ATI Exams A and B - 220

A nurse is caring for a client who has hypernatremia and requires IV fluid therapy due to his NPO status. Which of the following solutions should the nurse prepare to infuse for this client?

0.45% sodium chloride A client who has an elevated sodium level and is NPO requires a hypotonic IV solution, such as 0.45% sodium chloride or 0.225% sodium chloride.

A nurse is caring for a client who experienced a lacerated spleen and has been on bedrest for several days. The nurse auscultates decreased breath sounds in the lower lobes of both lungs. The nurse should realize that this finding is most likely an indication of which of the following conditions?

Atelectasis Atelectasis is the collapse of part or all of a lung by blockage of the air passages (bronchus or bronchioles) or by hypoventilation. Prolonged bedrest with few changes in position, ineffective coughing, and underlying lung disease are risk factors for the development of atelectasis.

A nurse is preparing to administer the hepatitis B vaccine to a client. Which of the following techniques should the nurse use to locate the deltoid muscle?

Place one finger across the acromion process and measure 3 fingerbreadths below to the midpoint and center of the lateral aspect of the upper arm. This identifies the deltoid muscle, into which the nurse should inject the vaccine.

A nurse is providing teaching to a group of assistive personnel (AP) about hand hygiene. Which of the following statements by one of the APs indicates a need for further teaching?

"As long as I change gloves between clients, it is not necessary to wash my hands." While the use of gloves does reduce contamination, it is still necessary to perform hand hygiene between clients. This statement by one of the APs indicates a need for further teaching.

A nurse assumes a variety of roles while working with clients. Which of the following describes the nursing role of protecting the client and supporting the client's decisions?

Advocate A client advocate acts to protect clients' rights and helps clients to speak for themselves.

Before administering a medication to a client, the nurse must identify the client. Which of the following methods of identification should the nurse use?

Ask the client's full name and date of birth. The nurse must use two identifiers before administering medications. Acceptable identifiers include the client's name, date of birth, identification number within the facility or system, telephone number, and photo identification card or badge.

A nurse is assessing a client's circulatory system. Which of the following pulse sites should the nurse avoid assessing bilaterally at the same time?

Carotid The nurse should avoid assessing the carotid pulse sites bilaterally at the same time. This action can induce syncope by reducing blood flow to the brain and causing a reflex drop in the blood pressure and heart rate.

A nurse prepares to replace the nearly empty container of total parenteral nutrition (TPN) for a client when she finds that there has been a delay in receiving the new container of solution from the pharmacy. Which of the following solutions should the nurse infuse until the next container of TPN solution becomes available?

Dextrose 10% in water Sudden withdrawal from TPN, which is a hypertonic solution that contains dextrose, vitamins, electrolytes and sometimes lipids, can result in a sudden drop in the client's blood glucose levels. Administering an infusion of 10% dextrose will prevent hypoglycemia.

A nurse is caring for a client who refuses treatment and asks to be discharged from the hospital against medical advice. The nurse notifies the client's provider, who tells the nurse to restrain the client, if necessary, to keep her from leaving the hospital. The nurse understands that restraining this client would be considered which type of civil action by the nurse?

False imprisonment False imprisonment is detaining a client against her will to seek freedom. The client has the right to refuse treatment against medical advice and leave the hospital.

A nurse is caring for an older adult client who states, "I am afraid that I may fall while walking to the bathroom during the night." Which of the following actions should the nurse take?

Leave a nightlight on in the client's room. This is an appropriate action for keeping the client safe. Night vision may be impaired in older adult clients. If the client awakens in the night, a nightlight may help the client to recognize the surroundings, decreasing the likelihood of disorientation. It will also help to decrease the possibility of a fall on the way to the bathroom because the path will be illuminated and the client will be less likely to trip over objects in the room.

A nurse is completing discharge teaching with a client. Of the following barriers to learning the nurse identifies with this client, which should the nurse interpret as a need to postpone the session?

Pain If the client reports pain, the nurse should address managing the client's pain and postpone the learning session until the client reports pain relief.

A nurse is caring for a client who experienced an infection at the insertion site of her intravenous catheter. Which of the following findings should the nurse expect?

Purulent drainage is noted from the site. Signs of infection include warmth, redness, swelling, and possible purulent drainage.

A nurse is caring for four clients who have drainage tubes. Which of the following clients should the nurse recognize as being at risk for hypokalemia?

The client who has a nasogastric (NG) tube to suction Hypokalemia is a low serum potassium value. An NG tube is used to decompress the stomach. When attached to suction, an NG tube will remove gastric contents, which are high in electrolytes, especially potassium, and this loss places the client at risk for hypokalemia.

A nurse is caring for a client who is scheduled for an elective surgical procedure. Which of the following actions should the nurse take regarding informed consent?

Witness the client's signature. It is the nurse's responsibility to witness the client's signing of the consent form, and to verify that the client is consenting voluntarily and appears to be competent to do so.

A nurse is caring for a client who has active pulmonary tuberculosis (TB). The client requires airborne precautions and is receiving multidrug therapy. Which of the following precautions should the nurse take to transport the client safely to the radiology department for a chest x-ray?

Have the client wear a mask. When a client who has a communicable disease must leave his room, it is important to protect everyone with whom the client comes in contact. Having the client wear a mask protects others from airborne particles should the client cough.

A nurse is inserting an IV catheter for an older client in preparation for an outpatient procedure. Which of the following veins should the nurse select?

Median vein in the forearm The nurse should use the median vein in the forearm because it is distal to other potential venipuncture sites and it avoids areas of flexion. The bones in the forearm provide natural splinting and protection for IV insertion sites in the forearm and allow more freedom of movement for the client.

A nurse is providing care to a client who is on strict bed rest following surgery. The nurse assists the patient to the bedside commode and the client sustains an injury to the operative area. Which of the following types of torts has the nurse committed?

Negligence Negligence is the failure to provide the expected standard of care. The expected standard of care was strict bedrest.

A nurse is preparing a client for outpatient surgery. After the nurse inserts the IV catheter, the client reports pain in the insertion area. Which of the following actions should the nurse take?

Remove the catheter and insert another into a different site. It is possible that the catheter is up against a valve or near a nerve and is causing more pain than an IV catheter insertion should. The nurse should remove the source of the pain and establish peripheral IV access elsewhere.

A nurse is preparing to administer penicillin IM to an adult client. Which of the following angles should the nurse use for injection into the client's ventrogluteal muscle?

90° With this angle, the nurse will deposit the medication deeply into the muscle to ensure rapid absorption of the medication due to the vascularity of muscle tissue.

A nurse is preparing to administer a soapsuds enema to an adult client. Which of the following actions should the nurse take?

Assist the client to the left Sims' position. This position makes it easier for the enema solution to flow by gravity into the sigmoid and descending colon. The nurse should also have the client's right leg flexed to facilitate insertion.

A nurse is helping an older adult client ambulate in the hallway for the first time since admission. The client has brought her standard walker from home. To ensure proper use of the walker and the safety of the client, which of the following actions should the nurse take?

Check that the client lifts the walker and then places it down in front of her. The client should lift the walker and advance it about 15 cm (6 in), then set it down. This allows her a wide base of support while she moves forward.

A nurse is caring for a client who came to the emergency department with abdominal distention and is now on the medical-surgical unit with an NG tube in place to low gastric suction. The client is reporting anxiety, discomfort, and a feeling of bloating. Which of the following actions is the nurse's priority?

Check to see if the suction equipment is working. The first action the nurse should take using the nursing process is to assess the situation. The nurse should check for the most obvious reason why the client's symptoms have returned. If the suction equipment has malfunctioned, the nurse should adjust it or replace it with working equipment.

A nurse is caring for an older adult client. The nurse informs the client that straining while defecating can cause which of the following?

Dysrhythmias Dysrhythmias can result from straining while defecating. Pressure can be exerted with the Valsalva maneuver, when the client contracts the abdominal muscles and holds their breath while bearing down. When the client exhales, there is a sudden release of intraabdominal pressure against the closed airway, which can result in cardiac dysrhythmias and elevated blood pressure.

A nurse is completing a client assessment for admission to the medical unit. Which of the following abdominal assessment findings require further investigation by the nurse?

Ecchymosis Ecchymosis is a finding outside of the expected reference range for an abdominal assessment and would require the nurse to further investigate for potential injury, bleeding disorder, or physical abuse.

A nurse is caring for a client who has an NG tube. The nurse tests the pH of the secretions to determine if the tube is correctly placed. Which of the following readings should the nurse expect?

4.0 This is an acidic pH, which is consistent with gastric drainage. This indicates that the NG tube is correctly placed.

A nurse is calculating the total fluid intake for a client during a 4-hr period. The client consumes 1 cup of coffee, 4 oz of orange juice, 3 oz of water, 1 cup of flavored gelatin, 1 cup of tea, 5 oz of broth, and 3 oz of water. The nurse should record how many mL of intake on the client's record?

1. Ask client of abdominal pain history 2. inspect the abdomen for skin integrity 3. Auscultate the abdomen for bowel sounds 4. Percuss the abdomen in all 4 quadrants 5. Palpate the abdomen lightly for tenderness

A nurse is caring for a client who has a prescription for a clear liquid diet. Which of the following foods should the nurse allow the client to have?

Apple juice A clear liquid diet includes foods that are fluids and clear at body and room temperatures. This includes apple and grape juices, broth, black coffee, and plain gelatin.

A nurse is caring for a client who has a prescription for a stool test for guaiac. The nurse understands the purpose of the test is to check the stool for which of the following substances?

Blood A guaiac test detects the presence of occult or hidden blood in the stool. The guaiac test is an extremely useful diagnostic screening test for the presence of colon cancer and gastrointestinal ulcers.

A nurse is assessing a client's cranial nerves as part of a neurological examination. Which of the following actions should the nurse take to assess cranial nerve III?

Checking the pupillary response to light Cranial nerve III is the oculomotor nerve and is responsible, along with cranial nerves IV (trochlear) and VI (abducens), for eye movement and pupillary response to light. If the cranial nerve is functioning properly, the expected reaction is pupil constriction in response to light.

A nurse is developing the plan of care for a client who does not speak the same language as the nurse. Which of the following interventions should the nurse include?

Determine the client's level of fluency in his primary language. It is important to determine the client's level of fluency in her primary language and the nurse's language to provide teaching the client can understand.

A nurse is planning care for a client who has a decreased level of consciousness. The client is receiving continuous enteral feedings via a gastrostomy tube due to an inability to swallow. Which of the following is the priority action by the nurse?

Elevate the head of the client's bed 30° to 45°. A client who has a decreased level of consciousness and an inability to swallow is at risk for aspiration. Lying flat also increases this risk. The priority action by the nurse is to keep the head of the bed elevated 30o to 45o to promote gastric emptying and reduce the risk of aspiration.

A nurse needs to lift a box in a supply room. Which of the following actions should the nurse take to prevent an injury due to lifting?

Keep the box close to his body as he lifts. Proper body mechanics requires keeping the object as close to the body as possible to keep it close to the lifter's center of gravity.

A nurse is completing a client's history and physical examination. Which of the following information should the nurse consider subjective data?

Nausea Subjective data include information that only the client can perceive and report. The nurse cannot determine that the client feels nauseated.

A nurse is caring for a client who is discussing his post-traumatic stress disorder and states: "Everyone thinks you should be able to put it out of your mind. It happened so long ago - just get over it!" The nurse responds, "It must be very frustrating to encounter this kind of attitude." The nurse is using which of the following therapeutic communication techniques?

Reflection Reflection involves responding to the content and emotional components of a message by restating the client's feelings.

A nurse is caring for a client who needs a stool specimen collected. Which of the following actions should the nurse take when obtaining the specimen?

Send specimen container immediately to the lab. The nurse should label the specimen contain and send it immediately to the laboratory. A delay in transport can result in altered laboratory findings.

A nurse is administering a cold therapy application to a client. Which of the following manifestations should the nurse identify as an indication for discontinuing the application due to a systemic response?

Shivering Shivering is a systemic response to cold therapy as the body attempts to promote heat production.

A nurse is preparing an in-service presentation for a group of newly licensed nurses about the use of restraints. Which of the following should the nurse include as a criterion for applying restraints?

The nurse has already considered alternatives to restraints. Restraints physically prevent a client from moving freely in the environment. However, they are a last resort. The nurse must consider other alternatives before implementing a restraint device.

A nurse in a clinic is caring for a female client who has a new diagnosis of acne vulgaris on her cheeks. Which of the following should the nurse include in the teaching plan for this client?

Use a new cosmetic pad with each limited application of makeup. Use of a new cosmetic pad with each makeup application decreases the risk of reinfection. Makeup should be applied on a limited basis, as many are oil-based products, clog pores, and exacerbate acne.

A nurse in a clinic is teaching a group of clients about preventing low back pain and injury. Which of the following statements should the nurse identify as an indication that the client requires further clarification?

"I'll sit with my knees lower than my hips." To prevent back injuries, the clients should sit with their knees slightly higher than their hips.

A nurse is assessing a client for pitting edema and notes an indentation of 6 mm (0.25 in) at the point of pressure. Which of the following notations should the nurse use to document the severity of the client's edema?

3+ The nurse should document pitting edema of 5 to 7 mm as 3+.

A nurse is preparing a client for ambulation. Which of the following actions should the nurse take to determine the client's level of strength?

Ask the client to push her feet against the nurse's palms. Asking the client to push with her feet against the nurse's hands is an appropriate method of determining the client's level of physical strength, which is needed for ambulation.

A nurse is reviewing the medical record of a client who has a potassium level of 3.0 mEq/L. Which of the following findings should the nurse recognize as a potential causative factor?

Client has an NG tube to gastric suction. The client who has an NG tube to gastric suction is at risk for developing hypokalemia due to the gastrointestinal loss of potassium.

A nurse is assessing an older adult client who has osteoporosis. Which of the following spinal deformities should the nurse expect to find in this client?

Kyphosis Kyphosis, a forward "stooping" posture with a loss of height, is an angulation of the posterior curve of the thoracic spine, usually a result of osteoporosis. It is most common in older adults and increases with aging and vertebral fractures.

A nurse is assessing an older adult client who has experienced some loss of bone density. The nurse observes a "hunchback" curvature of the client's spine. The nurse should expect the provider to document which of the following disorders?

Kyphosis Kyphosis, a forward, "hunchback" curvature of the spine, is an abnormal angulation of the posterior curve of the thoracic spine resulting from multiple compression fractures, usually a result of osteoporosis. It is most common in older adults and tends to increase with aging.

A nurse is caring for an older adult client who was alert and oriented at admission, but now seems increasingly restless and intermittently confused. Which of the following actions should the nurse take to address the client's safety needs?

Move the client to a room closer to the nurses' station. This will make it easier for the staff to observe the client, should the client behave in an unsafe manner.

A nurse is observing an assistive personnel performing postmortem care for a client who is Muslim. Which of the following actions should prompt the nurse to intervene?

Prepares to cleanse the body Following the death of a client who followed the Muslim faith, a Muslim of the same gender must ritualistically wash and wrap the body.

A nurse is caring for a client who has a very low white blood cell count. Which of the following infection-control precautions should the nurse use while caring for this client?

Protective Clients whose immune system is compromised, such as from chemotherapy, AIDS, or after a stem-cell transplant, require a protective environment.

A nurse is working with an assistive personnel (AP) while caring for a surgical client who is 1 day postoperative. Which task should the nurse take responsibility for completing?

Removing the abdominal dressing The nurse cannot delegate assessment, diagnosis, planning, or evaluation because these are steps of the nursing process that require nursing judgment. When removing an abdominal dressing, the nurse should assess the surgical wound and determine if any further action is needed. This could include notifying the provider and using sterile technique to complete a dressing change.

A nurse is performing tracheostomy care for a client and suctioning to remove copious secretions. Which of the following actions should the nurse take?

Suction two to three times with a 60-second pause between passes. Copious secretions may require several passes of the suction catheter. An interval of 60 seconds should be allowed between passes to prevent hypoxia.

A nurse is caring for a client who receives intermittent enteral feedings through an NG tube. Before administering a feeding, the nurse should measure the gastric residual for which of the following purposes?

To identify delayed gastric emptying The nurse should measure the amount of unabsorbed formula from the previous enteral feeding to identify delayed gastric emptying. If it is delayed, the nurse should avoid overfeeding the client and causing gastric distention.

A nurse is completing an 8-hr I&O record for a client who consumed 4 oz juice, 6 oz hot tea, 100 mL ice chips, an IV bolus of 150 mL, and 8 oz broth. The nurse should record how many mL of intake on the client's record?

740ml 1oz = 30ml Ice chips are 50% of their ml consumed

A nurse is caring for a client who is receiving enteral tube feeding and has a new prescription to dilute the formula. The nurse recognizes this is being done to resolve which of the following conditions?

Diarrhea Diarrhea is treated by diluting the formula. Diarrhea can also be treated by reducing the rate of delivery or changing to an isotonic enteral formula.

A nurse is caring for a client who has a new diagnosis of type 1 diabetes mellitus. To focus on effective learning with this client, which of the following interventions should the nurse use?

Explore the client's feelings about dietary modifications. This teaching intervention allows the client to express his acceptance of this change and focuses on affective learning.

A nurse is providing preoperative teaching by demonstrating diaphragmatic breathing to a client who is scheduled for surgery in the morning. Which of the following actions should the nurse include in the demonstration?

Inhale slowly and evenly through her nose. The nurse should inhale slowly and evenly through her nose until chest expansion is maximized.

A nurse is caring for a client who is prescribed bedrest. The plan of care indicates that the client should perform isometric exercises every 2 hr. Which of the following actions should the nurse take as directed by the plan of care?

Instruct the client to tighten muscle groups for a short period, and then relax. Isometric exercises involves static (no movement) contraction of a muscle without any movement of the joint. Isometrics promote increased muscle mass, strength, and tone for clients who are on bedrest.

A nurse in a long-term care facility is observing an assistant personnel (AP) changing the linen for a client who has fecal incontinence. Which of the following actions indicates that the AP understands the principles of infection control?

Places clean linen that touched the floor in the soiled linen bag Linen that touches the floor or the AP drops requires laundering.

A nurse is preparing to transfer a client from lying in bed to sitting in a chair. When identifying the safest method of transfer, which of the following is most important for the nurse to determine?

The client's current weight-bearing status The client's weight-bearing status is the most important information the nurse needs to know to identify the safest method of transfer.

A nurse is assessing a client who has a wrist restraint applied. For which of the following findings should the nurse loosen the restraint?

The client's hand is cool and pale. This finding indicates a decrease in blood flow to the client's hand, which can be caused by applying a restraint too tightly. This is the finding that indicates a complication of the restraint, and the nurse should loosen the restraint and exercise the limb.

A nurse is providing oral care for a client who is immobile. Which of the following actions should the nurse take?

Turn the client on his side before starting oral care. Placing the client on his side helps fluid run out of his mouth by gravity, thus preventing aspiration and choking.

A nurse is reviewing information about the Health Insurance Portability and Accountability Act (HIPAA) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates a need for further teaching?

"Information about a client can be disclosed to family members at any time." This statement reflects a need for further teaching. Privacy relates to the client's rights over the use and disclosure of his or her own personal health information.

A nurse is working with a licensed practical nurse (LPN) to care for a client who is receiving a continuous IV infusion. Which of the following findings reported by the LPN indicates to the nurse the client has phlebitis at the IV insertion site?

"The area surrounding the insertion site feels warm to the touch." The IV fluid is at room temperature, so the area around the injection site will feel cool, not warm, to the touch when the IV is infiltrated. A warm area around the injection site indicates infection or phlebitis.

A nurse is caring for a client who has fallen while getting out of bed and states, "I'm okay! I guess I should have called for help to the bathroom." After assessing the client, the nurse notifies the provider. Which of the following documentation should the nurse include in the client's medical record?

"The provider was notified." Nursing interventions that support factual information should be documented in the health record.

A nurse is providing preoperative teaching for a client who will undergo surgery. The nurse explains that the client will wear antiembolism stockings during and after the procedure. When the client asks what the stockings do, which of the following responses should the nurse make?

"They improve your circulation to keep blood from pooling in your legs." Antiembolism stockings promote venous return from the legs, thus helping to prevent venous thrombosis, also known as clot formation, and peripheral edema.

A nurse at an extended-care facility is instructing a class of assistive personnel (AP) about client use of assistive devices during ambulation. Which of the following instructions should the nurse give the APs about the clients' use of a cane?

"When the client moves, he should move the cane forward first." When the client moves, he should first move the cane forward about 30.5 cm (12 in). Then, he should move the weak leg even with the cane. Finally, he should bring the strong leg forward and ahead of the cane and his weak leg.

A nurse enters an older adult client's room to insert a saline lock. The client asks the nurse, "Why do I need that? I am drinking plenty of fluids." Which of the following responses should the nurse provide?

"Your provider has prescribed antibiotic therapy to be administered intravenously every 6 hours." Intermittent antibiotic medications are frequently administered parenterally. This allows the client to ambulate between medication administrations, enhances client safety and promotes comfort. The response addresses the client's concern.

A nurse is assisting a provider with a sterile procedure and prepares to pour a solution onto a piece of gauze. Identify the sequence of steps the nurse should follow when pouring the solution.

1. remove the bottle camp 2. place the bottle cap face up on clean surface 3. pick up the bottle with the label facing his palm 4. pour 1-2 ml of solution into a receptacle 5. pour solution onto the gauze

A nurse is calculating the total fluid intake for a client during a 4-hr period. The client consumes 1 cup of coffee, 4 oz of orange juice, 3 oz of water, 1 cup of flavored gelatin, 1 cup of tea, 5 oz of broth, and 3 oz of water. The nurse should record how many mL of intake on the client's record?

1170ml 1 cup = 240ml

A charge nurse is anticipating the admission of four clients and planning their room assignments. Which of the following clients should the nurse assign to the room closest to the nurses' station?

A client who sustained a head injury and is having periods of confusion A client who sustained a head injury and is confused is at risk for seizures. The nurse should place this client in a room near the nurses' station so that he can be closely monitored to prevent injury if a seizure occurs

A nurse in a clinic is interviewing a client who will undergo diagnostic testing. The nurse should ask about a client's potential allergies during which phase of the nursing process?

Assessment The assessment phase includes asking the client about her health history, physical concerns and health care expectations. A review of possible allergies is included in the assessment phase.

An assistive personnel (AP) reports a client's vital signs as tympanic temperature 37.1° C (98.8° F), pulse 92/min, respiratory rate 18/min, and BP 98/58 mm Hg. Which of the following vital signs should the nurse re-measure?

BP A nurse who is supervising an AP's work is accountable for the work that the AP completes. Therefore, the nurse should verify anything that seems unusual. The BP the AP reported is low; therefore, the nurse should verify that this result is accurate before taking any other actions.

A clinical nurse educator is preparing an educational program about transmission of methicillin-resistant Staphylococcus aureus (MRSA) in hospitalized clients. Which of the following information should the nurse include in the program?

Bathe clients with water and chlorhexidine gluconate. Bathing hospitalized clients with pre-moistened cloths or warm water that is mixed with chlorhexidine gluconate significantly decreases infection with MRSA.

A nurse is caring for a client who has an indwelling urinary catheter and notes blood-tinged urine in the catheter bag. The nurse recognizes this finding can be a manifestation of which of the following urinary alterations?

Bladder infection The nurse should recognize that hematuria, or blood-tinged urine, can be a manifestation of a bladder or kidney infection.

A nurse on a medical unit is caring for a client who suddenly becomes confused and drowsy. Additional data includes pulse 100/min, respiratory rate 24/min, BP 132/76 mm Hg, and temperature 36.8º C (98.2º F). Which of the following actions should the nurse perform?

Complete a neurological check. Neurological assessment is an appropriate nursing intervention when a client displays sudden confusion. Sensory alterations can occur when a client is experiencing multiple sensory stimuli and can result in inappropriate sensory responses. Tolerance to stimuli may be affected by fatigue and emotional and physical well-being.

A nurse is preparing to administer three liquid medications to a client who has an NG feeding tube with continuous enteral feedings. Which of the following actions should the nurse take?

Flush the NG feeding tube with 30 mL of water immediately following medication administration The nurse should flush the NG feeding tube with 15 to 60 mL of sterile water following medication administration to ensure the feeding tube is cleared of the medications.

A nurse is assisting with transferring a client from the bed to a wheelchair. Which of the following actions should the nurse take?

Lock the wheels of the bed and the wheelchair. The nurse should keep the wheels of the bed and the wheelchair in the locked position to prevent them from moving when transferring a client.

A nurse accidentally administers the wrong medication to a client, which results in a severe allergic reaction and prolongs the client's hospitalization. The client could rightfully sue the nurse for which of the following?

Malpractice The client could sue the nurse for malpractice, which is the failure to meet the standard of conduct another professional would exercise in similar circumstances and that failure causes harm. This nurse has made an error that harmed the client.

A nurse is caring for a client who has peripheral vascular disease and reports difficulty sleeping because of cold feet. Which of the following nursing actions should the nurse take to promote the client's comfort?

Obtain a pair of slipper-socks for the client. In cold weather or when the client's feet are cold, he should wear extra socks or slipper socks to help provide warmth and increase his level of comfort.

A nurse is caring for a client who is recovering from a cerebrovascular accident (CVA). Which of the following information should the nurse include when teaching family members about repositioning the client? (Select all that apply.)

Remove pillows prior to repositioning is correct. The family caregivers should remove pillows that are supporting the client and then place one against the head of the bed. This prevents injury from the client's head striking the headboard when the family members pull the client up in bed. Elevate the bed to waist height is correct. Working at waist height promotes ergonomics and minimizes the risk of injury to the individuals performing repositioning maneuvers and to the client. Position the client toward the edge of the bed on the side the client will face after turning is incorrect. The family caregivers should position the client toward the side of the bed opposite the side the client will face after turning. This action will help the client to be in the center of the bed after repositioning. Stand with feet wide apart is correct. A wide base of support when moving a client facilitates movement and minimizes the risk of injury to individuals performing repositioning maneuvers. The body's center of gravity is the pelvis. The closer the center of gravity is to the base of support, the more stable the movement. A wide stance achieves this.Face the direction of movement when positioning the client is correct. When repositioning a client, family members should move their rear leg back to promote ergonomic stability. Facing the direction of movement maintains alignment for both the client and the caregivers. This prevents straining back muscles or bending at the waist. Sliding, rolling, and pushing in the same direction that the caregivers face require less energy and pose less risk for injury.

A nurse is preparing to assist a client who can partially bear weight and is cooperative with transfer from the bed to a chair. Which of the following actions should the nurse take to maintain safety during the transfer?

Use a powered standing-assist lift. Using a powered standing-assist lift will best ensure the safety of the client and the nurse.

A nurse is performing a cardiac assessment on a client and auscultates an S3 sound. The nurse should recognize that this sound represents which of the following heart conditions?

Ventricular gallop An S3 represents a ventricular gallop caused by a rush of blood into a ventricle that is stiff or dilated. This can be a finding of heart failure and hypertension.