PN VATI FUNDAMENTALS 2020
A nurse is planning care for a client who practices Judaism. Which of the following questions should the nurse ask the client to better understand how they practice Judaism? ➖ "Do you eat salmon?" ➖ "Do you drink beverages containing caffeine?" ➖ "Do you use herbal medications?" ➖ "Do you observe the Sabbath?"
"Do you observe the Sabbath?" Rationale: Some clients who practice Judaism might avoid a number of activities on the Sabbath, including medical procedures and business transactions.
A nurse is caring for a client who is upset about receiving a terminal diagnosis. The client states, "I want some time alone to pray." Which of the following is an appropriate response by the nurse? ➖ "Why do you feel prayer will bring you comfort?" ➖ "Let's think of some other ways you can deal with your feelings." ➖ "I will sit quietly and hold your hand while you pray." ➖ "How much time alone do you think you will need?"
"How much time alone do you think you will need?" Rationale: It is important for the nurse to respect and accommodate the client's choice to pray. This statement by the nurse is open-ended and provides a lead for the client to offer more information. It also helps the nurse minimize interruptions for the client during prayer.
A nurse is reinforcing teaching about sleep promotion with a client who reports difficulty sleeping. Which of the following client statements indicates an understanding of the teaching? ➖ "I should drink a cup of hot chocolate before I go to bed." ➖ "I should stop vigorous exercise 1 hour before bedtime." ➖ "I should play music that relaxes me before I go to bed." ➖ "I will nap for 1 hour each afternoon."
"I should play music that relaxes me before I go to bed." Rationale: The client should establish a relaxing routine such as taking a warm bath, reading, or listening to soothing sounds, such as soft music. The client should avoid playing music while sleeping because this can be a distraction and interrupt sleep.
A nurse is reinforcing discharge teaching about preventing thrombophlebitis with a client who is post-operative. Which of the following statements by the client indicates an understanding of the teaching? ➖ "When I am in bed, I will place pillows under my knees." ➖ "I will do leg exercises every 1 to 2 hours while I am awake." ➖ "I will put my antiembolic hose on 30 minutes after getting out of bed." ➖ "If my legs become sore, I can massage them gently."
"I will do leg exercises every 1 to 2 hours while I am awake." Rationale: The client should perform range-of-motion exercises to promote venous return and prevent the stasis of blood in the veins, which can cause thrombus formation and subsequent thrombophlebitis.
A nurse is reinforcing teaching with a client who has a BMI of 27. Which of the following client statements indicates an understanding of the teaching? ➖ "I will eat more carbohydrates with every meal." ➖ "I will try to lose 5 pounds each week." ➖ "I will increase my physical activity." ➖ "I will drink a protein shake between meals."
"I will increase my physical activity." Rationale: The client's BMI of 27 indicates that the client is within the overweight range of 25 to 29.9. Inactivity contributes to weight gain; therefore, increasing physical activity should promote a healthy weight, and reduce the client's risk for cardiovascular disease, diabetes, and hypertension.
A nurse is reinforcing teaching with a client who has a new prescription for home oxygen therapy with an oxygen tank. Which of the following statements by the client indicates an understanding of the teaching? ➖ "I can store my spare oxygen tank on its side." ➖ "I will lubricate my nostrils with mineral oil twice a day." ➖ "I will replace my wool blanket with one made of cotton material." ➖ "I can wait until the oxygen tank is empty before replacing it."
"I will replace my wool blanket with one made of cotton material." Rationale: Wool and synthetic should not be used, they can generate sparks from static electricity. Cotton fabrics are recommended.
A nurse is reinforcing dietary teaching with a client who is receiving chemotherapy and has lost 6.8 kg (15 lbs.) since beginning therapy. Which of the following client statements indicates an understanding of the teaching? ➖ "I will heat my food and drinks before consuming them." ➖ "I will eat three large meals each day." ➖ "I will replace water in recipes with whole milk." ➖ "I will eat a meal 1 hour before my chemotherapy appointment."
"I will replace water in recipes with whole milk." Rationale: Clients receiving chemotherapy should replace water with whole milk to increase caloric intake.
A nurse is reinforcing teaching about home safety with a client who is at risk for falls. Which of the following client statements indicates an understanding of the teaching? ➖ "I will keep my floors well waxed." ➖ "I will take my shoes off when I come back into the house." ➖ "I will secure all of my electrical cords to the baseboard." ➖ "I will place area rugs on my tile floors."
"I will secure all of my electrical cords to the baseboard." Rationale: Securing cords along the baseboards with electrical tape minimizes the tripping hazard for clients who are at risk for falls.
A home health nurse is reinforcing teaching about infection control with a client who has hepatitis A. The nurse should identify that which of the following client statements indicates an understanding of the teaching? ➖ "I will use a 10 to 1 solution of soap and water to clean my bathroom fixtures." ➖ "I will wear a surgical mask when around others." ➖ "I will wash my hands with soap and water for 15 seconds after having a bowel movement." ➖ "I will avoid contact with house plants."
"I will wash my hands with soap and water for 15 seconds after having a bowel movement." Rationale: The nurse should inform the client to wash their hands with soap and warm water for 15 seconds to remove micro-organisms after having a bowel movement. This reduces the risk for transmitting the virus to others because hepatitis A is a virus that is transmitted via the oral-fecal route.
A nurse is reinforcing teaching with the partner of a client who has left-sided weakness about how to safely move the client from a bed to a chair at home. Which of the following statements by the partner indicates an understanding of the teaching? ➖ "I'll avoid using assistive devices to prevent obstacles with transfers." ➖ "I'll keep my feet close together to avoid straining my back." ➖ "I'll place the chair at a 90-degree angle on my partner's weak side before transferring them" ➖ "I'll bend at the knees when lifting to get better leverage."
"I'll bend at the knees when lifting to get better leverage." Rationale: Bending at the knees maintains the center of gravity and helps avoid strain on the back.
A nurse is explaining the purpose of informed consent to a client. Which of the following statements should the nurse make? ➖ "Informed consent documents your concerns about the procedure." ➖ "Informed consent indicates your understanding of the procedure." ➖ "Informed consent protects the facility and provider from liability." ➖ "Informed consent ensures you don't change your mind about the procedure."
"Informed consent indicates your understanding of the procedure." Rationale: An informed consent is permission given by the client to be treated or have a procedure after they have been completely informed of the procedure, risks, benefits, and any alternative treatments that my have been available. It is providing the client the right to choose or refuse treatment.
A nurse is caring for a client who states that he is concerned that his neighbor, who works as an assistive personnel (AP) on another inpatient unit, will access his records and share his information with others. Which of the following is an appropriate response by the nurse? ➖ "I'm sure that your neighbor won't share any confidential information." ➖ "Only those who are involved with some aspect of your care can access your health care information." ➖ "Assistive personnel do not have permission to view clients' medical records." ➖ "I will put a note in your medical record stating that the assistive personnel cannot receive any information about your care."
"Only those who are involved with some aspect of your care can access your health care information." Rationale: The nurse should inform the client that HIPAA regulations require that only members of the health care team who are involved with a client's care can access the client's health care information. Health care institutions are responsible for taking reasonable steps to limit the use of disclosure of protected health information.
A nurse is caring for a client who is post-operative following an above-the-knee amputation. The client tells the nurse they do not want to go to physical therapy and are "ready to give up." Which of the following responses should the nurse make? ➖ "The physical therapist said you made progress yesterday." ➖ "You sound like you are feeling pretty discouraged." ➖ "I am sure you will fell better once you get your prosthesis." ➖ "Why don't you give physical therapy one more try?"
"You sound like you are feeling pretty discouraged." Rationale: This response by the nurse validates the client's feelings, which encourages the client to express feelings of grief and loss.
A nurse is contributing to the plan of care for a client who is receiving continuous enteral nutrition. The client has a prescription for 2,000 calories/day. The high-calorie enteral formula the client is receiving, provides 2 calories/mL. How many mL/hr should the client receive? (Round answer to nearest whole number.)
42 mL/hr. Rationale: Using the drip factor formula, determine whether the amount to infuse makes sense. If the provider prescribed 2,000 calories/day to infuse over 24 hrs, and the enteral formula provides 2 calories/mL, then it makes sense for the nurse to set the IV pump to infuse and deliver continuous enteral nutrition at 42 mL/hr. Now let's work this out together =) Step 1: Divide the calories prescribed by the calories the client will be receiving. Ex: 2,000 calories ➗ by 2 calories gives you an answer of 1,000 mL. Step 2: Next divide the volume (mL) over time (hr). Ex: 1,000 mL ➗ 24 hrs gives you an answer of 41.6666 mL/hr. However, because you cannot give a point of any number via a drop and the question is asking you to round your answer to the nearest whole number 41.6666 then becomes 42 mL/hr. unit of measurement: ml/hr. volume to infuse: 2,000 cal total infusion time : 24hrs.
A nurse is caring for a client who is 1 day post operative following an abdominal hysterectomy. The client states, " I am so sad that I can't have any more children." Which of the following is a therapeutic response by the nurse? ➖ "This feeling will go away with time." ➖ "I am sorry to hear that you feel that way." ➖ "You should focus on healing right now." ➖ "I will stay with you while we talk some more about this."
: "I will stay with you while we talk some more about this." Rationale: The nurse should remain with the client to listen to their feelings and concerns. This action is a form of active listening and a therapeutic response.
A nurse is collecting data from a client who is receiving potassium in their IV fluids. Which of the following findings can indicate hyperkalemia? ➖ Confusion ➖ Constipation ➖ Heart rate of 110/min ➖ Potassium 4.5 mEq/L
: Confusion. Rationale: Hyperkalemia changes nerve impulse transmission in nerve tissues including the brain resulting in confusion. Tips: Hyperkalemia increases gastric activity with diarrhea, nausea and/or vomiting. Hyperkalemia is manifested by a decreased heart rate with an ECG that has peaked T-waves and a widened QRS, which can progress to cardiac arrest.
A licensed practical nurse (LPN) is planning care for a group of clients a the beginning of a shift. For which of the following clients should the nurse request a change in assignment? ➖ A client who needs a wound culture. ➖ A client who needs an indwelling urinary catheter removed. ➖ A client who requires evaluation of an established plan of care. ➖ A client who requires an intermittent enteral feeding.
A client who requires an evaluation of an established plan of care. Rationale: Evaluating an established plan of care for a client requires advanced nursing knowledge and skill and is outside the scope of practice of an LPN. It is within the scope of practice of an LPN to assist in establishing the plan of care for a client.
A nurse discovers a fire in the trash can in a client's room. After removing the client from the room, which of the following actions should the nurse take next? ➖ Pull the pin on the fire extinguisher. ➖ Activate the fire alarm. ➖ Turn off oxygen supply in client rooms. ➖ Close the client's door.
Activate the fire alarm. Rationale: The greatest risk to the client and to other clients is injury from the fire; after removing the client from the room, the priority action the nurse should take is to activate the fire alarm. Tip: FOR FIRE SAFETY THINK OF RACE.
A nurse is reinforcing teaching with an assistive personnel about measuring oxygen saturation using a pulse oximeter. The nurse should include in the teaching that which of the following factors can cause a false reading? (Select all that apply.) ➖ Nail polish ➖ Bright lights ➖ Dark pigmented skin ➖ Motion of the fingers ➖ Warm fingers
Answer & Rationale: Nail polish is correct because it can interfere with light absorption and the ability to obtain an accurate reading. Bright lights is correct because outside light sources can interfere with the ability of the oximeter to process reflected light. Dark pigmented skin is correct because dark pigmented skin interferes with light absorption and distorts oximeter readings, resulting in an overestimation of results or a loss of signal. Motion of the fingers is correct because motion of the fingers interferes with the oximeter's ability to process reflected light, resulting in an inaccurate reading.
A home health nurse is collecting data during a home visit with a client. Which of the following findings places the client at a risk for falls? (Select all that apply) ➖ Clutter in living areas ➖ Grab bars in the bathroom ➖ Dim lighting in the entrance hall ➖ Bedroom on the second floor ➖ Throw rugs on the floor
Answer & Rationale: Clutter in living areas is correct because cluttered areas increase the client's risk for falls. The presence of scattered furniture and objects on the floor can cause the client to trip and fall. Dim lighting in the entrance hall is correct because a poorly lit entrance hall increases the client's risk for falls. The nurse should ensure that there is proper lighting in hallways so that the client can see any potential hazards. Bedroom on the second floor is correct because moving between multiple levels of a house increases the client's risk for falls. If the client must use the steps, the nurse can decrease the risk for falls by marking the edges of the stairs. Throw rugs on the floor is correct because throw rugs present a tripping hazard, which increases the risk for falls. The nurse should encourage the client to limit the use of throw rugs and ensure that area rugs are securely fastened to the floor.
A nurse is reinforcing teaching with a client who has a prescription for crutches. What is the correct method of going up stairs when using crutches? (Move the steps into the box on the right, placing them in the selected order of performance. ) Place the unaffected foot onto the stair Shift body weight to crutches Advance the crutches onto the stair Transfer body weight to the unaffected leg
Answer & Rationale: First, the nurse should instruct the client to stand in the tripod position with the crutches held to the front and laterally 15 cm (6 in. ) and shift their body weight onto the crutches in preparation for forward movement. Second, the client should advance the unaffected leg up one step while the weight remains supported by the crutches. Third, the client should transfer body weight onto the unaffected leg so that the crutches can be moved forward. Finally, the client should advance the crutches up one step. The affected leg should move at the same time as the crutches, following a three-point gait pattern.
A nurse is providing change-of-shift report for a client who had a stroke 48 hrs ago. Which of the following information should the nurse include in the report? ➖ The client's CT scan results from the emergency department. ➖ The client's pupil reaction on admission. ➖ The client's physical therapy schedule for the next day. ➖ The client's Glasgow coma scale score.
Answer: The client's Glasgow Coma Scale score. Rationale: The nurse should include the client's current physical findings, such as the Glasgow coma scale score, in the change-of-shift report to promote accurate monitoring and safe care.
A nurse is preparing to collect blood samples from an older adult client. Which of the following actions should the nurse take when performing venipuncture? ➖ Use a 12-gauge needle to obtain the sample. ➖ Use a needle insertion angle of 35°. ➖ Apply the tourniquet over the client's sleeve. ➖ Apply traction above the projected insertion site.
Apply the tourniquet over the client's sleeve. Rationale: The nurse should apply the tourniquet over the client's sleeve to reduce the risk for trauma to the fragile skin of older adult clients.
A charge nurse is reinforcing teaching about ethics with a group of newly licensed nurses. The nurse uses the example of performing CPR on a client who has a do-not-resuscitate (DNR) order. Which of the following ethical principals is being violated in this example? ➖ Justice ➖ Veracity ➖ Fidelity ➖ Autonomy
Autonomy. Rationale: The nurse should identify that autonomy is the obligation of a nurse to respect the client's right to make health care decisions. Performing CPR for a client who has a DNR order is unethical because it violates the client's wishes.
A nurse is collecting data from an older adult client. Which of the following findings is an indication of infection? ➖ Decreased pulse rate ➖ Urinary retention ➖ Change in mental status ➖ Decreased respiratory rate
Change in mental status. Rationale: The nurse should identify that changes in the client's mental status, such as confusion and agitation, might be manifestations of infection in an older adult client. Typical manifestations of infection might not occur with an older adult client.
A home health nurse is assisting with the plan of care for a client. Which of the following should the nurse include during the orientation phase of the helping relationship? ➖ Review current client data. ➖ Assist to meet client goals. ➖ Review shared memories of interactions with client. ➖ Clarify the role of this individual nurse.
Clarify the role of this individual nurse. Rationale: The nurse should plan to establish a warm, caring relationship while clarifying the role of each participant, which occurs during the orientation phase of the relationship.
A nurse observes a client having difficulty breathing when responding to interview questions. Which of the following documentations should the nurse make? ➖ Client reports shortness of breath. ➖ Client requires oxygen therapy. ➖ Client becomes short of breath while speaking. ➖ Client appears to be in distress.
Client becomes short of breath while speaking. Rationale: The nurse is correctly documenting objective data that includes specific information observed about the client's condition.
A nurse is caring for a client who reports difficulty sleeping due to the noise on the nursing unit. Which of the following actions should the nurse take to reduce environmental noise? ➖ Close the door to the client's room. ➖ Turn off the alarms and beeps on monitoring equipment. ➖ Conduct change-of-shift report outside the client's door. ➖ Keep the television on low in the client's room.
Close the door to the client's room. Rationale: The nurse should close the door to the client's room whenever possible to reduce environmental noise.
A nurse is assisting in the plan of care for a client who has a closed-wound drainage system. Which of the following interventions should the nurse include in the plan? ➖ Release hand pressure before replacing the drainage plug. ➖ Wear surgical gloves when emptying the drainage device. ➖ Wipe the port with soap and water before closing the drain. ➖ Compress the bulb to re-establish constant low negative pressure.
Compress the bulb to re-establish constant low negative pressure. Rationale: The nurse should include in the plan of care to compress the bulb as needed to re-establish a constant low negative pressure that will work as a closed suction to draw secretions into the bulb. Tips: The nurse should include in the plan of care to maintain hand pressure while replacing the drainage plug to create negative pressure, wear clean gloves while emptying the drainage device to prevent contamination of the surgical wound, and wipe the port and plug with an alcohol wipe before closing the drain to decrease the risk for contamination.
A nurse is assisting with the plan of care for an older adult client. When planning care, the nurse should consider that which of the following is a common physiological change that occurs with aging? ➖ Increased production of saliva ➖ Decreased subcutaneous fat ➖ Increased gastric motility ➖ Decreased anterior-posterior chest diameter
Decreased subcutaneous fat. A common physiological change that occurs with aging is decreased subcutaneous fat. To compensate, the nurse should provide the client with warm clothing and blankets.
A nurse is caring for a client who has a visual impairment. When setting up the client's meal tray, the nurse should take which of the following actions? ➖ Arrange the food in the order the client want to eat it. ➖ Describe food placement using the numbers on the face of a clock. ➖ Give the client straws for drinking liquids. ➖ Remove hot foods from the client's tray.
Describe food placement using the numbers on the face of a clock. Rationale: By using the numbers of a clock to describe the placement of food on the client's plate, the nurse is providing the client an opportunity to eat independently.
A nurse at a rehabilitation facility is assisting with the admission of a client who has left-sided hemiplegia following a stroke. Which of the following actions should the nurse take first? ➖ Demonstrate use of the call light. ➖ Give the client a list of assigned caregivers for the shift. ➖ Provide the client with nonskid footwear. ➖ Determine the client's mental status.
Determine the client's mental status. Rationale: The first action the nurse should take using the nursing process is to collect data from the client. By determining the client's mental status, the nurse can determine whether the client has an increased risk for injury. Confusion and disorientation can impair the client's judgment and can place the client at risk for falls.
A nurse in a community center is reinforcing teaching about health risks with a group of adolescent clients. Which of the following topics is the priority for this age group? ➖ Driving while intoxicated ➖ Tobacco use ➖ Pregnancy prevention ➖ Discussion of eating disorders
Driving while intoxicated. Rationale: The greatest risk to this age group is injury from motor vehicle crashes due to driving while intoxicated. Therefore, the priority topic to reinforce with adolescents is the importance of abstaining from the use of alcohol or drugs while operating a motorized vehicle. Motor vehicle crashes is a frequent cause of death in adolescents.
A charge nurse is reviewing written documentation in case of an EHR system failure with a group of newly licensed nurses. Which of the following information should the nurse include? ➖ Leave space to document late entries. ➖ Have the provider cosign each entry. ➖ Entries should be signed with name and title. ➖ Written errors should be completely scratched through.
Entries should be signed with name and title. Rationale: Each written entry in the medical record should be signed and dated with full name and title.
A nurse is caring for a client who says, "I have to focus on not falling over when I walk." Which of the following information should the nurse document? ➖ Safely ambulates down the hall with assistance ➖ Has difficulty with balance when ambulating ➖ Will require physical therapy for ambulation ➖ Reports dizziness when ambulating
Has difficulty with balance when ambulating. Rationale: This documentation provides objective evidence that supports the subjective statement by the client.
A nurse is reviewing the laboratory data of a client who has AIDS. Which of the following laboratory findings indicates the need for a nutritional consultation? ➖ Sodium 137 meq/L ➖ Potassium 4.5 mEq/L ➖ Hemoglobin 9.0 g/dL ➖ HbA1c 5.5%
Hemoglobin 9.0 g/dL. Rationale: This hemoglobin level is below the expected reference range of 12 to 18 g/dL, indicating anemia. A low hemoglobin level can indicate a deficiency of certain vitamins and minerals. Expected Reference Range Sodium 135 - 145 mEq/L Potassium 3.5 - 5.0 mEq/L Hemoglobin 12 - 18 g/dL HbA1c 4% - 5.9%
A nurse is reinforcing teaching about health promotion with a client. Which of the following actions should the nurse take first to promote effective learning? ➖ Identify areas of concern. ➖ Prioritize learning objectives. ➖ Demonstrate psychomotor skills. ➖ Observe nonverbal communication.
Identify areas of concern. Rationale: The first action the nurse should take when using the nursing process is to collect data from the client. Identifying and understanding the client's concerns prior to reinforcing teaching promotes effective learning.
A nurse is assisting with the plan of care for a young adult client who is attending college and is living in a dormitory. The nurse should recommend a prescription for which of the following immunizations? (Select all that apply.) ➖ Pneumococcal immunization ➖ Respiratory syncytial virus immunization ➖ Inactivated poliovirus ➖ Meningococcal conjugate immunization ➖ Influenza immunization
Meningococcal conjugate immunization is correct because this immunization is given to students who are entering college and living in college dormitories. Influenza immunization is correct because this immunization is given annually to young adult clients to protect from the newest strain of the virus.
A nurse is caring for a client who reports pruritus after taking a prescription medication. Which of the following is the priority action for the nurse to take? ➖ Withhold the medication ➖ Monitor for manifestations of an allergic reaction ➖ Apply cold compresses for itchy skin ➖ Request a prescription for an antihistamine
Monitor for manifestations of an allergic reaction. Rationale: The first action the nurse should take using the nursing process is to collect data from the client. The nurse should monitor the client for any manifestations that suggest anaphylaxis, such as airway constriction, throat swelling, shortness of breath, or severe wheezing.
A nurse is reviewing a client's laboratory results. Which of the following findings should the nurse report to the charge nurse as a manifestation of infection? ➖ Neutrophils 80% ➖ Lymphocytes 30% ➖ Basophils 0.6% ➖ WBC count 6,000/mm³
Neutrophils 80%. Rationale: The nurse should identify that this laboratory result is above the expected reference range of 55% to 70%. The neutrophil proportion increases with acute infection and decreases with viral infections. Expected Reference Ranges Neutrophils 55% - 70%. Lymphocytes 20% - 40%. Basophils 0.5% - 1.0% WBC 5,000 - 10,000/mm³
A nurse is reinforcing teaching about health promotion with an older adult client. Which of the following instructions to the client is an example of secondary prevention? ➖ Participate in screenings for tuberculosis. ➖ Follow dietary recommendations to reduce the risk for osteoporosis. ➖ Limit alcohol intake to one drink per day. ➖ Perform yoga exercises three times per week.
Participate in screenings for tuberculosis. Rationale: The nurse should encourage the client to participate in screenings for tuberculosis, a secondary prevention measure. Secondary prevention measures focus on diagnosis and early intervention.
A nurse is performing fecal occult blood testing. Which of the following actions should the nurse take? ➖ Perform quality control test after determining the client's results. ➖ Wait 1 to 2 min before adding developing solution to the specimen. ➖ Apply two smears of fecal specimen obtained from the same part of the stool. ➖ Wait 30 to 60 min to interpret color after applying solution to the specimen.
Perform quality control test after determining the client's results. Rationale: A blue color on the guaiac paper 30 to 60 seconds after the application of a developing solution to the stool specimen obtained from the client signifies the presence of occult blood and this result must be followed up for treatment or other diagnostic procedures. The developing solution is applied to the quality control section and interpreted after 10 seconds.
A nurse is reviewing the laboratory results of a client who has malnutrition and has been receiving total parenteral nutrition (TPN). The nurse should identify that which of the following laboratory values indicates the treatment has been effective? ➖ Prealbumin 28 mg/dL ➖ Prothrombin time of 11 seconds ➖ Hematocrit 36% ➖ WBC count 7,000/mm³
Prealbumin 28 mg/dL. Rationale: A prealbumin level of 28 mg/dL is within the expected reference range of 15 to 36 mg/dL and indicates the client is receiving adequate nutrition. A prealbumin level below 15 mg/dL indicates malnutrition. Expected Reference Ranges Prealbumin 15 - 36 mg/dL Prothrombin time 11 - 12.5 seconds Hematocrit 37% - 52% WBC 5,000 - 10,000/mm³
A nurse is performing a finger stick blood glucose test on a client who has diabetes. Which of the following actions should the nurse take? ➖ Puncture the side of the finger. ➖ Squeeze the hand and finger tightly. ➖ Smear the blood on the end of test strip. ➖ Remove excess blood from the tip of the test strip.
Puncture the side of the finger. Rationale: The nurse should puncture the side of the client's finger, rather than the pad, because the side has an increased blood flow. This helps to ensure an adequate specimen and reduces the need for a repeat puncture.
A nurse is caring for a client who is newly diagnosed with diabetes mellitus and needs to learn how to perform a fingerstick blood glucose test. Which of the following members of the health care team can develop a teaching plan for this task? (Select all that apply.) ➖ A registered nurse (RN) ➖ A licensed practical nurse (LPN) ➖ An assistive personnel (AP) ➖ A clinical nurse specialist (CNS) ➖ A nurse educator
RN, CNS, and Nurse Educator. Rationale: A registered nurse (RN), is correct because developing a teaching plan is within the scope of practice for the registered nurse. A clinical nurse specialist (CNS), is correct because developing a teaching plan is also within the scope of practice for the clinical nurse specialist and the CNS is and advanced practice nurse who has expertise in a particular clinical area. A Nurse Educator, is correct because developing a teaching plan is within the scope of practice for the nurse educator. A nurse educator is a registered nurse who is prepared to teach in various areas of nursing and patient care.
A nurse is preparing to perform suctioning for a client who has a tracheostomy tube. Which of the following materials should the nurse obtain? ➖ A size 18 French suctioning catheter ➖ Silicone-based lubricant ➖ Oral airway device ➖ Resuscitation bag
Resuscitation bag. Rationale: The nurse should have a resuscitation bag connected to 100% oxygen available to provide supplemental oxygen to the client during tracheal suctioning to reduce the risk for hypoxia. If the client does not have a large amount of secretions, the nurse should hyperventilate the client's lungs with 100% oxygen three to five times before and after suctioning. If the client develops respiratory distress during the procedure, the nurse should provide manual breaths and supplemental oxygen with the resuscitation bag.
A licensed practical nurse (LPN) is receiving change-of-shift report for a client who had a stroke. For which of the following tasks should the nurse request assistance from a registered nurse (RN)? ➖ Administering a cleansing enema ➖ Staging a pressure ulcer ➖ Inserting an indwelling urinary catheter ➖ Performing passive range-of-motion exercises
Staging a pressure ulcer. Rationale: An LPN can collect data for the client and report findings to an RN. However, staging a pressure ulcer requires advance knowledge and skill, and is outside the scope of practice of an LPN. An RN should assess the stage of a complex wound, such as a pressure ulcer, and provide primary client teaching about pressure ulcer prevention and care.
A nurse is reinforcing teaching with a group of adolescent clients about testicular self-examination. Which of the following instructions should the nurse include? ➖ Plan to start performing the exam at 21 years of age. ➖ Take a warm shower before performing the exam. ➖ Perform the exam every 3 months until 50 years of age. ➖ Feel for lumps by squeezing the testicles against the inner thigh.
Take a warm shower before performing the exam. Rationale: The nurse should instruct the client to take a warm shower or bath to relax the scrotal sac before performing the testicular self-examination. Tips: The client should begin performing testicular cancer self-examination at 15 years of age and on a monthly basis. To aid in remembering to perform the exam, the client should designate a specific date in the month to perform the exam. The client should feel for lumps by rolling the testicles between the thumb and fingers. The testicles should feel smooth, round, and easily movable.
A nurse is monitoring an assistive personnel (AP) who is measuring a client's oxygen saturation using a pulse oximeter. Which of the following observations by the nurse indicates that the AP is correctly performing the task? ➖ The AP chooses a site with a capillary refill of less than 2 seconds. ➖ The AP documents the heart rate using the oximeter device. ➖ The AP leaves the probe in place for 5 seconds and records the reading. ➖ The AP places the probe on a finger that is painted with fingernail polish.
The AP chooses a site with a capillary refill of less than 2 seconds. Rationale: The nurse should evaluate that the AP is performing the task correctly by choosing a site with a capillary refill of less than 2 seconds. The oximeter probe calculates the percentage of oxygen in hemoglobin. Decreased peripheral circulation will result in an inaccurate reading.
A nurse is reinforcing teaching with an assistive personnel (AP) about positioning a client who has GERD. Which of the following actions by the AP indicates an understanding of the teaching? ➖ The AP positions the client to rest with pillows on the over-bed table. ➖ The AP positions the client side-lying in bed with legs flexed. ➖ The AP positions the foot of the client's bed lower than the head of the bed. ➖ The AP positions the client on their abdomen with their head turned to one side.
The AP positions the foot of the client's bed lower than the head of the bed. Rationale: The Reverse Trendelenburg position promotes gastric emptying to reduce esophageal reflux in clients who have GERD.
A nurse is collecting data from a client who is receiving a continuous IV infusion of Lactated Ringer's for dehydration. Which of the following findings indicates infiltration of the solution into the subcutaneous area? ➖ The vein feels hard upon palpation. ➖ Purulent drainage is noted at the IV site. ➖ Seepage of fresh blood is visible at the IV insertion location. ➖ The area around the infusion site is cool to the touch.
The area around the infusion site is cool to the touch. Rationale: Swelling, coolness, paleness, and discomfort at the infusion site indicate infiltration. The nurse should stop the infusion and discontinue the IV line.
A nurse is entering client care information using the SOAP method of documentation. Which of the following information would be entered under the heading "S"? ➖ The client reports experiencing a headache. ➖ The client exhibits an abrasion on their right heel. ➖ The client has a 2.5 cm ( 1 in.) reddened area on their sacrum. ➖ The client has a blood pressure of 150/90 mm Hg.
The client reports experiencing a headache. Rationale: The nurse should document the client reporting a headache as subjective data in the client's medical record. Subjective data is information obtained from the client and consists of his perception of his experience or conditions.
A nurse is caring for a client who has a terminal illness. Which of the following is an expected response by a family member during the anger stage of grieving? ➖ The family member criticizes care provided by the nurse. ➖ The family member changes the subject when the client mentions their illness. ➖ The family member expresses grief about the past. ➖ The family member talks about how much the client will be missed.
The family member criticizes care provided by the nurse. Rationale: According to the Kübler-Ross stages of grieving, during the anger stage, a client or family member might direct their anger at others, including members of the health care team or members of their own family.
A nurse is preparing to assist with the admission of a client who has pneumonia. Which of the following observations about the client's room requires immediate attention? ➖ The wall BP gauge is missing. ➖ The room has no IV infusion pump. ➖ The examination light above the bed does not work. ➖ The wheel locks on the bed are malfunctioning.
The wheel locks on the bed are malfunctioning. Rationale: The greatest risk to this client is injury from a fall when getting into or out of a bed that is unstable due to malfunctioning locks. Therefore, the priority is to report and replace the bed before admitting the client to the room.
A nurse is collecting data from a client who has an elevated temperature with no sweating. Which of the following findings is an indication of hypernatremia? ➖ Thirst ➖ Muscle twitching ➖ Headache ➖ Abdominal cramps
Thirst. Rationale: Thirst, combined with an elevated temperature and a lack of sweating, can be an indication of hypernatremia.
A nurse is reinforcing teaching about guided imagery with a client who has chronic pain. Which of the following information should the nurse include? ➖ This method uses electronic instruments to cause a physical change. ➖ This method uses the mind to create pictures to produce physical changes in the body. ➖ This method uses a single repetitive word to calm the mind. ➖ This method focuses on body postures to promote physical well-being.
This method uses the mind to create pictures to produce physical changes in the body. Rationale: Guided imagery uses the mind to create images to decrease anxiety, stress, and pain.
A nurse is reinforcing teaching with a male client about clean intermittent self-catheterization. Which of the following instructions should the nurse include? ➖ Use water-soluble jelly to lubricate the tip of the catheter up to 2.5 cm ( 1 in. ). ➖ Hold the penis downward at a 30° angle when inserting the catheter. ➖ Remove the catheter quickly after urine stops flowing. ➖ Wash the catheter with soap and water after use.
Wash the catheter with soap and water after use. Rationale: Medical aseptic technique is used for clean intermittent self-catheterization. Therefore, the client should wash the catheter with soap and water and store it in a clean place. The client should replace the catheter before it becomes dry and brittle.
A nurse is caring for a client who has vancomycin-resistant enterococci (VRE) in a wound. Which of the following actions should the nurse take to control the transmission of this infection? ➖ Remove gloves outside the client's room. ➖ Wear a gown when assisting the client with hygiene care. ➖ Wash hands for 10 seconds using an antimicrobial soap. ➖ Wear a mask or a respirator when giving direct care to the client.
Wear a gown when assisting the client with hygiene care. Rationale: Clients who have VRE require contact precautions. The nurse should wear gloves and a gown when assisting the client with hygiene care to reduce the risk of transmitting the infection.
A nurse is assisting with the plan of care for a client who has had diarrhea for 3 days. Which of the following foods should the nurse include in the plan? ➖ White rice ➖ Black coffee ➖ Fresh fruits ➖ Raw vegetables
White rice. Rationale: White rice is low in fiber, contains electrolytes, and promotes rehydration. This is a good food selection for a client who has diarrhea.
A nurse is contributing to the plan of care for a client who follows a kosher diet. Which of the following dietary interventions should the nurse expect to include in the plan? ➖ Offer pork as a source of protein at least once per day. ➖ Restrict caffeinated beverages. ➖ Withhold foods that contain both meat and dairy products. ➖ Provide shellfish as a meal option.
Withhold foods that contain both meat and dairy products. Rationale: The nurse should identify that kosher dietary practices include restrictions about food preparation, such as mixing milk and meat dishes.
