increased intracranial pressure 3. Increased environmental temperature 4. Stress

increased intracranial pressure

Which assessment technique will the nurse use first when examining a client with a fecal elimination problem? 1. Auscultation 2. Inspection 3. Palpation 4. Percussion

inspection

A client receives several tube feedings each day. After documenting the clients tolerance of the feedings and assessments in the medical record, the nurse should also document the amount of feeding provided on the 1. graphic sheet. 2. dietary consultation notes. 3. vital signs record. 4. intake and output record.

intake and output record

The nurse is performing a health assessment and notes a yellow tinge to the sclera of the eye. The nurse should document this as being 1. cyanosis. 2. jaundice. 3. pallor. 4. erythema.

jaundice

As a member of the safety committee, the nurses task is to identify actions to prevent falls within the organization. Which intervention should the nurse emphasize as important to prevent falls? 1. Display the phone number to the nurses station. 2. Keep electrical cords under the bed. 3. Keep the environment tidy. 4. Read label directions.

keep the environment tidy

The clients chief complaint is, I just cant get around like I used to. I have to stop halfway up the stairs to the bedroom, and just walking to the bathroom makes me so tired. Which nursing diagnosis is most likely appropriate for this client? Activity Intolerance: 1. Level 1. 2. Level 2. 3. Level 3. 4. Level 4.

level 3

The nurse needs to measure the temperature of a client who has a history of heart disease and has eaten a bowl of vegetable soup 45 minutes ago. Which site should the nurse use? 1. Axilla 2. Oral 3. Popliteal 4. Rectal

oral

When assessing a clients respirations, the nurse realizes that the respiratory centers and chemoreceptors respond to changes in which factors? Select all that apply. 1. Oxygen concentration 2. Carbon dioxide concentration 3. Hydrogen ions 4. Potassium level 5. Serum calcium level

oxygen concentration, carbon dioxide concentration, hydrogen ions

A clients urinalysis is reported as being normal. What were the clients results? 1. Blood present and no ketones 2. Dark amber color and output less than 500 cc in 24 hours 3. pH 6 and no glucose present 4. Specific gravity 1.035 and faint aromatic odor

pH 6 and no glucose present

The nurse is assisting the physician who is preparing to test a sexually active female client for cervical cancer. What should the nurse expect the health care provider to perform? 1. Pap test 2. Breast exam 3. Rectal exam 4. Abdominal exam

pap test

The nurse is preparing to assist a client to a lateral position to position a bedpan. What action should the nurse take first? 1. Perform hand hygiene. 2. Move the client to the side of the bed. 3. Place the clients arm over the chest. 4. Raise the opposite side rail.

perform hand hygiene

Which determinant of blood pressure would explain a clients blood pressure reading of 120/100? 1. Blood viscosity 2. Blood volume 3. Pumping action of the heart 4. Peripheral vascular resistance

peripheral vascular resistance

A clients laceration has been closed with tissue adhesive. What instruction should the nurse provide the client about wound healing? 1. Primary intention 2. Open approximation 3. Secondary healing 4. Delayed closure

primary intention

The nurse is discussing different types of ostomy appliances with a client with a new ostomy. During this discussion, the nurse should keep in mind that an ostomy appliance should.. Select all that apply. 1. be changed daily. 2. protect the skin. 3. collect stool. 4. control odor. 5. be open, so the client can empty it sporadically throughout the day.

protect the skin. collect stool. control odor.

The nurse documents that a clients postoperative wound is purosanguinous. What did the nurse assess in this clients wound? 1. Water and red blood cells 2. Pus and red blood cells 3. Watery drainage 4. Pus

pus and red blood cells

The nurse is planning to assess a clients pulse. What characteristics should the nurse include in this assessment? Select all that apply. 1. Rate 2. Rhythm 3. Volume 4. Tone 5. Viscosity

rate, rhythm, volume

The nurse is identifying care goals for a client who is prone to getting hurt. Which care goal should the nurse select for this client? 1. Assess the clients mental status. 2. Keep the client dependent on the staff for all care. 3. Make all choices for the client. 4. Remain free from injury.

remain free from injury

When assessing a clients peripheral pulse, the health care provider is also assessing which of the following? 1. Depth 2. Rhythm 3. Sound 4. Stress

rhythm

The nurse needs to assess a clients respiratory status. Which client position would be the best for this assessment? 1. Prone 2. Semi-Fowlers 3. Side-lying 4. Supine

semi-fowlers

The newly hired nurse learns that the facility uses the Braden Scale for Predicting Pressure Sore Risk to assess all new admissions. Before using this scale the nurse 1. should receive specific training. 2. must be certified. 3. is required to ask the clients permission. 4. has to obtain special assessment equipment.

should receive specific training

The nurse is preparing for morning rounds. What should the nurse avoid delegating to unlicensed assistive personnel? 1. Vital signs 2. Filling of water pitchers 3. Skull and face assessment 4. Ambulation of surgical clients

skull and face assessment

The nurse is preparing to transfer a client from the bed to a stretcher. The correct position for the bed to be placed is parallel to the stretcher and 1. slightly higher. 2. slightly lower. 3. at the same height. 4. at least 2 inches lower.

slightly higher

The nurse is attending a seminar on bioterrorism. What should the nurse identify as being the highest concern for homeland security? 1. Cancer 2. Seasonal flu 3. Tuberculosis 4. Smallpox

smallpox

As the RN is suctioning a client, the pulse oximetry reading drops to 83%. What should the nurse do? 1. Allow the client to take some extra deep breaths. 2. Continue to suction but only intermittently. 3. Keep the catheter in place and wait a few minutes. 4. Stop suctioning and give supplemental oxygen.

stop suctioning and give supplemental oxygen

A client is prescribed steroid medication. When preparing discharge instructions, the nurse should include information about infection control because steroids cause 1. decreased oxygen supply to tissues. 2. suppression of the inflammatory process necessary for healing. 3. a decrease in the amount of nutrients such as glucose in the blood. 4. blood vessel constriction, which impairs waste product removal.

suppression of the inflammatory process necessary for healing

A client has been receiving a new medication to address specific symptoms. The nurse will perform a physical examination to determine. Select all that apply. 1. the progress of the clients health problem. 2. the physiological impact of the prescribed medication. 3. baseline data. 4. data to support nursing diagnoses. 5. areas for health promotion.

the progress of the clients health problem. the physiological impact of the prescribed medication.

The nurse is assessing peripheral pulses on a client with suspected peripheral vascular disease. Which finding should the nurse report to the physician immediately? 1. Pulses equal bilaterally 2. Full pulsations 3. Thready pulses 4. Pulses present bilaterally

thready pulses

A client with a skin rash is prescribed a bath in which medication is added to the bath water. The nurse should plan for the client to receive which type of bath? 1. Shower 2. Tub 3. Partial 4. Complete

tub

A client is being treated for congestive heart failure. Which physical finding would lead the RN to believe the clients condition has not improved? 1. Temperature of 98.6F (37C) 2. Moderate amount of clear thin mucus 3. Pulse oximetry reading of 96% 4. Wheezing of breath sounds in all lobes

wheezing of breath sounds in all lobes