ATI Fundamentals for Nursing Edition 11.0

3. A nurse is caring for a client who has terminal lung cancer. The nurse observes the client's family assisting the client with all ADLs. What rationale for self-care should the nurse communicate to the family?

3. When taking actions, the nurse should communicate to the client's family that they should allow the client to perform their own ADLs as much as possible to maintain dignity, control, and self-esteem.

4. A nurse determines a client's radial pulse rate is 68/min and the simultaneous apical pulse rate is 84/min. What is the client's pulse deficit?

4. When analyzing cues, the nurse should determine that the pulse deficit is the difference between the apical and radial pulse rates. It reflects the number of ineffective or non-perfusing heartbeats that do not transmit pulsations to peripheral pulse points. Therefore, 84 - 68 = 16.

5. A nurse is performing a skin assessment on an older adult client. Sort the following findings as Expected or Unexpected in older adult clients. A. Thin, parchment-like skin B. Hematoma C. Diminished skin elasticity D. Wrinkles E. Petechiae

5. EXPECTED: A, C, D UNEXPECTED: B, E When analyzing cues, the nurse should identify that thin, parchment-like skin, diminished skin elasticity, and wrinkles are expected changes in the older adult client due to loss of moisture and subcutaneous fat. A hematoma and petechiae are not expected findings and might be a manifestation of an illness or disease process.

6. A nurse in a primary care clinie is assessing a client who has a history of herpes zoster. Which of the following findings suggests that the client has postherpetic neuralgia? A. Linear clusters of vesicles on the right shoulder B. Purulent drainage from both eyes C. Decreased white blood cell count D. Report of continued pain following resolution of the rash

6. A. Obtain a specimen for culture and sensitivity prior to, not after, the initiation of antimicrobial therapy. B. MRSA is resistant to most antibiotics except vancomycin. C. CORRECT: When evaluating the outcomes of teaching to a newly licensed nurse, the charge nurse should identifv that the statement, "I will protect others from exposure when I transport the client outside the room" indicates understanding of the teaching. With infections due to antibiotic-resistant bacteria, the nurse should protect everyone the client comes in contact with from transmission, especially when outside the isolation room. D. Discontinuing antimicrobial therapy prior to completing a full course of treatment increases the risk of producing resistant pathogens.].

8. A nurse is assessing an adult client's internal ear canals with an otoscope as part of a head and neck examination. Which of the following actions should the nurse take? (Select all that apply.) A. Pull the auricle down and back. B. Insert the speculum slightly down and forward. C. Insert the speculum 2 to 2.5 cm (0.8 to 1 in). D. Make sure the speculum does not touch the ear canal. E. Use the light to visualize the tympanic membrane in a cone shape.

8. A. The nurse should pull the auricle up and back for adults and down and back for children younger than 3 years. B. CORRECT: Inserting the speculum slightly down and forward follows the natural shape of the ear canal. C. Insert the speculum 1 to 1.5 cm (0.4 to 0.6 in). D. CORRECT: The lining of the ear canal is sensitive. Touching it with the speculum could cause pain. E. CORRECT: Due to the angle of the ear canal, the nurse can only visualize the light reflecting off of the tympanic membrane as a cone shape rather than a circle.

2. A nurse is teaching a newly licensed nurse about adverse effects of medications. Sort the adverse effects into extrapyramidal or anticholinergic reactions. A. Tremors B. Constipation C. Drooling D. Shuffling gait E. Dry mouth F. Photophobia

• 2. EXTRAPYRAMIDAL: A, C, D; ANTICHOLINERGIC: B, E, F When taking actions, the nurse should instruct that extrapyramidal reactions can include irregular body movements, tremors, rigidity, restlessness, acute dystonia (spastic movements of the back, neck, tongue, face), drooling, agitation, and shuffling gait. Anticholinergic reactions can include dry mouth, photophobia, blurred vision, urinary retention, and constipation.

1. A nurse is caring for a client who has terminal lung cancer. Match the client statements to the Kübler-Ross model stage of grief the client is experiencing. A. " am looking forward to our family reunion next year." B. "This is so unfair. Why is this happening to me?" C. "I promise to go to church every day, if I live through this. D. "I have nothing to live for anyway." E. "I have lived a good life." 1. Bargaining 2. Denial 3. Acceptance 4. Anger 5. Depression

1. A, 2; B, 4; C, 1; D, 5; E, 3 When analyzing cues, the nurse should identify that looking forward to an event the next year indicates the client is experiencing the Kubler-Ross model stage of denial. The client statement that the situation is unfair indicates the client is experiencing the Kübler-Ross model stage of anger. Making a promise in exchange for a longer life is an indication the client is experiencing the Kübler-Ross model stage of bargaining. The client is experiencing the Kübler-Ross model stage of depression by showing overwhelming sadness. The client is experiencing the Kübler-Ross model stage of acceptance by stating they have lived a good life.

1. A nurse is performing an assessment on a client who has hypovolemia due to vomiting and diarrhea. The nurse should expect which of the following findings? (Select all that apply.) A. Hyperthermia B. Bradycardia C. Orthostatic hypotension D. Distended neck veins E. Decreased skin turgor

1. A, C, E. CORRECT: When analyzing cues, the nurse should identify that hyperthermia, orthostatic hypotension, and decreased skin turgor are expected findings for the client who has hypovolemia.

1. A nurse is teaching a client who has recurrent UTIs. Which of the following instructions should the nurse include? (Select all that apply.) A. Urinate after sexual intercourse. B. Drink at least 1L of fluid each day. C. Clean perineum from the front to back. D. Wear nylon undergarments. E. Avoid bubble baths.

1. A, C, E. CORRECT: When taking actions, the nurse should instruct the client to urinate after sexual intercourse to flush bacteria from the urinary system. The client should clean the perineum from the front to back to reduce the risk of introducing bacteria in the urinary system and avoid bubble baths that might irritate the urethra.

1. The nurse is preparing to insert an NG tube on a client for stomach decompression. When determining the length of the tube to be inserted, what anatomical locations should the nurse use for measurement? (Select all that apply.) A. Tip of nose B. Abdomen C. Clavicle D. Earlobe E. Xyphoid process

1. A, D, E. CORRECT: When generating solutions, the nurse should determine the length of the tube to be inserted by measuring from the tip of the client's nose to the earlobe, and down to the xyphoid process. B, C. Anatomical locations that include a measurement point of the clavicle and stomach are not indicated for determining the length of a nasogastric tube.

1. A charge nurse is explaining the various stages of the lifespan to a group of newly licensed nurses. Which of the following examples should the charge nurse include as a developmental task for a young adult? A. Becoming actively involved in providing guidance to the next generation B. Adjusting to major changes in roles and relationships due to losses C. Devoting time to establishing an occupation D. Finding oneself "sandwiched" between and being responsible for two generations

1. A. Active involvement in the next generation is a developmental task for middle adults. B. Adjusting to major role changes associated with loss is a developmental task for older adults. C. CORRECT: The nurse should identify that exploring career options and then establishing oneself in a specific occupation is a major developmental task for a young adult D. Assuming responsibility for the previous as well as the next generation is a developmental task for middle adults.

1. A nurse is teaching a group of clients how to care for their colostomies. Which of the following statements indicates an issue with self-concept? A. "I was having difficulty with attaching the appliance at first, but my partner was able to help." B. "I'll never be able to care for this at home. Can't you just send a nurse to the house?" C. "I met a neighbor who also has a colostomy, and they taught me a few things." D. "It can take me a while to get the hang of this. I have to admit, I am pretty nervous.

1. A. Although the client was having difficulty at first, the client expressed how resources would be used, resulting in a positive outcome, and does not show signs of self-concept issues. B. CORRECT: The nurse should identify that the client is displaying a lack of interest in learning how to care for the colostomy and preferring dependence on others to perform the care. Issues with self-concept should be suspected. C. This client is displaving a positive self-concept by reaching out and using resources to learn additional information regarding the colostomy.. D. Expression of feelings is an indication of a positive self-concept even if the client admits to anxiety or hesitance about caring for the colostomy..

1. A nurse is teaching a client who has a new prescription for oxybutynin about managing the medication's anticholinergic effects. Which of the following instructions should the nurse include? (Select all that apply.) A. Take sips of water frequently. B. Wear sunglasses when outdoors in sunlight. C. Use a soft toothbrush when brushing teeth. D. Take the medication with an antacid. E. Urinate prior to taking the medication.

1. A. CORRECT: The nurse should instruct the client to take sips of water frequently to relieve dry mouth. B. CORRECT: The nurse should instruct the client to wear sunglasses to relieve the photophobia. C. The client should not use a soft toothbrush when brushing teeth. D. The client should not take the medication with an antacid. E. CORRECT: The nurse should instruct the client to urinate prior to taking the medication to relieve the anticholinergic effect of urinary retention.

1. A nurse is caring for a client who has been sitting in a chair for 1 hr. Which of the following complications is the greatest risk to the client? A. Decreased subcutaneous fat B. Muscle atrophy C. Pressure injury D. Fecal impaction

1. A. The client is at risk for decreased subcutaneous fat due to altered mobility. However, there is another risk that is the priority. B. The client is at risk for muscle atrophy due to altered mobility. However, there is another risk that is the priority. C. CORRECT: When prioritizing hypotheses, the nurse should identify that the greatest risk to this client is injury from skin breakdown due to unrelieved pressure over a bony prominence from prolonged sitting in a chair. Instruct the client to shift their weight every 15 min, and reposition the client after 1 hr. D. The client is at risk for fecal impaction due to altered mobility. However, there is another risk that is the priority.

1. A nurse is teaching a client about performing a fecal occult blood test at home. Which of the following information should the nurse include? A. Do not eat red meat within one day of the test. B. One stool specimen is sufficient for testing. C. A red color change indicates a positive test. D. Ensure the specimen does not include urine.

1. A. The consumption of red meat should be avoided for 3 days prior to testing. B. The test should be repeated a minimum of 3 times on 3 separate stool specimens. C. The client should be instructed that a blue color change on the guaiac paper indicates the specimen is positive for fecal occult blood. D. CORRECT: When taking actions, the nurse should instruct the client to avoid contaminating the stool specimen with urine or water to ensure accurate test results.

1. A nurse is teaching the guardian of a 12-year-old male client about manifestations of puberty. The nurse should explain that which of the following physical changes occurs first? A. Appearance of downy hair on the upper lip B. Hair growth in the axillae C. Enlargement of the testes and scrotum D. Deepening of the voice

1. A. The emergence of facial hair, hair growth in non-genital areas, and changing vocal quality are late pubescent changes. Evidence-based practice indicates that another change occurs first. B. The emergence of facial hair, hair growth in non-genital areas, and changing vocal quality are late pubescent changes. Evidence-based practice indicates that another change occurs first. C. CORRECT: When using evidence-based practice to take action and teaching to the parent of a 12-year-old male client about the manifestation of puberty, the nurse should explain that the first prepubescent change in boys is an increase in the size of the testicles and scrotum, and growth of pubic hair. D. The emergence of facial hair, hair growth in non-genital areas, and changing vocal quality are late pubescent changes. Evidence-based practice indicates that another change occurs first...

1. A nurse provides an introduction to a client as the first step of a comprehensive physical examination. Which of the following strategies should the nurse use with this client? (Select all that apply.) A. Address the client with the appropriate title and their last name. B. Use a mix of open- and closed-ended questions. C. Reduce environmental noise. D. Have the client complete a printed history form. E. Perform the general survey before the examination.

1. A. The nurse should ask for the client's preference on how to be addressed.. B. CORRECT: The nurse should identify that open-ended questions help the client tell a story in their own words. Closed-ended questions are useful for clarifying and verifying information gathered from the client's story. C. CORRECT: A quiet, comfortable environment eliminates distractions and helps the client focus on the important aspects of the interview. D. The nurse should recognize that having the client fill out a printed history form might deter the establishment of a therapeutic relationship. When asking about history, the client might feel they are wasting time because that information was already written on the form. E. CORRECT: The general survey is noninvasive and, along with the health history and vital sign measurement, can help put the client at ease before the more sensitive parts of the process (the examination)...

Application Exercises 1. A nurse is providing information about age-related physical changes to the family member of an older adult. Which of the following information should the nurse include? A. Older adults have oilier skin than younger persons. B. Dry mouth is common for older adults. C It is common for older adults to have increased perspiration. D. Hair in the eyebrows decreases.

1. A. Typically, older adults have drier skin. B. CORRECT: It is common for older adults to experience dry mouth due to decreased saliva production, and many older adults take medications that lead to dry mouth. C. Due to a decrease in ability to function, older adults are expected to have less perspiration. D. It is typical for the hair in the ears, nose, and eyebrows to increase.

1. A nurse is caring for a client who is newly admitted to the unit. Which action should the nurse take to establish a helping relationship with the client? A. Make sure the communication is equally distributed between the nurse's and client's desires. B. Encourage the client to communicate their thoughts and feelings. C. Give the nurse-client communication no time limits. D. Allow communication to occur spontaneously throughout the nurse-client relationship.

1. A. When taking actions to establish a helping relationship with the client, the nurse should establish communication that is client-focused. B. CORRECT: Therapeutic communication facilitates a helping relationship that maximizes the client's ability to express their thoughts and feelings openly. C. Limit therapeutic communication to the boundaries of the therapeutic relationship, including time. D. Plan therapeutic communication.

1. A nurse is assessing a client's musculoskeletal system as part of a comprehensive physical examination, Which of the following findings should the nurse expect? (Select all that apply.) A. Concave thoracie spine posteriorly B. Exaggerated lumbar curvature C. Concave lumbar spine posteriorly D. Exaggerated thoracie curvature E. Muscles slightly larger on the dominant side

1. C, E. CORRECT: When analyzing cues, the nurse should expect the client to have a concave lumbar spine posteriorly, and muscle size that is equal on both sides or slightly larger on the client's dominant side.

1. A nurse is reviewing the stages of infection with new nurses. Place the stages in the order in which they occur. A. Prodromal B. Convalescence C. Incubation D. Illness

1. C-incubation A-prodromal D-illness B-convalescence When taking actions to review the stages of infection in order, the nurse will first review the incubation stage, the interval between the pathogen entering the body and the presentation of manifestations. The nurse will then review the prodromal stage, the interval from onset of general manifestations to more distinct findings. The nurse will then review the illness stage, in which manifestations specific to the infection occur. The nurse will discuss last the convalescence stage, in which acute findings disappear and total recovery occurs.

1. The nurse is reviewing the client's medical administration record and notes a prescription for docusate 100 mg PO once every day. The nurse should identify this as which of the following types of prescription? A. Single B. Stat C. Routine D. Now

1. C. CORRECT: When analyzing cues, the nurse should identify that a routine or standing prescriptions are medications that are administered on a regular schedule with or without a termination date or a specific number of doses. The nurse should administer this medication every day until it is discontinued.

1. A nurse is reviewing motor development with the parents of an infant. Identify the order in which these motor skills are expected to occur. A. Pulls self up into a standing position B. Rolls from stomach to back C. Walks holding someone's hand D. Lifts head off mattress E. Sits without support

1. D, B, E, A, C When taking actions to explain the expected development of motor skills in order, the nurse will explain that lifting the head off of the mattress is expected to occur at 2 to 4 months; rolling from back to stomach is expected to occur at 4 to 6 months; sitting without support is expected to occur at 6 to 8 months; pulling self into a standing position is expected to occur at 8 to 10 months; and walking holding onto a hand or furniture is expected to occur at 10 to 12 months.

1. A nurse is discussing the care of a group of clients with a newly licensed nurse. Which of the following clients should the newly licensed nurse identify as experiencing chronic pain? A. A client who has a broken femur and reports hip pain. B. A client who has incisional pain 72 hr following pacemaker insertion. C. A client who has food poisoning and reports abdominal cramping. D. A client who has episodic back pain following a fall 2 years ago.

1. D. CORRECT: When analyzing cues, the nurse should identify that a client who reports pain that lasts more than 6 months and continues beyond the time of tissue healing is experiencing chronic pain. The nurse should assist with planning interventions to relieve manifestations associated with the pain. A, B, C. A client who has hip pain from a broken femur, a client who is having pain from an incision site, and a client who is reporting abdominal pain from experiencing food poisoning are all experiencing acute pain.

1. A nurse is instructing a newly licensed nurse about choosing a site to measure a client's temperature. Sort the following clients with the correct temperature site: Oral or Rectal. A. A clients who breathes through the mouth B. A client who has a low platelet count C. A client who has facial trauma D. A client who has hemorrhoids

1. ORAL: B, D RECTAL: A, C When taking actions, the nurse should take an oral temperature on a client who has a low platelet count to decrease the risk of bleeding. The nurse should take a rectal temperature on a client who breathes through the mouth to obtain an accurate reading. The nurse should take an oral temperature on a client who has hemorrhoids to decrease the risk of bleeding. The nurse should take a rectal temperature on a client who has facial trauma to reduce the risk of injury to the client.

6. A nurse is examining a client's tonsils for size using a grading tool. Match the grade with the findings. 1. The tonsils touch the uvula. 2. The tonsils are behind the soft structures supporting the palate. 3. The tonsils touch each other. 4 The tonsils are between the soft structures and the uvula. D. Grade 4 C. Grade 3 B. Grade 2 A. Grade 1

1. The tonsils touch the uvula. C. Grade 3 2. The tonsils are behind the soft structures supporting the palate. A. Grade 1 3. The tonsils touch each other. D. Grade 4 4 The tonsils are between the soft structures and the uvula. B. Grade 2 The nurse should recognize that expected finding are that the tonsils are pink and smooth and without discharge and behind the soft structures. With each grade the tonsils are progressively larger. Grades 2, 3, and 4 are unexpected finding and should be reported to the provider.

1. A nurse is caring for a client who takes several medications. The client states, "I fast for several days each week to control my weight." The nurse should instruct the client that fasting increases the risk for medication toxicity due to what physiological factor?

1. When taking actions, the nurse should instruct that inadequate nutrition, such as from intermittent fasting, can decrease the level of plasma albumin, which decreases the protein-binding response of medications. This causes an increase in level of medication and increases the risk for medication toxicity.

1. A nurse is teaching a newly licensed nurse about contributing factors for sensory alterations. What contributing factors should the nurse include in the teaching?

1. When taking actions, the nurse should instruct that presbyopia, cataracts, glaucoma, diabetic retinopathy, macular degeneration, infection, inflammation, injury, or brain tumor are risk factors for vision loss. Obstruction, wax accumulation, tympanic membrane perforation, ear infections, or otosclerosis are risk factors for conductive hearing loss. Exposure to loud noises, ototoxic medications, aging, and acoustic neuroma are risk factors for sensorineural hearing loss. Xerostomia or reduced salivation are risk factors for taste deficit. Neurological deficits can result in peripheral numbness, and a stroke can result in loss of sensation and aphasia.

1. A nurse is providing information about how to reduce the risk of poisoning in infants and toddlers to a group of guardians. What information should the nurse include?

1. When taking actions, the nurse should recommend that the guardians keep house plants and cleaning agents out of reach; look for paint chips which can expose the infant to lead; have the poison control hotline readily available; place poisons, paint, and gasoline in a locked cabinet; keep medications, including vitamins, in child-proof containers and locked up; and dispose of unused medications.

10. A nurse is performing a head and neck examination for an older adult client. Which of the following age-related findings should the nurse expect? (Select all that apply.) A. Reddened gums B. Lowered vocal pitch C. Tooth loss D. Glare intolerance E. Thickened eardrums

10. A. Expect an older adult's gums to be pale. B. Expect an older adult's vocal pitch to rise. C. CORRECT: Tooth loss and gum disease are common in older adults. D. CORRECT: Older adults tend to become intolerant of glaring lights and also lose some ability to distinguish colors. E. CORRECT: Tympanic membranes (eardrums) thicken in older adults, and they tend to accumulate cerumen in their ear canals.

2. A nurse is conducting screening assessments for infants. Sort the findings by whether the nurse expects to observe them in infants under 6 months of age or infants 6 to 12 months of age. A. Development of object permanence B. Closure of posterior fontanel C. Presence of grasping reflex D. Sits without support E. Birth weight doubles

2. WITHIN FIRST 6 MONTHS: B, C, E; 6 TO 12 MONTHS: A, D When recognizing cues, the nurse should expect the grasping reflex to be present until 3 to 6 months of age. The nurse should expect the posterior fontanel to be closed by age 2 to 3 months. The nurse should expect the birth weight to double within the first 6 months. The nurse should expect the infant to realize that objects that can no longer be seen still exist by 7 to 9 months. The nurse should expect the infant to sit without support at 6 to 8 months.

2. A nurse is discussing complementary or alternative therapies with a newly licensed nurse. Match the therapy with the method. A. Muscles are stretched to promote relaxation. B. The spine is manipulated to promote healing. C. Needles are placed along meridians to produce analgesia. D. Instruments are used to visualize a body function to control a physiologic response. E. Herbal remedies are used to promote healing 1. Acupuncture 2. Massage therapy 3. Naturopathic medicine 4. Chiropractic medicine 5. Biofeedback

2. A, 2; B, 4; C, 1; D, 5; E, 3 When taking actions, the nurse should identify that acupuncture regulates vital energy by inserting needles along meridian pathways to produce analgesia or improve body function. Muscles are stretched and loosened to promote circulation and relaxation during massage therapy. Naturopathic medicine involves using herbal remedies to promote healing. Spine manipulation occurs during chiropractic medicine. Biofeedback involves using instruments to see or hear physiological data to gain voluntary control of a physiological response.

2. The nurse is reviewing the data on the client who has hypovolemia. The nurse should identify which of the following findings is a manifestation of hypovolemia? A. Increased Hct B. Increased blood pressure C. Decreased urine specific gravity D. Decreased urine output E. Elncreased sodium level

2. A, D, E. CORRECT: When analyzing cues, the nurse should identify that increased Het, decreased urine output, and increased sodium levels are expected findings for the client who has hypovolemia.

2. Which of the following actions should the nurse take when demonstrating an empathic presence to a client? (Select all that apply.) A. Use an open posture. B. Write down what the client says to avoid forgetting details. C. Establish and maintain eye contact. D. Nod in agreement with the client throughout the conversation. E. Sit facing the client.

2. A. CORRECT: Having an open posture, facing the client, and leaning forward are ways that can demonstrate an empathic presence. B. Writing down everything the client says can interfere with the ability to convey full attention and interest. C. CORRECT: Establishing and maintaining eye contact are ways that can demonstrate an empathic presence. D. If the nurse nods in agreement throughout the conversation, the client could interpret that as agreement with what the client is saying when instead the nurse meant to convey attending to and understanding what they are saying E. CORRECT: Sitting while facing the client directly can demonstrate an empathic presence. It also helps clients who have a hearing loss understand verbal communication.

2. A nurse is delivering an enteral feeding to a client who has an NG tube in place for intermittent feedings. When the nurse pours water into the syringe after the formula drains from the syringe, the client asks the nurse why the water is necessary. Which of the following responses should the nurse make? A. "Water helps clear the tube so it doesn't get clogged." B. "Flushing helps make sure the tube stays in place." C. "This will help you get enough fluids." D. "Adding water makes the formula less concentrated."

2. A. CORRECT: The nurse should take action by telling the client that flushing the tube after instilling the feeding will help keep the NG tube patent by clearing any excess formula from the tube so that it doesn't clump and clog the tube. B. A securing device, not flushing the tube with water, helps to maintain the position of the NG tube. C. The small amount used for flushing the NG tube will not ensure that the client receives enough fluids. D. Additional fluids will need to be administered. Dietary staff prepares the formula according to the prescription before the nurse instills it.

2. The client is experiencing difficulty swallowing. Which of the following cranial nerves controls swallowing? A. Glossopharyngeal B. Trigeminal C. Trochlear D. Hypoglossal

2. A. CORRECT: When analyzing cues, the nurse should identify that the glossopharyngeal nerve controls swallowing. The nurse tests the ability of the client to swallow by checking the client's gag reflex.

2. A nurse in a senior center is counseling a group of older adults about their nutritional needs and considerations. Which of the following information should the nurse include? (Select all that apply.) A. Older adults are more prone to dehydration than younger adults. B. The recommended intake of daily fiber decreases in older adults. C. Many older adults need calcium supplementation. D. Older adults need more calories than they did when they were younger. E. Older adults should consume a diet low in carbohydrates.

2. A. CORRECT: When taking actions, the nurse should include that sensations of thirst diminish with age, leaving older adults more prone to dehydration. B. CORRECT: The recommended amount of daily fiber intake decreases in the older adult due to their lower caloric intake. C. CORRECT: Many older adults need an increased intake of calcium, whether through their diet or through calcium supplements to help prevent bone demineralization (osteoporosis). D. Older adults have a slower metabolic rate, so they require less energy (unless they are very active), and therefore need fewer calories. E. Older adults should consume a healthy diet with an appropriate intake o conjures through a balanced diet vehle appropriate intake of calories through a balanced diet while limiting intake of fat, salt, refined sugars, and alcohol.

2. A nurse is caring for a client who has an oral temperature of 38.6° C (101.5° F), heart rate 114/min, and respiratory rate 22/min. Which of the following interventions should the nurse take? (Select all that apply.) A. Obtain culture specimens before initiating antimicrobials. B. Restrict the client's oral fluid intake. C. Encourage the client to rest and limit activity. D. Allow the client to shiver to dispel excess heat. E. Assist the client with oral hygiene frequently.

2. A. CORRECT: When taking actions, the nurse should obtain culture specimens before initiating antimicrobials to accurately detect the causative microorganism.. C. CORRECT: The nurse should encourage the client to rest and limit activity to conserve energy and decrease their metabolic rate.. E. CORRECT: The nurse should assist the client with oral hygiene frequently to promote comfort and reduce the risk of dry mucous membranes of the mouth and lips...

2. A nurse is counseling a young adult who describes having difficulty dealing with several issues. Which of the following statements should the nurse identify as the priority to assess further? A. "I have my own apartment now, but it's not easy living away from my guardians." B. "It's been so stressful for me to even think about having my own family." C. "I don't even know who I am yet, and now I'm supposed to know what to do." D. "My partner is pregnant, and I don't think I have what it takes

2. A. Living away from home and establishing independent living is nonurgent because it is an expected challenge during a young adulthood. There is another statement to identify as the priority. B. Transitioning from being single to being a member of a new family is nonurgent because it is an expected challenge during young adulthood. There is another statement to identify as the priority. C. CORRECT: The nurse should identify that when using the urgent vs. nonurgent approach to client care, the counseling priority is the problem that reflects a lack of completion of the previous stage of development and progression to the current stage. According to Erikson, it is a task of adolescence to develop identity vs. role confusion. The nurse should recognize this young adult is still struggling with this task and needs assistance in working through that dilemma. D. Considering childbearing and parenting is nonurgent because it is an expected challenge during young adulthood. There is another

2. A nurse is teaching a client how to check blood glucose levels. The nurse should include which of the following instructions about transferring blood onto the reagent portion of the test strip? A. Smear the blood onto the strip. B. Squeeze the blood onto the strip. C. Touch the puncture to stimulate bleeding. D. Hold the test strip next to the blood on the fingertip.

2. A. Smearing the blood on the test strip can cause inaccurate results. B. The client should milk the finger gently to obtain a drop of blood. Forceful milking or squeezing can cause pain, bruising, and scarring. C. Touching the puncture site can cause transfer of micro-organisms to the site. D. CORRECT: The nurse should take action by telling the client that holding the pad of the strip next to the puncture allows the blood to flow until the amount on the strip is adequate. Too little blood can result in falsely low readings.

2. A nurse is caring for a client whose partner passed sway 4 months ago. The client has a recent diagnosis of diabetes mellitus. The client is tearful and states, "How could you possibly understand what I am going through?" Which of the following responses should the nurse make? A. "It takes time to get over the loss of a loved one." B. "You are right. I cannot really understand. Perhaps you'd like to tell me more about what you're teding" C. "Why don't you try something to take your mind off your troubles, like watching a funny movie." D. "I might not share your exact situation, but i do know what people go through when they deal with a lons."

2. A. Telling the client it will take more time to heal belittles the client's feelings and gives false reassurance. B. CORRECT: The nurse should identify that by stating there is a lack of understanding, the nurse is using the therapeutic communication technique of validation, whereby a person shows sensitivity to the meaning behind a behavior. The nurse is also creating a supportive and nonjudgmental environment and inviting the client to express frustrations C. Telling the client to try a distraction dismisses the dients feelings and gives common advice instead of expert adrice. D. Saying the nurse knows what clients feel is presumptive and inappropriate.

2. A nurse is caring for a client who is postoperative. Which of the following interventions should the nurse take to reduce the risk of thrombus development? (Select all that apply.) A. Instruct the client not to perform the Valsalva maneuver. B. Apply elastic stockings. C. Review laboratory values for total protein level. D. Place pillows under the client's knees and lower extremities. E. Assist the client to change positions often.

2. A. The Valsalva maneuver increases the workload of the heart, but it does not affect peripheral circulation. B. CORRECT: When taking actions, the nurse should identify that elastic stockings promote venous return and prevent thrombus formation. C. A review of the client's total protein level is important for evaluating his ability to heal and prevent skin breakdown. D. Placing pillows under the knees and lower extremities •can impair circulation of the lower extremities. E. CORRECT: When taking actions, the nurse should identify that frequent position changes prevent venous stasis.

2. A nurse is preparing to administer a cleansing enema to a client. Place the steps the nurse should plan to take in the correct order. A. Slowly insert the rectal tube into the client's rectum. B. Warm the enema solution. C. Ask the client to retain the solution. D. Lubricate the end of the rectal tube. E. Hang the enema container 30 to 45 cm (12 to 18 in) above the client's anus.

2. B, D, A, E, C When taking actions, the nurse should first warm the enema solution to promote comfort. The next action the nurse should take is to lubricate the end of the rectal tube to promote comfort. The nurse should slowly insert the rectal tube about 7.5 to 10 cm (3 to 4 in) into the client's rectum to reduce the risk of injury of the rectal mucosa. The nurse should hang the enema container 30 to 45 cm (12 to 18 in) above the client's anus to allow for slow instillation of the solution. Finally, the nurse should ask the client to retain the solution for the prescribed amount of time, or until the client is no longer able to retain it to promote peristalsis and defecation.

2. A nurse is teaching a client how to self-administer ear drops. Which of the following client statements indicates an understanding of the teaching? A. "I will pull my ear down and back before I insert the drops." B. "I will gently apply pressure with my finger to the front part of my ear after putting in the drops." C. "I will chill my ear drops before I use them." D. "I will place a cotton ball into my inner ear canal after the drops are in."

2. B. CORRECT: When evaluating outcomes, the nurse should identify that the client understands the instructions to gently apply pressure to the tragus of the ear after putting in the drops to promote the instillation of the medication into the ear canal.

2. A nurse manager is assigning care of a client who is being admitted from the PACU following thoracic surgery. The nurse manager should assign the client to which of the following staff members? A. Nursing supervisor B. Registered nurse (RN) C. Practical nurse (PN) D. Assistive personnel (AP)

2. B. CORRECT: When taking actions, the nurse manager should identify that a client who is postoperative following thoracic surgery requires the professional nursing knowledge, skills, and judgment of an RN to provide safe and effective client care

2. A nurse is teaching a class about physiological factors that can alter how a medication can affect infants and older adults. Sort the following physiological factors into either infants or older adults. A. High body water content B. High percentage of body fat C. Increased blood flow to skin D. Decreased total body water

2. INFANTS: A, C OLDER ADULTS: B, D When taking actions, the nurse should instruct that pharmacokinetic factors that alter how a medication affects infants include high body water content, increased blood flow to skin which can increase absorption of topical medications, and immature liver. The nurse should instruct that pharmacokinetic factors that alter how a medication affects older adults include decreased total body water, higher percentage of body fat, and decreased liver enzymes. The nurse should provide the lowest medication dose possible to infants and older adults, and carefully monitor for adverse effects, to reduce the risk of toxicity.

2. A charge nurse is talking with a newly licensed nurse about nursing interventions that require a provider's prescription and nursing interventions that are nurse-initiated. Sort the following interventions into Nurse-Initiated or Provider-Initiated. A. Inserting a nasogastric tube to relieve gastric distention B. Showing a client how to use progressive muscle relaxation C. Performing a daily bath after the evening meal D. Repositioning a client every 2 hr to reduce pressure injury risk E. Wri

2. PROVIDER-INITIATED: A, E; NURSE-INITIATED: B, C, D When analyzing cues, the nurse should identify that nursing interventions that require a provider's prescription include prescription for medications and insertion of a nasogastric tube. Nurse-initiated interventions include showing a client how to use progressive muscle relaxation, performing an evening bed bath, and repositioning a client to reduce pressure injury risk.

2. A nurse caring for clients in an inpatient pediatric unit is planning age-appropriate activities. Sort the activities by whether they are more appropriate for Toddlers or for School-age children. A. Building simple models B. Painting C. Stacking blocks D. Reading chapter books E. Using toy carpentry tools

2. TODDLER: C, E; SCHOOL-AGE CHILDREN: A, B, D When generating solutions for age-appropriate activities, the nurse should plan activities for toddlers that are appropriate for their fine motor skill and cognitive development, including stacking blocks and using toy carpentry tools. The nurse should plan activities for school-age children that are appropriate for their fine motor skill and cognitive development, including building models, painting, and reading chapter books.

2. A nurse is examining a client's chest. Matching the name of the vertical chest landmarks with their location. uron jocaton. 1. Over the center of the sternum. 2. Extends down from the anterior axillary fold. 3. Runs down from the apex of the axillary 4. Is along the center of the spine. A. Midaxillary line B. Anterior axillary line C. Midsternal line D. The vertebal line

2. The midsternal line is through the center of the sternum. The anterior axillary line extends down from the anterior axillary fold. The midaxillary line runs down from the apex of the axilla and is between the anterior and posterior axillary line. The vertebral line is along the center of the spine.

2. A nurse is planning caring for a client who has a potassium level of 5.2 mEq/L. What actions should the nurse plan to take?

2. When generating solutions, the nurse should plan to implement continuous ECG monitoring because the client is at risk for dysrhythmias. The nurse should stop infusion of IV potassium and withhold oral potassium. Provide a potassium-restricted diet for the client. Administer IV fluids with dextrose and regular insulin as prescribed to promote the movement of potassium from the ECF to the IF, maintain IV access, monitor serum potassium levels and prepare the client for dialysis if prescribed, administer Sodium Dolvstvrene sulfonate as prescribed. Administer loop diuretics if kidney function is adequate to increase the excretion of potassium from the renal system. Administer sodium polystyrene sulfonate to increases the excretion of potassium from the gastrointestinal system if prescribed.

2. The nurse is preparing to administer a medication to the client. What actions should the nurse take?

2. When taking actions, the nurse should avoid distractions during medication preparation because interruptions increase the risk of error. The nurse should prepare the medication for one client at a time, carefully check the label for the medication's name and concentration. Measure doses accurately and double-check dosage calculations with a colleague. Check the medication's expiration date. Follow the rights of medication administration consistently. Take the MAR to the client's bedside. The nurse should give only medications that the nurse has prepared. The nurse should not administer a medication prepared by someone else. The nurse should follow all laws and regulations for preparing and administering controlled substances. Keep the controlled substances in a secure area. Have another nurse witness the discarding of unused controlled substances.

3. A nurse is reviewing CDC immunization recommendations with a young adult client. Which of the following vaccines should the nurse recommend as routine, rather than catch-up, during young adulthood? (Select all that apply) A. Influenza B. Measles, mumps, rubella C. Pertussis D. Tetanus E. Polio

3. A, C, D. CORRECT: The nurse should identify that the CDC recommends an annual influenza immunization, a booster dose of pertussis vaccine, and a booster dose of diphtheria and ongoing booster doses of tetanus during adulthood. B. The CDC recommends obtaining the measles, mumps, and rubella vaccines routinely during childhood. The series can be administered during adulthood for individuals who meet certain criteria. E. The CDC recommends the polio vaccine to be administered routinely during childhood. The series can be administered during adulthood for individuals who meet certain criteria.

3. A nurse in a residential care facility is assessing an older adult client. Which of the following findings should the nurse identify as atypical indications of infection in this client? (Select all that apply.) A. Urinary incontinence B. Malaise C. Acute confusion D. Fever E. Agitation

3. A, C, E. CORRECT: When recognizing cues during the assessment of an older adult client, the nurse should identify that urinary incontinence, acute confusion, and agitation are atypical indications of infection in the older adult client. B. Malaise is a typical indication of infection. D. Fever is a typical indication of infection.

3. A nurse is assessing a client's thyroid gland as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply.) A. Palpating the thyroid in the lower half of the neck B. Visualizing the thyroid on inspection of the neck C. Hearing a bruit when auscultating the thyroid D. Feeling the thyroid ascend as the client swallows E. Finding symmetric extension off the trachea on both sides of the midline

3. A. CORRECT: The thyroid is located in the anterior lower neck on both sides of the trachea. B. An average-sized thyroid gland is not visible on inspection. Visualization of the thyroid gland could indicate a thyroid disorder. C. A bruit indicates increased blood flow and can indicate hyperthyroidism. D. CORRECT: When a client swallows a sip of water, the nurse should expect to feel the thyroid move upward with the trachea. E. CORRECT: The thyroid gland lies in front of the trachea and extends symmetrically to both sides of the midline.

3. A nurse is instructing a client, who has an injury of the left lower extremity, about the use of a cane. Which of the following instructions should the nurse include? (Select all that apply.) A. Hold the cane on the right side. B. Keep two points of support on the floor. C. Place the cane 38 cm (15 in) in front of the feet before advancing. D. After advancing the cane, move the weaker leg forward. E. Advance the stronger leg so that it aligns evenly with the cane.

3. A. CORRECT: When taking actions, the nurse should Instruct the client to hold the cane on the uninjured side to provide support for the injured left leg. B. CORRECT: When taking actions, the nurse should instruct the client to keep two points of support on the ground at all times for stability. C. The client should place the cane 15 to 25 cm (6 to 10 in) in front of their feet before advancing. D. CORRECT: When taking actions, the nurse should instruct the client to advance the weaker leg first, followed by the stronger leg. E. The client should advance the stronger leg past the cane.

3. A nurse is using the FICA screening tool to gather more data about a client's interfaith needs. Which of the following questions should the nurse ask when using the tool? A. "What gives you a sense of purpose?" B. "Who inspires you?" C. "How has this condition affected you?" D. "Do you have a communication barrier?"

3. A. CORRECT: When using the FICA screening tool, the nurse should ask open-ended questions to gather more information about the client's interfaith needs. The nurse should ask questions to check the client's faith, implications/ influence, community, and address. "What gives you a sense of purpose?" is an appropriate question to ask because this is addressing the client's faith. "Who inspires you?", "how has this condition affected you?", and "do you have a communication barrier?" are not appropriate questions to ask because they will not address the client's interfaith needs.

3. A nurse is teaching a newly licensed nurse who is caring for a client who is receiving enteral feedings, how to administer medications through a jejunostomy tube. Which of the following instructions should the nurse include? A. "Flush the tube before and after each medication." B. "Mix the medications with the enteral feeding." C. "Use a parenteral syringe to administer the medications." D. "Combine multiole medications together to administer at the same time."

3. B. CORRECT: When taking actions, the nurse should instruct the newly licensed nurse to flush the jejunostomy tube before and after administering each medication to reduce the risk of clogging the tube.

3. A nurse is preparing to instill an enteral feeding for a client who has an NG tube in place. Which of the following actions is the nurse's highest assessment priority before performing this procedure? A. Check how long the feeding container has been open. B. Verify the placement of the NG tube. C. Confirm that the client does not have diarrhea. D. Make sure the client is alert and oriented.

3. A. Checking that the container has not exceeded its expiration date, either for having it open or for opening it, is important. However, there is a higher assessment priority among these options. B. CORRECT: The nurse should prioritize hypotheses by identifying that the greatest risk to the client receiving enteral feedings is injury from aspiration. The priority nursing assessment before initiating an enteral feeding is to verify proper placement of the NG tube. C. Assess the client for any possible complications of enteral feedings (diarrhea) is important. However, there is another assessment that is the priority. D. Determining the client's level of consciousness as an assessment parameter should precede any procedure. However, another assessment is the priority.

3. A nurse is caring for a client who is 3 days postoperative following a below-the-knee amputation as a result of a motor-vehicle crash. Which of the following statements indicates that the client has a distorted body image? A. "I'll be able to function exactly as I did before the accident." B. "I just can't stop crying." С. "I am so mad at that guy who hit us. I wish he lost a leg." D. "I don't even want to look at my leg. You can check the dressing.

3. A. Denial is a normal and expected reaction when adjusting to body changes. B. Depression and sadness are normal and expected reactions when adjusting to body changes. C. Anger is a normal and expected reaction when adjusting to body changes. D. CORRECT: This would imply a distorted body image. The nurse should identity that refusing to look at the leg or the dressing indicates that the client is having difficulty acknowledging the fact that the leg has been amputated.

3. A nurse is collecting data to evaluate a middle adult's psychosocial development. The nurse should expect middle adults to demonstrate which of the following developmental tasks? (Select all that apply.) A. Develop an acceptance of diminished strength and increased dependence on others. B. Spend time focusing on improving job performance. C. Welcome opportunities to be creative and productive. D. Commit to finding friendship and companionship. E. Become involved with community issues and acti

3. A. Identify acceptance of diminished strength and increased dependence as a developmental task for older adulthood. B. CORRECT: Psychosocially healthy middle adults strive to do well in their environment as part of achieving Erikson's stage of generativity vs. stagnation. C. CORRECT: Psychosocially healthy middle adults accept life's opportunities for creativity and productivity and use these opportunities for achieving Erikson's stage of generativity vs. stagnation. D. Identify seeking and forming friendships as a developmental task of young adulthood. E. CORRECT: Psychosocially healthy middle adults work to contribute to future generations through community involvement and parenting as part of achieving Erikson's stage of generativity vs. stagnation.

3. A nurse is providing instructions about foot care to a client who has diabetes mellitus. Which of the following instructions should the nurse include? (Select all that apply.) A. Wear wool socks. B. Apply lotion between the toes. C. Wash the feet daily, using warm water. D. Warm the feet using a heating pad. E. Smooth the edges of the toenails with an emery board.

3. A. The nurse should instruct the client to wear cotton socks because cotton can absorb excessive moisture. B. The client should apply lotion to the feet to moisten the skin but avoid applying lotion between the toes because this action can lead to skin breakdown and possible infection. C. CORRECT: Clients who have diabetes mellitus often experience neuropathy, which can lead to loss of sensation; therefore, the client should wash the feet daily using warm, not hot, water because they cannot determine when the water is too hot. D. The client should warm the feet using socks and blankets. Due to lack of sensation, the use of heating pads or hot water bottles places the client at risk for burns. E. CORRECT: The client should trim the toenails every week and use an emery board or nail file to smooth the edges.

3. A nurse in a provider's office is performing a physical examination of an adult client. Which part of the hands should the nurse use during palpation for optimal assessment of skin temperature? A. Palmar surface B. Fingertips C. Dorsal surface D. Base of the fingers

3. A. The palmar surface of the hands is especially sensitive to vibration, not temperature. B. The fingertips are sensitive to pulsation, position, texture, size, and consistency, not temperature. C. CORRECT: The nurse should identify that the dorsal surface of the hand is the most sensitive to temperature D. The base of the fingers is especially sensitive to vibration, not temperature.

3. A nurse is planning a presentation for a group of older adults about health promotion and disease prevention. Which of the following interventions should the nurse plan to include in the presentation? (Select all that apply.) A. Human papilloma virus (HPV) immunization B. Pneumococcal immunization C. Yearly eye examination D. Periodic mental health screening E. Annual fecal occult blood test

3. B, C, D, E. CORRECT: The nurse should plan to include information about pneumococcal vaccines, specifically, PCV15, PCV20, and PPSV23. The nurse should also include information about a yearly eye examination to screen for glaucoma and vision changes, periodic mental health assessments, and an annual fecal occult blood test for the group of older adult clients. A. The HPV vaccine is recommended for female clients from age 11 to 26 and male clients from age 9 to 20. It is not a recommendation for older adults

3. A nurse is caring for a client who has an indwelling. urinary catheter. Which of the following actions should the nurse take? (Select all that apply.) A. Empty the client's urinary drainage bag when it is ¾ full. B. Keep the urinary drainage bag below the level of the client's bladder. C. Assess the client's need for the indwelling urinary catheter daily. D. Rest the urinary collection bag on the floor when the client is sitting in a chair. E. Maintain a closed system of the client's urinary catheter. 4. A nurse is teaching a client who reports stress urinary incontinence What inctructions should the nurse include?

3. B, C, E. CORRECT: When taking actions, the nurse should keep the urinary drainage bag below the level of the client's bladder to reduce the risk of urine draining back into the client's bladder. The nurse should assess the need for the indwelling urinary catheter daily and maintain a closed urinary drainage system, to reduce the risk for a CAUTI.

3. A nurse is reviewing the CDC's immunization recommendations with the guardians of an adolescent. Which of the following recommendations should the nurse include in this discussion? (Select all that apply.) A. Rotavirus B. Varicella C. Herpes zoster D. Human papilloma virus E. Seasonal influenza

3. B, D, E. CORRECT: When taking action and reviewing the CDC's immunization recommendations with the caregivers of an adolescent, the nurse should include the varicella, human papilloma, and seasonal Influenza immunizations as immunizations that are recommended during adolescence. A. The CDC recommends rotavirus immunizations during infancy and not generally beyond 8 months of age. C. The CDC recommends herpes zoster (shingles) immunizations during middle adulthood, typically one dose at age 60 or beyond.

3. A nurse is teaching an older adult client about medication self-administration. Which of the following instructions should the nurse include? (Select all that apply.) A. Adjust doses to daily weight. B. Place pills in daily pill holders. C. Set up a daily calendar with medication reminders. D. Ask a relative to assist as needed. E. Request child-resistant caps on medication containers.

3. B. CORRECT: When taking actions, the nurse should instruct the client to place pills in a daily pill holder, to promote adherence to medication regimen. C. CORRECT: When taking actions, the nurse should instruct the client to set up a daily calendar as a reminder to take medications, to promote adherence to medication regimen. D. CORRECT: When taking actions, the nurse should instruct the client to ask a relative to assist as needed, to promote adherence to medication regimen.

3. The nurse is teaching the newly licensed nurse about complications of IV therapy. Sort the following findings into infiltration or phlebitis. A. Localized warmth B. Cool to touch C. Red line D. Pallor

3. INFILTRATION: B, D; PHLEBITIS: A, C When taking actions, the nurse should instruct the newly licensed nurse that manifestations of infiltration include pallor, local swelling at the site, decreased skin temperature around the site, damp dressing, and slowed rate of infusion. Manifestations of phlebitis include edema, throbbing, burning, or pain at the site, increased skin temperature, erythema, a red line up the arm with a palpable band at the vein site, and slowed rate of infusion.

3. A nurse is teaching a newly licensed nurse about interventions for clients who have sensory deprivation or overload. Sort the following interventions into those that should be implemented for clients who have sensory deprivation and those that should be implemented for clients who have sensory overload. A. Encourage the client's family to visit with the client. B. Provide a private room for the client. C. Limit visitors for the client. D. Dim lighting in the client's room. E. Increase the ringer volume on the client's phone. F. Communicate frequently with the client

3. SENSORY DEPRIVATION: A, E, F SENSORY OVERLOAD: B, C, D When taking actions, the nurse should encourage visitors, increase the ringer volume on the client's phone, and communicate frequently with the client who has sensory deprivation to provide meaningful stimulation for the client. The nurse should provide a private room, limit visitors, and dim lights for clients who have sensory overload to minimize stimulation.

3. A home health nurse is educating a new home health aide about home safety for the older adult. What information should the nurse include?

3. When generating solutions, the home health nurse should remind the new home health aide that items such as throw rugs and loose carpets should be removed and electric cords and extension cords should be against the wall and behind furniture because they could cause the client to trip; steps and sidewalks should be in good repair; grab bars should be installed near the toilet, shower and tub; a stool riser should be used; a nonskid mat should be in the shower or tub; a shower chair and a beside commode might be necessary; there should be adequate lighting both inside and outside the home; and all clutter should be removed.

3. The nurse is planning care for the client who is admitted to an acute care facility with dehydration. What actions should the nurse include in the plan?

3. When generating solutions, the nurse should plan to monitor the client's respiratory rate, oxygen saturation and administer supplemental oxygen as prescribed, check the client's urinalysis, CBC, and electrolytes, and alert the provider for a urine output less than 30 mL/hr. The nurse should measure the client's weight daily at same time of day using the same scale, observe for nausea and vomiting, assess for blood pressure for postural hypotension, and encourage the client to change positions slowly and to use the call light and ask for assistance before getting out of bed. The nurse should check the client's neurologic status, observe level of gait stability, assess heart rhythm, initiate, and maintain IV access, provide oral and IV rehydration therapy as prescribed, monitor I&O, and encourage fluids as tolerated.

3. A nurse is performing a peripheral vascular assessment of the lower extremities on a client who is postoperative following knee surgery. What information should the nurse include in the assessment?

3. When taking actions, the nurse should check and compare the skin color and temperature of the client's lower extremities. Pallor, cyanosis, and coolness are manifestations of inadequate circulation. The nurse should check and compare the pulses of the client's lower extremities. A decreased pulse strength indicates impaired circulation to the client's legs. The nurse should assess the client for the presence of edema. Edema is a manifestation of inadequate venous circulation and should be reported.

3. A nurse is administering a cleansing enema to a client who reports abdominal cramping. What actions should the nurse take?

3. When taking actions, the nurse should slow the flow of the solution by lowering the container. Slowing the flow of the enema should decrease abdominal cramping. If the client is experiencing severe abdominal cramping, stop the enema, assess the client's vital signs, and notify the provider.

4. A nurse at a clinic is collecting data about pain from of a client who reports severe abdominal pain. The nurse asks the client if there has been any accompanying nausea and vomiting. Which of the following pain characteristics is the nurse attempting to determine? A. Presence of associated manifestations B. Location of the pain C. Pain quality D. Aggravating and relieving factors

4. A. CORRECT: When asking the client if they are also experiencing nausea and vomiting with their pain, the nurse is assessing the presence of associated manifestations. B, C, D. The nurse should also include the location of the pain, the pain quality, and any aggravating and relieving factors when assessing pain.

4. A nurse is planning activities for toddlers on an inpatient unit. Sort the following activities into those that are considered Safe for toddlers and those that are considered Unsafe for toddlers. A. Playing with toys that contain small parts B. Looking at books C. Playing with blocks D. Playing with balloons E. Tossing a ball

4. SAFE: B, C, E; UNSAFE: A, D When taking actions, the nurse should identify that playing with balloons and playing with toys that contain small parts are considered unsafe activities for toddlers. Toddlers might place balloon fragments or small objects in their mouth, which can lead to choking or aspiration. Looking at books, playing with blocks, and tossing a ball, are considered safe activities for toddlers. These activities promote fine motor skills, imagination, and provide sensory stimulation.

4. A nurse is teaching a class about fluid imbalances. Sort the following manifestations into either Hypovolemia or Hypervolemia. A. Breath sounds with crackles B. Weight gain C. Decreased urine specific gravity D. Flat neck veins E. Sunken eyeballs

4. HYPOVOLEMIA: D, E HYPERVOLEMIA: A, B, C When taking action, the nurse should instruct that crackles heard in lungs, weight gain, and decreased urine specific gravity are manifestations of hypervolemia. Flat neck veins and sunken eyeballs are manifestations of hypovolemia. © NCLEX® Connection: Physiological Adaptation, Fluid and Electrolyte Imbalances

4. A nurse is teaching clients about their medications. Match the following medication category to the corresponding nursing instructions. A. Immunosuppressant B. Antihypertensive C. Anticoagulant D. Anticholinergic 1. Change positions slowly. 2. Monitor for bruising. 3. Monitor for an infection. 4. Wear sunglasses when outside.

4. A, 3 B, 1 C, 2 D, 4 When taking actions, the nurse should instruct a client who is taking an antihypertensive to change positions slowly to reduce the risk of postural hypotension. The nurse should instruct a client who is taking an anticoagulant to monitor for manifestations of bleeding, such as bruising or dark tarry stools. The nurse should instruct a client who is taking an immunosuppressant to monitor for manifestations of an infection, such as a fever or sore throat. The nurse should instruct a client who is taking an anticholinergic to wear sunglasses when outside to reduce photophobia.

4. The nurse is assessing the client. Which of the following findings are a manifestation of fluid overload? (Select all that apply.) A. Respiratory rate B. Blood pressure C. Heart rate D. Pedal pulses E. Neurological status

4. A, B, C. CORRECT: When analyzing cues, the nurse should identify manifestations of fluid overload include distended neck veins, increased blood pressure, tachycardia, shortness of breath, crackles in the lungs, and edema.

4. A nurse is preparing to inspect the ears, nose, mouth, and throat of a client. Which of the following equipment does the nurse need? A. Ophthalmoscope B. Tongue blade C. Penlight D. Gauze square E. Stethoscope

4. A. An ophthalmoscope is used to examine a client's eyes. B. CORRECT: When examining the ears, mouth a nose of a client, the nurse needs a tongue blade to examine the client's tongue on all sides and the floor of the mouth. C. CORRECT: A penlight to examine the color, size, position, and texture of the tongue. D. CORRECT: A gauze square to grasp the tongue during the examination. E. A stethoscope is used when the nurse is performing auscultation.

4. A nurse is caring for a client in a long-term care facility who is receiving enteral feedings via an NG tube. Which of the following actions should the nurse complete prior to administering the tube feeding? (Select all that apply.) A. Auscultate bowel sounds. B. Assist the client to an upright position. C. Test the pH of gastric aspirate. D. Warm the formula to body temperature. E. Discard any residual gastric contents.

4. A. CORRECT: The nurse should take action by auscultating for bowel sounds and ensure the client's gastrointestinal tract is able to absorb nutrients. B. CORRECT: The nurse should place the client in an upright position, with at least a 30° elevation of the head of the bed. An upright positioning helps prevent aspiration. C. CORRECT: Testing the pH of gastric aspirate is an acceptable method between x-ray confirmations. D. The nurse should have the enteral formula at room temperature before administering the feeding. E. The nurse should return the residual to the client's stomach, unless the volume of gastric contents is more than 250 mL, or the facility has other guidelines in place.

4. A nurse is preparing to admit a client who is suspectéd to have pulmonary tuberculosis. Which of the following actions should the nurse plan to perform first? A. Implement airborne precautions. B. Obtain a sputum culture. C. Administer antituberculosis medications. D. Recommend a screening test for family members.

4. A. CORRECT: When generating solutions while preparing to admit a client who is suspected to have pulmonary tuberculosis, the nurse should plan to first implement airborne precautions. The greatest safety risk to the nurse and others is transmission of the infection from airborne exposure to tuberculosis. B. The nurse should plan to obtain a sputum culture to help confirm the diagnosis, but another action is the priority.. C. The nurse should plan to administer medications to treat tuberculosis, but another action is the priority.. D. The nurse should plan to recommend screening tests for those in close contact with the client to determine whether they need antibiotic therapy, but another action is the priority.

4. A nurse is planning care for a client who is on bed rest. Which of the following interventions should the nurse plan to implement? A. Encourage the client to perform antiembolic exercises every 2 hr. B. Instruct the client to cough and deep breathe every 4 hr. C. Restrict the client's fluid intake. D. Reposition the client every 4 hr.

4. A. CORRECT: When generating solutions, the nurse should encourage the client to perform antiembolic exercises every 1 to 2 hr to promote venous return and reduce the risk of thrombus formation. B. The nurse should instruct the client to cough and deep breathe every 1 to 2 hr to reduce the risk of atelectasis. C. The nurse should increase the client's intake of fluids, unless contraindicated, to reduce the risk of thrombus formation, constipation, and urinary dysfunction. D. The nurse should plan to reposition the client every 1 to 2 hr to reduce the risk for pressure injuries.

4. A nurse is obtaining a health history for a client's comprehensive physical examination. After inspecting the client's abdomen, which of the following skills of the physical examination process should the nurse perform next? A. Olfaction B. Auscultation C. Palpation D. Percussion

4. A. Olfaction is the use of the sense of smell to detect any unexpected findings that cannot be detected via other means (a fruity breath odor). Unless there is an open lesion on the client's abdomen, this is not the next step in an abdominal examination. B. CORRECT: The nurse should identify that because palpation and percussion can alter the frequency and intensity of bowel sounds, auscultation of the abdomen should occur next. C. Palpation is the next step in examining other areas of the body, but not the abdomen. D. Percussion is important for detecting gas, fluid, and solid masses in the abdomen, but it is not the next step in an abdominal assessment.

4. A nurse is caring for a family who is experiencing a crisis. Which of the following approaches should the nurse use when working with a family using an open structure for coping with crisis? A. Prescribing tasks unilaterally B. Delegating care to one member C. Speaking to the primary client privately D. Convening a family meeting

4. A. Prescribing tasks and delegating care is too rigid for acceptance by a family with an open structure. B. Prescribing tasks and delegating care is too rigid for acceptance by a family with an open structure. C. Speaking to the primary client privately excludes the family. D. CORRECT: The nurse should identify that an open structure is loose and convening a family meeting would give all family members inout and an opportunity to express their felings.

4. A nurse is caring for a client who is at high risk for aspiration. Which of the following actions should the nurse take? A. Giving the client thin liquids B. Instructing the client to tuck their chin when swallowing C. Having the client use a straw D. Encouraging the client to lie down and rest after meals

4. A. Thin liquids increase the client's risk for aspiration. B. CORRECT: When taking actions, the nurse should identify that tucking the chin when swallowing allows food to pass down the esophagus more easily. C. Using a straw increases the client's risk for aspiration. D. Sitting for an hour after meals helps prevent gastroesophageal reflux and possible aspiration of stomach contents after a meal.

4. A nurse is preparing to inject heparin subcutaneously for a client who is postoperative. Which of the following actions should the nurse take? A. Use a 22-gauge needle. B. Select a site on the client's abdomen. C. Use the Z-track technique to displace the skin on the injection site. D. Observe for bleb formation to confirm proper placement.

4. B. CORRECT: When generating solutions, the nurse should plan to administer the heparin subcutaneously into the client's abdomen, thighs, or lateral upper arms. This location should have adequate subcutaneous fat which decreases the risk for a hematoma.

4. A nurse is preparing to perform endotracheal suctioning for a client. Place the following actions in the proper order. A. Apply suction intermittently by covering and releasing the suction port with the thumb for 10 to 15 seconds. B. Assist the client to high-Fowler's or Fowler's position for suctioning if possible. C. Don the required personal protective equipment. D. Encourage the client to breathe deeply and cough in an attempt to clear the secretions without artificial suction. E. Obtain baseline breath sounds and vital signs, including SaO2 by pulse oximeter. Can monitor SaOz continually during the procedure. F. Pull the catheter back 1 cm (0.4 in) prior to applying suction. G. Reattach the BVM or ventilator and administer 100% oxygen. H. Rinse catheter and suction tubing with sterile saline until clear. 1. Remove the bag or ventilator from the tracheostomy or endotracheal tube and insert the catheter into th

4. C B D E I F A G H

4. A nurse is providing teaching for an older adult client who has lost 4.5 kg (9.9 lb) since the last admission 6 months ago. Which of the following instructions should the nurse include in the teaching? (Select all that apply.) A. "Eat three large meals a day." B. "Eat your meals in front of the television." C. "Eat foods that are easy to eat, such as finger foods." D. "Invite family members to eat meals with you." E. "Exercise every day to increase appetite."

4. C, D, E. CORRECT: The nurse should instruct the client to involve family members with meals and to eat finger foods because finger foods are easier for the older adult client to eat. Socialization during meals promotes nutritional intake, and daily exercise increases appetite. A. The nurse should educate the client to eat small frequent meals and to avoid distractions during meals to increase nutritional intake. B. The nurse should educate the client to eat small frequent meals and to avoid distractions during meals to increase nutritional intake.

4. A nurse is teaching a class about expected changes associated with aging. What information should the nurse include?

4. When recognizing cues, the nurse should instruct that expected changes that can occur with aging can include reduced muscle mass, decline in speed, strength, resistance to fatigue, reaction time, and coordination, decalcification of bones can lead to loss of bone mass and height, and an increasing risk for osteoporosis. Other changes that can occur include minimal decline in short-term memory, decreased vision, hearing, taste, smell, and touch.

4. A nurse is caring for a client who tells the nurse that, based on religious values and mandates, a blood transfusion is not an acceptable treatment option. What actions should the nurse take?

4. When taking actions, the nurse should demonstrate culturally responsive care and show respect for the client's religious beliefs. The nurse should have the provider discuss the necessity for a blood transfusion, alternatives to the use of blood products, and allow the client to make an informed decision.

4. A nurse is caring for a client who is scheduled for abdominal surgery. The client reports being worried. What interventions can the nurse implement to reduce the client's anxietv?

4. When taking actions, the nurse should implement complementary and alternative therapies to promote relaxation and reduce the client's anxiety. The nurse should use therapeutic communication to allow the client to verbalize their fears and anxieties. The nurse can assist the client in relaxation therapies, such as guided imagery, healing intention, breath work, humor, meditation, simple touch, music or art therapies, and passive or progressive relaxation.

4. A nurse is teaching a client who is in the first trimester of pregnancy about medications. What instructions should the nurse include in the teaching?

4. When taking actions, the nurse should instruct that pregnancy is a contraindication for live-virus vaccines, including rubella, due to possible teratogenic effects. Most medications, including over-the-counter, are potentially harmful to the fetus. The client should avoid any medications unless prescribed by the provider. Nutritional supplements that include iron are prescribed during pregnancy to support the health of the mother and fetus, Providers can prescribe medications to treat nausea and other discomforts of pregnancy.

5. A nurse is teaching a newly licensed nurse about administering injections. Match the injection method to the associated information. A. Intradermal B. Subcutaneous C. Intramuscular 1. Use a 45° angle 2. Can inject up to 3 mL 3. Observe for a small bleb

5. A, 3 B, 1 C, 2 When taking actions, the nurse should instruct to observe for a small bleb when administering an intradermal medication. The nurse should use a 45° angle when administering a subcutaneous medication. Intramuscular injections can inject up to 3 mL of fluid.

5. A nurse is caring for a client who is concerned about being discharged to home with a new colostomy because of being an avid swimmer. Which of the following statements should the nurse make? (Select all that apply) A. "You will do great! You just have to get used it" B. "Why are you worried about going home?" C. "Your daily routines will be different when you get home." D. "Tell me about the support system you'll have after you leave the hospital." E. "It sounds like you are not sure how having a colostomy will affect swimming."

5. A Giving false reassurance and minimizing the client's feelings are both barriers to effective communication. B. Although this might appear to help the client discuss their feelings, asking a "why" question is a barrier to effective communication, because it could make the client react defensively. C. CORRECT: Presenting reality is an effective communication technique that can help the client focus on what will really happen after the changes the surgery has made. D. CORRECT: Asking open-ended questions and offering general leads and broad opening statements are effective communication techniques that encourage the client to express feelings through dialogue and offer additional information. E CORRECT: Focusing is an effective communication technique that clearly directs the interaction to the relevant point.

5. A nurse is preparing a wellness presentation for families about health screening for adolescents. Which of the following information should the nurse include? (Select all that apply.) A. Obtain a periodic mental status evaluation. B. Discuss prevention of sexually transmitted infections. C. Regularly screen for tuberculosis. D. Provide education about drug and alcohol use. E. Teach monthly breast examinations.

5. A, B, C, D. CORRECT: When generating solutions for a wellness presentation for families about health screening for adolescents, the nurse should include that adolescent should have occasional mental status evaluations. The nurse should also include interventions to prevent sexually transmitted infections, periodic screening for tuberculosis, and education about drug and alcohol use. E. Monthly breast examinations are no longer recommended for the detections of breast cancer.

5. A nurse in a provider's office is documenting findings following an examination performed for a client new to the practice. Which of the following parameters should the nurse include as part of the general survey? (Select all that apply.) A. Posture B. Skin lesions C. Speech D. Allergies E. Immunization status

5. A, B, C. CORRECT: The nurse should identify that posture and skin lesions are part of the body structure or general appeararc portion of the general survey. Speech is part of the behavior portion of the general survey. Allergies and immunization stats are part of the health history, not the general survey.

5. A nurse is reviewing safety precautions with a group of young adults at a community health fair. Which of the following recommendations should the nurse include to address common health risks for this age group? (Select all that apply.) A. Install bath rails and grab bars in bathrooms. B. Wear a helmet while skiing. C. Install a carbon monoxide detector. D. Secure firearms in a safe location. E. Remove throw rugs from the home.

5. A. Although bath rails and grab bars add a measure of safety to bathing activities, this recommendation addresses health risks common to the older adult population due to their risk for falls. B. CORRECT: The nurse should encourage the client to wear a helmet while skiing to reduce the risk of head injury. Although it applies to other age groups, many young adults engage in winter sports. Therefore, this is an age-appropriate recommendation for this developmental group. C. CORRECT: The nurse should remind the client to install a carbon monoxide detector in the home. This is an essential safety precaution for young adults as well as for all other developmental stages. D. CORRECT: The nurse should warn the client to secure firearms in a safe location to reduce the risk of accidental gunshot injuries. Although it applies to all age groups, many young adults own firearms, so this is an age-appropriate recommendation for this developmental group. E. Throw rugs can pose a safety hazard, t

5. A nurse is caring for a ellent who has left-sided hemiplegia resulting from a cerebrovascular accident. The client works as a carpenter and is now experiencing a situational role change based on physical limitations. The client Is the primary wage earner in the family. Which of the following describes the client's role problem? A. Role conflier B. Role overload C. Role ambiguity D. Role strain

5. A. CORRECT: The nurse should identify that the client is experiencing role conflict because their career is extremely physical and they can no longer perform the job duties. However, the client is the primary wage earner in the family. B. Although the client can feel overloaded and overwhelmed, role overload occurs when the client is trying to juggle too many roles. C. The client is not experiencing role ambiguity because their job duties and physical limitations are quite clear. D. The client is not experiencing role strain. That occurs when one feels inadequate for assuming a role.

5. A nurse is preparing a health promotion course for a group of middle adults. Which of the following strategies should the nurse recommend? (Select all that apply.) A. Eve examination every 1 to 3 years B. Decrease intake of calcium supplements C. DXA screening for osteoporosis D. Increase intake of carbohydrate in the diet E. Screening for depressive disorders

5. A. CORRECT: The nurse should recommend middle adult clients have an eye examination every 1 to 3 years to screen for glaucoma and other disorders. B. The nurse should recommend that middle adult clients, especially females, increase intake of vitamin D and calcium to prevent osteoporosis. C. CORRECT: Middle adults should have a DXA scan to screen for osteoporosis, obtain adequate protein, and consume more fresh fruits, vegetables and whole grains. D. CORRECT: Middle adults should have a DXA scan to screen for osteoporosis, obtain adequate protein, and consume more fresh fruits, vegetables and whole grains. E. CORRECT: The nurse should also recommend screening for anxiety and depression during middle adulthood

5. A home health nurse is assessing a client who experienced extreme exposure to heat and has a body temperature of 40°C (104°F). The nurse should anticipate that the client will display which of the following manifestations? A. Hypotension B. Bradycardia C. Clammy skin D. Bradypnea

5. A. CORRECT: When analyzing clues, the home health nurse should recognize that manifestations of heat stroke include hypotension, tachycardia, hot, dry skin and dyspnea.

5. A nurse is assessing a client who is reporting pain despite taking analgesia. Which of the following actions should the nurse take to determine the intensity of the client's pain? A. Ask the client what precipitates the pain. B. Question the client about the location of the pain. C. Offer the client a pain scale to measure their pain. D. Use open-ended questions to identify the client's pain sensations.

5. C. CORRECT: When assessing the intensity of a client's pain, the nurse should use a numeric, verbal, or visual analog scale that is appropriate to the client's individual needs the nurse to help the client report the intensity of their pain. A, B, D. When conducting a full pain assessment, the nurse should also ask what precipitates the client's pain to determine the cause of the pain, ask the location of the client's pain to help determine the cause or classify the pain as deep, subcutaneous, or radiating, and ask open-ended questions about the client's pain sensation to help determine the quality of the pain (exhausting, tight, or burning).

5. A nurse is teaching a client who is lactating about taking medications. Which of the following instructions should the nurse include? A. Drink 8 oz of milk with each dose of medication. B. Use sustained-release medications. C. Take medications right after breastfeeding. D. Pump breast milk and freeze it prior to feeding.

5. C. CORRECT: When taking actions, the nurse should instruct the client to take medications immediately after breastfeeding to minimize medication concentration in the next feeding. This action reduces the risk of harm to the infant.

5. A nurse is caring for a client who is taking cimetidine and imipramine. Knowing that cimetidine decreases the metabolism of imipramine, what are the potential effects of this combination?

5. When analyzing cues, the nurse should identify that the client is at risk for imipramine toxicity. A medication that decreases the metabolism of another medication increases the blood level of that medication which can result in toxicity.

5. A nurse enters the room of a client who is reading from a religious book. The client begins to cry and asks to be left alone. What actions should the nurse take?

5. When taking actions, the nurse should demonstrate culturally responsive care and show respect to the client by providing time for the client to be alone. The nurse should close the door to the client's room and give the client time without interruption to pray and reflect. After giving the client quiet, uninterrupted time, the nurse can establish presence with the client by sitting, listening, showing acceptance, and supporting the client. The nurse can offer to contact a spiritual care provider to provide the client with spiritual support if needed.

6. Match the therapeutic communication technique to the correct definition. 1. Show clients that they have your undivided attention. 2. Use initially to encourage clients to tell their story in their own way. Use terminology clients can understand. 3. Question clients about specific details in greater depth or direct them toward relevant parts of their history. 4. Use active listening phrases ("Go on" and "Tell me more") to convey interest and to prompt disclosure of the entire story. 5. Ask mo

6. 1. Show clients that they have your undivided attention. D-active listening 2. Use initially to encourage clients to tell their story in their own way. Use terminology clients can understand. C-open ended questions 3. Question clients about specific details in greater depth or direct them toward relevant parts of their history. B-clarifying 4. Use active listening phrases ("Go on" and "Tell me more") to convey interest and to prompt disclosure of the entire story. A-back channeling 5. Ask more open-ended questions ("What else would you like to add to that?") to help obtain comprehensive information. F-probing 6. Ask questions that require yes or no answers to clarify information ("Do you have any pain when you cannot sleep?"). G-close end questions 7. Validate the accuracy of the story. E-summarizing

6. A nurse in a provider's office is preparing to perform a breast examination for an older adult client who is postmenopausal. Which of the following findings should the nurse expect? (Select all that apply.) A. Smaller nipples B. Less adipose tissue C. Nipple discharge D. More pendulous E. Nipple inversion

6. A. CORRECT: In older adulthood, the nipples become smaller and flatter. B. Older adults have more adipose tissue and less glandular tissue in their breasts. C. Older adults have no nipple discharge, unless there is some underlying pathophysiology. D. CORRECT: In older adulthood, breasts become softer and more pendulous. E. CORRECT: Nipple inversion is common among older adults, due to fibrotic changes and shrinkage.

7. A nurse in a provider's office is preparing to auscultate and percuss a client's thorax as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply.) A. Rhonchi B. Crackles C. Resonance D. Tactile fremitus E. Bronchovesicular sounds

7. A. Rhonchi are coarse sounds that result from fluid or mucus in the airways. B. Crackles are fine to coarse popping sounds that result from air passing through fluid or re-expanding collapsed small airways. C. CORRECT: Resonance is the expected percussion sound over the thorax. It is a hollow sound that indicates air inside the lungs. D. Tactile fremitus is an expected vibration the nurse can expect to feel or palpate as the client vocalizes. Speech creates sound waves, the vibrations of which travel from the vocal cords through the lungs and to the chest wall. E. CORRECT: Bronchovesicular sounds are expected breath sounds of medium pitch and intensity and of equal inspiration and expiration time. The nurse can expect to hear them over the larger airways.

7. A nurse in a provider's office is preparing to test a client's cranial nerve function. Which of the following directions should the nurse include when testing cranial nerve V? (Select all that apply.) A. "Close your eyes." B. "Tell me what you can taste." C. "Clench your teeth." D. "Raise your eyebrows." E. "Tell me when you feel a touch."

7. A. The first step of testing cranial nerve I, the olfactory nerve, is to have the client close their eyes prior to testing the sense of smell. B. Testing the sensory function of cranial nerve VIl, the facial nerve, involves testing the mouth for taste sensations. C. CORRECT: Testing cranial nerve V, the trigeminal nerve, involves testing the strength of muscle contraction by asking the client to clench their teeth while the nurse palpates the masseter and temporal muscles, and then the temporomandibular joint. D. Testing cranial nerve VII, the facial nerve, involves testing for a range of facial expressions by having the client smile, raise their eyebrows, puff out the cheeks, and perform other facial movements. E. CORRECT: Testing cranial nerve V, the trigeminal nerve, involves testing light touch by having the client tell the nurse when they feel a gentle touch on the face from a wisp of cotton.

2. A nurse is examining a client's head and neck lymph nodes. Match the name of the lymph node with the location of the lymph node. A. Submental B. Postauricular nodes C. Anterior cervical nodes D. Tonsillar nodes E. Occipital nodes 1. Base of the skull 2. Over the mastoid 3. Angle of the mandible 4. Under the chin 5. Along the sternocleidomastoid muscle

A. Submental 4. Under the chin B. Postauricular nodes 2. Over the mastoid C. Anterior cervical nodes 5. Along the sternocleidomastoid muscle D. Tonsillar nodes 3. Angle of the mandible E. Occipital nodes 1. Base of the skull

5. A nurse is performing auditory screening for a client. Match the name of the test with the technique the nurse should use. A. The nurse has the client occlude one ear and then tests the other ear to see if the client can hear sounds without seeing the nurse's mouth. B. The nurse places a vibrating tuning fork against the mastoid bone and asks the client to state when the sound can no longer be heard. C. The nurse places a vibrating tuning fork on the top of the head and asks the client if th

A. The nurse has the client occlude one ear and then tests the other ear to see if the client can hear sounds without seeing the nurse's mouth. 3. Whisper tests B. The nurse places a vibrating tuning fork against the mastoid bone and asks the client to state when the sound can no longer be heard. 1. Rine test (air conduction) C. The nurse places a vibrating tuning fork on the top of the head and asks the client if the sound is best in the left or right ear. 2. Weber test (bone conductivity) The nurse uses the whisper test to assess high-frequency hearing in both ears. Abnormal findings include the client asking the nurse to repeat the words and/or the client is unable to repeat the words. If the client has difficulty with the Whisper test, the nurse proceeds to the Rinne test and Weber's test. During the Rinne test, the nurse places a vibrating tuning fork against the client's mastoid bone and measures the length of time the client can hear the sound. An expected finding is that the

1. A nurse is discussing complementary and alternative medicine (CAM) with a newly licensed nurse. Match the CAM category with the therapy. A. Whole medical systems B. Botanical therapy C. Manipulative methods D. Mind-body therapy E. Energy therapy 1. Meditation 2. Homeopathy 3. Magnet therapy 4. Probiotics 5. Massage

A. Whole medical systems 2. Homeopathy B. Botanical therapy 4. Probiotics C. Manipulative methods 5. Massage D. Mind-body therapy Meditation E. Energy therapy 3. Magnet therapy When taking actions, the nurse should instruct that homeopathy is an example of whole medical systems. Other whole medical systems include traditional Chinese medicine and Ayurveda. Probiotics are an example of botanical therapy. Other botanical therapies include herbal preparations and vitamins. Massage is an example of manipulative therapy. Other manipulative therapies are acupuncture and chiropractic medicine. Meditation is an example of mind-body therapy. Other mind-body therapies are biofeedback and yoga. Magnet therapy is an example of energy therapy. Other energy therapies are Reiki and therapeutic touch.

Application Exercises 1. A nurse is preparing a presentation about basic nutrients for a group of high school athletes. The nurse should include that which of the following provides the body with the most energy? A. Fat B. Protein C. Glycogen D. Carbohydrates

Application Exercises Key 1. A. Although the body gets more than half of its energy supply from fat, it is an inefficient means of obtaining energy. it produces end products the body has to excrete, and it requires energy from another source to burn the fat. B. Protein can supply energy, but it has other very essential and specific functions that only it can perform. Therefore, it is not the body's primary energy source. C. Glycogen, which the body stores in the liver, is a backup source of energy, not a primary or priority source. D. CORRECT: When taking actions, the nurse should state that carbohydrates are the body's greatest energy source; providing energy for cells is their primary function. They provide glucose, which burns completely and efficiently without end products to excrete. They are also a ready source of energy, and they spare proteins from depletion.

1. A nurse is performing an admission assessment for an older adult client. After gathering the assessment data and performing the review of systems, which of the following actions is a priority for the nurse? A. Orient the client to their room. B. Conduct a client care conference. C. Review medical prescriptions. D. Develop a plan of care.

Application Exercises Key 1. A. CORRECT: When taking actions, the nurse should identify that the greatest risk to this client is injury from unfamiliar surroundings. Therefore, the priority action is to orient the client to the room. Before the nurse leaves the room, the client should know how to use the call light and other equipment at the bedside. It is important to conduct a client care conference. However, another action is the priority. It is important to review prescriptions in the medical record. However, another action is the prioritv. It is important to develop a plan of care. However, another action is the priority.

1. A nurse is teaching a client who has a new prescription for a time-release medication. What instructions should the nurse include?

Application Exercises Key 1. When taking actions, the nurse should instruct the client to swallow the time-release medication whole. These medications should not be crushed or chewed because time-released medications are intended to release slowly. Chewing or crushing the time-release medication causes all the medication to release at once, placing the client at risk for toxicity.

Application Ex 1. A school nurse is preparing a presentation about physical, cognitive, and psychosocial development for families of school-age children. Which of the following characteristics should the nurse include? (Select all that apply.) A. Onset of separation anxiety B. Peer influence is minimal C. Uncoordinated fine motor control D. Good understanding of time and routines E. Fully developed vision and hearing

1. D, E. CORRECT: When generating solutions for a presentati for parents about the development of school-age children, the nurse should include that the characteristics of school. age children are a good understanding of time (cognitive development) and developed vision and hearing.

1. A nurse is assessing/collecting data from a client. Sort the findings into objective or subjective data. A. Respiratory rate is even and unlabored at 22/min. B. The client's partner states, "They had burning leg pain after walking 10 minutes." C. The client's pain rating is 3 on a scale of 0 to 10. D. The client's skin is consistent with genetic background, warm, and dry. E. An assistive personnel reports that the client walked with a limp.

1. OBJECTIVE DATA: A, D, E; SUBJECTIVE DATA: B, C The nurse should analyze cues to identify objective and subjective data. Objective data includes information the nurse can feel, see, hear, or smell, through observation or physical measurement such as respiratory rate, skin color, temperature, and characteristics, and observation that the client is walking with a limp. Subjective data includes a client's feelings, perceptions, and descriptions of health status, such as pain level, description of pain, and contributing factors to pain.

2. A nurse notes a fire in a trash can in a client's room. In what order should the nurse take action? A. Pull the fire alarm. B. Use the fire extinguisher. C. Help the client and others leave the area. D. Close doors.

2. C-help pt and others leave area A-pull alarm D-close doors B-use extinguisher Using the RACE mnemonic, the nurse should: Rescue the client and other individuals from the area. Sound the fire alarm, which activates the EMS response system. Systems that could increase fire spread are automatically shut down with activation of the alarm. After clearing the room or area, close the door leading to the area in which the fire is located as well as the fire doors and any open windows. Fire doors are kept closed as much as possible when moving from area to area within the facility to avoid the spread of smoke and fire. Make an attempt to extinguish small fires using a single fire extinguisher, smothering them with a blanket, or dousing with water (except with an electrical or grease fire). Complete evacuation of the area occurs if the nurse cannot put the fire out with these methods. Attempts at extinguishing the fire are only made when the employee is properly trained in the safe use of

2. A charge nurse is discussing the components of critical thinking with a newly licensed nurse. Match the following situations to the appropriate component of critical thinking. A. A nurse uses an electronic database to gather information about a medication before administering it to a client. B. A nurse has been working with clients who have diabetes mellitus for over 5 years. C. A nurse uses the nursing process when caring for a client who has hypoglycemia. 1. Knowledge 2. Experience 3. Com

2. A, 1 B, 2 C, 3 When recognizing cues, the charge nurse should identify that using the electronic database to gather information about a medication demonstrates the knowledge component of critical thinking. The nurse is taking initiative to increase their knowledge base. The nurse who has been working with clients who have diabetes mellitus for over 5 years demonstrates the experience component of critical thinking. A nurse who has experience has clinical expertise and can apply intuition to critical thinking in clinical situations. A nurse who uses the nursing process when caring for a client who has hypoglycemia is demonstrating the competence component of critical thinking. Competence involves identifying client problems and making clinical judgments using a systematic, individualized process.

2. A nurse is caring for a client who is sitting in a chair and asks to return to bed. Which of the following actions is the nurse's priority at this time? A. Obtain a walker for the client to use to transfer back to bed. B. Call for additional staff to assist with the transfer. C. Use a transfer belt and assist the client back into bed. D. Determine the client's ability to help with the transfer.

2. A. Although this might be a necessary assistive device for this client, obtaining a walker is not the priority action the nurse should take. B. Although this might be necessary for a safe transfer, calling for assistance is the not the priority action the nurse should take. C. Although this might be a necessary assistive device for the transfer of this client, using a transfer belt is not the priority action the nurse should take. D. CORRECT: The first action that should be taken using the nursing process is to assess or collect data from the client. Determine the client's ability to help with transfers and then proceed with a safe transfer.

3. A nurse is caring for a client who is two days postoperative and has not achieved satisfactory pain relief. According to the nursing process, which of the following actions should the nurse take first? A. Check the client to determine the reason for inadequate pain relief. B. Determine whether the change in plan reduces the client's pain. C. Change the plan of care to provide a different method of pain relief. D. Educate the client about the plan of care for managing the pain.

3. A. CORRECT: When prioritizing hypotheses, and using the nursing process, the first action the nurse should take is to check the client to determine the reason for inadequate pain relief. The nurse should collect obiective and subjective data to determine a new plan of care to promote comfort and reduce the client's pain.

3. The ostomy nurse is educating the client about the new colostomy. Match the nursing actions to the appropriate domain of learning. A. The ostomy nurse encourages the client to share their feelings about their colostomy. B. The client performs a return demonstration of emptying the colostomy pouch. C. The ostomy nurse provides the client with a list of foods they can eat and foods they should avoid in their diet. 1. Cognitive 2. Affective 3. Psychomotor

3. A, 1 B, 3 C, 2 When taking actions, the ostomy nurse is using the cognitive domain of learning when providing the client with a list of foods they can eat and foods they should avoid in their diet. The ostomy nurse is encouraging the client to ask questions to promote understanding about the teaching. The ostomy nurse is using the affective domain of learning when encouraging the client to share their feelings about their colostomy. The affective domain promotes the expression of feelings and encourages support from others. The ostomy nurse is using the psychomotor domain of learning when demonstrating how to empty the ostomy pouch and asking the client to perform a return demonstration of the procedure. The psychomotor domain of learning involves performing a physical task.

3. A nurse is teaching the parent of a toddler about discipline. Which of the following statements should the nurse make? A. "Establish consistent boundaries for the toddler." B. "Place the toddler in a room by themselves when they misbehave." C. "Inform the toddler how you feel when they misbehave." D. "Use the toddler's favorite snack as a reward"

3. A. CORRECT: When taking actions, the nurse should instruct the parent to establish consistent boundaries to promote a sense of security in the toddler and an understanding of what is right and what is wrong.

6. A nurse is giving a presentation to a group of parents of toddlers about home safety. Which of the following strategies should the nurse include? (Select all that apply.) A. Ensure crib slats are no further apart than 10 cm (3.9 in). B. Keep toilet lids up. C. Turn pot handles toward the back of a stove. D. Make sure balloons are fully inflated. E. Cover electrical outlets with safety covers. F. Place safety gates across stairways.

6. C, E, F. CORRECT: When taking actions, the nurse should include in the presentation to turn pot handles toward the bat of a stove when cooking to reduce the risk of a toddler pulley on the pot and spilling its contents on themselves; to cover electrical outlets with safety covers or safety plugs to prevent the risk of electrocution; and place safety gates across stair to reduce the risk of the toddler falling down the stairs.

6. A nurse is caring for a client who is receiving continuous enteral feedings. Which of the following nursing interventions is the highest priority when the nurse suspects aspiration of the feeding? A. Auscultate breath sounds. B. Stop the feeding. C. Obtain a chest x-ray. D. Initiate oxygen therapy.

&. A. The nurse should listen to breath sounds whenever there is suspicion of the client aspirating. However, another action is the priority. & CORRECT: The nurse should identify that the greatest risk to the client is aspiration pneumonia. The first step is to take action and stop the feeding so that no more formula can enter the lungs. C. The nurse should obtain a chest x-rav whenever there is suspicion of the client aspirating. However, another action is the priority. D. The nurse should initiate oxygen therapy whenever there is suspicion of the client aspirating. However, another action is the priority.

2. Sort the following examples into the correct link in the chain of infection: Infectious Agent, Reservoir, Mode of Transmission, Susceptible Host, or Portal of Exit and Entry. (Some examples may be used in more than one link.) A. Virus B. Parasite C. Human D. Soil E. Food F. Respiratory tract G. Mucous membranes H. Genitourinary tract I. Contact with an infected person J. Droplets in the air K. Vectors L. Older adults M. Immunocompromised N. Client who is burned O. Bacterium

2. Infectious agent A. Virus B. Parasite O. Bacterium Reservoir C. Human D. Soil E. Food Mode of transmission I. Contact w/ infected person J. Droplets in the air K. Vectors Susceptible host L. Older adults M. Immunocompromised N. Client who is burned Portal of exit and entry F. Respiratory tract G. Mucus membranes H. Genitourinary tract

1. A nurse is examining the breast of a female young adult client. The nurse should determine that which of the following are expected findings? (Select all that apply) A. The client's nipples are inverted. B. The client has a dimple on the left breast. C. The client's left breast is smaller than the right breast. D. The client's areolae are oval shaped. E. The underlying veins in the breast are visible.

1. A. An expected finding is that the client's nipples are everted. The nurse should determine whether the client has a lifetime history of nipple inversion because a recent inversion of the nipple can indicate an underlying mass. B. A dimple can also indicate an underlying mass. C. CORRECT: One breast being larger than the other is a common, expected finding. D. CORRECT: The client's areolae can be either round or oval shaped. E. CORRECT: The veins can be visualized for client who is thin.

1. A nurse is collecting history and physical examination data from a middle adult. The nurse should expect to find decreases in which of the following physiologic functions? (Select all that apply.) A. Metabolism B. Ability to hear low-pitched sounds C. Gastric secretions D. Far vision E. Glomerular filtration

1. A. CORRECT: The nurse should expect metabolism to decline, causing weight gain during middle adulthood. B. The nurse should expect a decline in the ability to hear high-pitched sounds during middle adulthood. C. CORRECT: In middle adulthood, decreases in secretions of bicarbonate and gastric mucus begin and persist into older age. This increases the risk of peptic ulcer disease. D. The nurse should expect a decline in near vision (presbyopia) during middle adulthood. E. CORRECT: Middle adults begin to lose nephron units, which results in a decline in glomerular filtration rates.

1. A nurse is teaching a client who has a new prescriction for oxybutynin about managing the medication's anticholinergic effects. Which of the following instructions should the nurse include? (Select all that apply.) A. Take sips of water frequently. B. Wear sunglasses when outdoors in sunlight. C. Use a soft toothbrush when brushing teeth. D. Tale the medication with an antacid. E. Urinate prior to taking the medication.

1. A. CORRECT: The nurse should instruct the client to take sips of water frequently to relieve dry mouth. B. CORRECT: The nurse should instruct the client to wear sunglasses to relieve the photophobia. C. The client should not use a soft toothbrush when brushing teeth. D. The client should not take the medication with an antacid. E. CORRECT: The nurse should instruct the client to urinate prior to taking the medication to relieve the anticholinergic effect of urinary retention.

1. A nurse is reviewing the electronic medical record (EMR ) of a client who has a blood glucose of 260 mg/ dL and no documented history of diabetes mellitus. Which of the following types of medications can cause hyperglycemia as an adverse effect? (Select all that apply.) A. Diuretics B. Corticosteroids C. Oral anticoagulants D. Opioid analgesics E. Antipsychotics

1. A. CORRECT: When analyzing cues, the nurse should identify that diuretics can cause hyperglycemia, especially in clients who have diabetes mellitus, and also can cause many electrolyte imbalances. B. CORRECT: Corticosteroids can cause hyperglycemia and glycosuria. C. Anticoagulants can cause excessive bleeding during blood sampling for glucose testing. D. Opioid analgesics cause many adverse effects, including respiratory depression, but they are unlikely to raise blood glucose levels. E. CORRECT: Antipsychotics, particularly atypical antipsychotics, can cause new-onset diabetes mellitus.

1. A nurse is discussing modes of transmission at a staff education session. Which of the following should the nurse include as examples of the direct contact mode of transmission? (Select all that apply.) A. Blood spurting from an arterial wound splashes into a nurse's eye. B. A nurse has a needlestick injury. C. A mosquito bites a hiker in the woods. D. A nurse finds a hole in their glove while handling a soiled dressing. E. A person fails to wash their hands after using the bathroom and touches a client.

1. A. CORRECT: When discussing modes of transmission during a staff education session, the nurse should include the following as direct contact modes of transmission: blood from an arterial wound splashing into a nurse's eye and failing to wash hands after using the bathroom and then touching a client. B. Transmission from a needle or other inanimate object is indirect transmission. C. Transmission from an insect is vector-borne (indirect) transmission. D. Transmission from a soiled dressing or other inanimate object is vehicle-borne (indirect) transmission. E. CORRECT: When discussing modes of transmission during a staff education session, the nurse should include the following as direct contact modes of transmission: blood from an arterial wound splashing into a nurse's eye and failing to wash hands after using the bathroom and then touching a client.

1. A nurse is reviewing the wound healing process with a group of newly licensed nurses. The nurse should include in the information which of the following alterations for wound healing by secondary intention? (Select all that apply.) A. Stage 3 pressure injury B. Sutured surgical incision C. Casted bone fracture D. Laceration sealed with adhesive E. Open burn area

1. A. CORRECT: When taking action, the nurse should include that open pressure injuries heal by secondary intention, which is the process for wounds that have tissue loss and widely separated edges. B. Sutured surgical incisions heal by primary intention, which is the process for wounds that have little or no tissue loss and well-approximated edges. C. Unless the bone edges have pierced the skin, a casted bone fracture is an injury to underlying structures and does not require healing of the skin. D. Lacerations sealed with tissue adhesive heal by primary intention, which is the process for wounds that have little or no tissue loss and well-approximated edges. E. CORRECT: Open burn areas heal by secondary intention, which is the process for wounds that have tissue loss and widely separated edges.

1. A nurse is providing teaching with a newly licensed nurse about incorporating culturally responsive nursing care. Which of the following statements by the newly licensed nurse indicates understanding? A. "It is a form of client ethnocentrism." B. "It involves being knowledgeable about various cultures." C. "It involves the delivery of care that includes the client's beliefs." D. "It is the examination of the nurse's personal attitude?

1. A. Cultural imposition is a form of ethnocentrism. B. Cultural sensitivity is the term used to describe being knowledgeable about various cultures C. CORRECT: Culturally responsive nursing care involves the delivery of care that considers a client's cultural beliefs that could affect their well-being D. Cultural awareness is self-awareness for the nurse to identify potential bias. & NCLEN® Connection: Psychosocial Integrity, Cultural Awareness/Cultural Influences on Health

1. A nurse in a provider's office is testing the cranial nerves during a head and neck examination. Which of the following cranial nerves are both sensory and motor? (Select all that apply) A. Cranial Nerve II (Optic) B. Cranial Nerve V (Trigeminal) C. Cranial Nerve VII (Facial) D. Cranial Nerve VIII (Auditory) E. Cranial Nerve XI (Spinal accessory)

1. A. During an examination of the head and neck, the nurse should recognize that Cranial Nerve II, the optic nerve whose function is visual acuity is sensory only. B. CORRECT: Cranial nerve V, the trigeminal nerve provides sensory input for the face as well as movement of the jaw; therefore, it is both sensory and motor. C. CORRECT: Cranial nerve VII, the facial nerve allows for facial expression and taste, therefore, it is both sensory and motor. D. Cranial nerve VIlI, the auditory nerve provides for hearing and thus, it is sensory only. E. Cranial Nerve XI, Spinal accessory, provides for movement of the head and shoulders and is motor only.

1. A nurse is caring for a client awaiting transport to the surgical suite for a coronary artery bypass graft. Just as the transport team arrives, the nurse takes the client's vital signs and notes an elevation in blood pressure and heart rate. The nurse should recognize this response as which part of the general adaptation syndrome (GAS)?? A. Exhaustion stage B. Resistance stage C. Alarm stage D. Recovery stage

1. A. The exhaustion stage is a component of GAS, however, body functions are no longer able to respond to the stressor in this stage, B. Although the resistance stage is a component of GAS, body functions normalize in an attempt to cope with the stressor in this stage. C. CORRECT: The nurse should identify that, in the alarm stage of GAS, body functions (blood pressure and heart rate) are heightened in order to respond to stressors. D. While it is not technically a component of GAS, recovery stare is an alternative to the exhaustion stage, but it would not account for an elevation in blood pressure and heart rate.

1. A nurse is assessing a client who has an acute respiratory infection, increasing the risk for hypoxemia. Which of the following findings are early indications that should alert the nurse that the client is developing hypoxia? (Select all that apply.) A. Restlessness B. Tachypnea C. Bradycardia D. Confusion E. Hypertension

1. A., B., D., E. CORRECT: Monitor for restlessness, tachypnea, confusion and hypertension which are early manifestations of hypoxia, along with tachycardia, elevated blood pressure, use of accessory muscles, nasal flaring, tracheal tugging, and adventitious lung sounds. C. Bradycardia is a late manifestation of hypoxia, along with stupor, cyanotic skin and mucous membranes, bradypnea, hypotension, and cardiac dysrhythmias.

1. A nurse is collecting data from an older adult client as part of a comprehensive physical examination. Which of the following findings should the nurse expect as associated with aging? (Select all that apply.) A. Skin thickening B. Decreased height C. Increased saliva production D. Nail thickening E. Decreased bladder capacity

1. B, D, E. CORRECT: The nurse should identify that physiological changes that occur with aging can include loss in height due to the thinning of intervertebral disks, thickening of the nails of the fingers and toes, and a reduced bladder capacity. While young adults have a bladder capacity of about 500 to 600 mL, older adults have a capacity of about 250 mL A. The nurse should identify that physiological changes that occur with aging can include decreased skin turgor, subcutaneous fat, and connective tissue (dermis), which can cause wrinkles and dry, thin, transparent skin. C. Other physiological changes that occur with aging can include decreased saliva production, making xerostomia (dry mouth) a common problem.

Application Exercises 1. The nurse is teaching the newly licensed nurse how to insert an IV catheter into the client. Which of the following statements by the newly licensed nurse indicates understanding of the procedure? A. "I will cleanse the area of the insertion site in a circular motion starting from the outside to the middle.' B. "I will insert the needle into the client's skin at an angle of 10° to 30° with the bevel up. C. "I will apply pressure 1 inch below the insertion site prior to removing the needle.' D. "I will choose a vein in the antecubital fossa for IV insertion."

1. B. CORRECT: When evaluating outcomes, the nurse should identify that the newly licensed nurse understands to use a smooth, steady motion to insert the catheter through the skin at an angle of 10° to 30° with the bevel up. This angle decreases the risk of puncturing the posterior wall of the vein.

1. A nurse is preparing a presentation at a local community center about sleep hygiene. Sort the following characteristics into either rapid eye movement (REM) sleep or non-rapid eye movement (NREM) sleep. A. Cognitive restoration occurs B. Light sleep C. 75% of time sleeping D. Loss of muscle tone occurs E. Vivid dreaming occurs

1. REM: A, D, E; NREM: B, C When taking actions, the nurse should identify that cognitive and brain tissue restoration, loss of muscle tone, and vivid, colorful dreams are characteristics of REM sleep. NREM sleep occurs during 75% of the sleep time and includes light sleep.

A nurse is planning care for a client who has hypernatremia. What actions should the nurse include in the plan of care?

1. When generating solutions, the nurse should monitor the client's level of consciousness and ensure the client's safety. Provide oral hygiene and other comfort measures to decrease the client's thirst. Monitor 1&0 and alert the provider if urinary output is inadequate. Monitor laboratory results. Maintain prescribed diet (low sodium, no added salt). Encourage oral fluids as prescribed. Administer hypotonic or isotonic (non-sodium) IV fluids and administer loop diuretics if impaired kidney excretion is the cause of hypernatremia.

2. A nurse on a pediatric unit is caring for an adolescent who has multiple fractures. Which of the following interventions should the nurse take? (Select all that apply.) A. Suggest that the guardians bring in video games to play. B. Provide a television and movies for the adolescent to watch. C. Limit visitors to the adolescent's immediate family. D. Involve the adolescent in treatment decisions when possible. E. Allow the adolescent to perform morning self-care.

2. A, B, D, E. CORRECT When taking action while caring for an adolescent who has multiple fractures the nurse should suggest the adolescent play nonviolent video games and watch nonviolent movies. These are suitable diversional activities for an adolescent. The nurse should also allow the adolescent to be involved in making decisions about their treatment. The adolescent is capable of thinking through problems, Involving the adolescent in decisions helps promote Independence and control, Allowing the adolescent to perform morning sell-care alao promotes Independence as well as shows respect for their privacy, C. An adolescent client forms a strong attachment to peers. Allowing friends to visit should reduce the adolescent's feelings of Isolation,

2. A nurse is using an interpreter to communicate with a client. Which of the following actions should the nurse take? (Select all that apply.) A. Using a facility approved medical interpreter B. Determining the client's understanding several times during the conversation C. Looking at the interpreter when asking the client questions D. Using medical terms during the conversation E. Asking one question at a time

2. A, B, E. CORRECT: When taking actions, the nurse should use a facility approved medical interpreter to ensure accuracy of the medical information and maintain client confidentiality. Determining client understanding throughout the conversation ensures the client comprehends the information and the nurse will know how to direct the conversation. Asking one question at a time and allowing the client time to respond will promote effective communication between the client and the nurse or interpreter.

2. A nurse is caring for a group of clients on a medical-surgical unit. Which of the following clients are at increased risk for body-image disturbances? (Select all that apply.) A. A client who had a laparoscopic appendectomy B. A client who had a mastectomy C. A client who had a left above-the-knee amputation D. A client who had a cardiac catheterization E. A client who had a stroke with right-sided hemiplegia

2. A. According to the concept of body image, an appendectomy would not place a client at high risk for a body-image disturbance. B. CORRECT: The nurse should identify that having a mastectomy involves a change in physical appearance and can lead to body-image disturbances related to sexuality. C. CORRECT: Having an above-the-knee amputation involves a change in physical appearance and can lead to body-image disturbances related to function, health, and strength. D. Depending on the prognosis postcatheterization, the client can have some limitations. However, in general, a cardiac catheterization would not place a client at high risk for a body-image disturbance. E. CORRECT: Having right-sided hemiplegia involves a change in physical appearance and can lead to body-image disturbances related to function, health, and strength.

2. A nurse is caring for a client who had a stroke and has aphasia. Which of the following actions should the nurse take to promote communication? (Select all that apply.) A. Make sure one person speaks to the client at a time. B. Let the client know if they are not understood. C. Allow time for the client to respond. D. Use long sentences when talking to the client. E. Speak loudly to the client.

2. A. B, C. CORRECT: When taking actions, the nurse should allow one person to speak to the client at a time, let the dient know when they do not understand them, and allow plenty of time for the client to respond. These actions will facilitate communication in the dient who has aphasia.

2. A client who had abdominal surgery 24 hr ago suddenly reports a pulling sensation and pain in their surgical incision. The nurse checks the surgical wound and finds it separated with viscera protruding. Which of the following actions should the nurse take? (Select all that apply.) A. Cover the area with saline-soaked sterile dressings. B. Apply an abdominal binder snugly around the abdomen. C. Use sterile gauze to apply gentle pressure to the exposed tissues. D. Position the client supine with the hips and knees bent. E. Offer the client a warm beverage (herbal tea).

2. A. CORRECT: When taking action, the nurse should cover the wound with a sterile dressing soaked with sterile normal saline solution to keep the exposed organs and tissues moist until the surgeon can assess and intervene. B. An abdominal binder can help prevent, not treat, a wound evisceration. C. The nurse should avoid handling or applying pressure to any exposed organs or tissues, because these actions increase the risks of trauma and perforation. D. CORRECT: The nurse should place the client supine with the hips and knees bent. This position minimizes pressure on the abdominal area. E. The client should be kept NPO in anticipation of the surgical team taking them back to the surgical suite for repair of the evisceration.

2. A nurse is performing a neurologic examination for a client. Which of the following assessments should the nurse perform to test the client's balance? A. Romberg test B. Weber's test C. Rosenbaum test D. Snellen test

2. A. CORRECT: When taking actions, the nurse should identify that the Romberg test is used to assess balance. The client stands with their eyes closed, arms at both side, and feet together. The nurse verifies balance if the client can stand with minimal swaying for at least 5 seconds.

3. The nurse administers the wrong medication to the client. Which of the following actions should the nurse take first? A. Report the error to the facility's risk manager. B. Notify the provider. C. Complete an incident report. D. Check the client's vital signs.

3. D. CORRECT: When prioritizing hypotheses, using the nursing process, the first action the nurse should take is to assess the client. The nurse should check the client's vital signs to determine the client's condition and report these findings to the provider.

2. A charge nurse is explaining the various stages of the lifespan to a group of newly licensed nurses. Which of the following examples should the nurse include as a developmental task for middle adulthood? A. The client evaluates their behavior after a social interaction. B. The client states they are learning to trust others. C. The client wishes to find meaningful friendships. D. The client expresses concerns about the next generation.

2. A. Evaluating behavior after a social interaction is a developmental task that begins during the preschool years. B. Learning to trust others is a developmental task of infancy during Erickson's trust vs. mistrust stage. C. Finding meaningful friendships is a developmental task for school-aged children. D. CORRECT: The nurse should identify that Erickson's task for a middle adult is generativity vs. stagnation. The nurse should include showing concern for the next generation as an example for this age group.

2. A nurse is preparing to perform a comprehensive physical examination of an older adult client. Which of the following interventions should the nurse use in consideration of the client's age? (Select all that apply.) A. Expect the session to be shorter than for a younger client. B. Plan to allow plenty of time for position changes. C. Make sure the client has any essential sensory aids in place. D. Tell the client to take their time answering questions. E. Invite the client to use the bathroom

2. A. Expect the session to take longer than for most clients, and allow adequate time. The older adult client might have had more medial conditions and has a more complex social and functional history B. CORRECT: Because many older adults have mobility challenges, plan to allow extra time for position changes. C. CORRECT: The nurse should make sure clients who use sensory aids have them available for use. The client has to be able to hear the nurse and see well enough to avoid injury. D. CORRECT: Some older clients need more time to collect their thoughts and answer questions, but most are reliable historians. Feeling rushed can hinder communication.. E. CORRECT: The nurse should also invite the client to use the bathroom before beginning the examination. This is a courtesy for all clients, to avoid discomfort during palpation of the lower abdomen for example, but this is especially important for older clients who have a smaller bladder capacity..

2. A provider is discharging a client who has a prescription for home oxygen therapy via nasal cannula. Client and family teaching by the nurse should include which of the following instructions? (Select all that apply.) A. Apply petroleum jelly around and inside the nares. B. Remove the nasal cannula during mealtimes. C. Check the position of the cannula frequently. D. Report any nausea or difficulty breathing. E. Post "No Smoking" signs in prominent locations.

2. A. Teach the client to apply a water-based lubricant to protect the nares from drying during oxygen therapy. B. Teach the client to leave the nasal cannula on while eating, because it does not interfere with eating. C. CORRECT: Teach the client that a disadvantage of the nasal cannula is that it dislodges easily. The client should form the habit of checking its position periodically and readjusting it as necessary. D. CORRECT: Teach the client about oxygen toxicity, which is a complication of oxygen therapy, usually from high concentrations or long durations. Manifestations include a nonproductive cough, substernal pain, nausea, and vomiting. The client should report any of these promptly. E. CORRECT: Teach the client that oxygen is combustible and thus increases the risk of fire injuries. No one in the house should smoke or use any device that might generate sparks in the area where the oxygen is in use.

2. A nurse is counseling an older adult who describes having difficulty dealing with several issues. Which of the following problems verbalized by the client should the nurse identify as the priority? A. "I spent my whole life dreaming about retirement, and now I wish I had my job back." B. "It's been so stressful for me to have to depend on my child to help around the house." C. " just heard my friend Al died. That's the third one in 3 months." D. "I keep forgetting which medications I have tak

2. A. The client is at risk for social isolation and loss of independence because of retirement. However, another issue is the priority. B. The client is at risk for loss of independence and reduced self-esteem due to dependence upon their child. However, another issue is the priority. C. The client is at risk for social isolation due to the loss of a friend. However, another issue is the priority. D. CORRECT: The nurse should identify that the greatest risk to this client is injury from overdosing or underdosing medications due to loss of short-term memory. The priority issue is to assist the client to implement safe medication strategies. Assist the client to use a pill organizer to help them remember to take their medications and to keep a list of all current medications.

2. A nurse is teaching a newly licensed nurse about urine specimen collection. Match the following tests to the procedure. A. Random urinalysis B. Clean-catch midstream for culture and sensitivity (C&S) C. Timed urine specimen D. Catheter urine specimen for C&S 1. Collect urine for a 24 hr period. 2. Obtain a non-sterile urine specimen. 3. Obtain a sterile urine specimen from an indwelling urinary catheter. 4. Clean the urethral meatus prior to obtaining the urine specimen.

2. A: 2 B: 4 C: 1 D: 3 When taking actions, the nurse should instruct the newly licensed nurse that a random urinalysis is a non-sterile urine specimen. A clean-catch midstream for C&S is a sterile specimen collected from a midstream void, after cleaning the urinary meatus. A timed urine specimen is collected over a prescribed period of time. A catheter urine specimen for C&S is a sterile specimen obtained from a straight or indwelling catheter.

2. Anurse is providing a client with a complete bed bath. When providing the care, the nurse must recognize the order in which areas of the body will be bathed. Place the options in the correct order. A. Trunk B. Feet C. Face D. Legs

2. C, A, D, B When providing the client with a complete bed bath, the nurse should begin with the cleanest area and work down toward the feet. The nurse cleanses the face first. Next, the nurse should wash the client's trunk and upper extremities followed by the legs and then the feet.

2. A nurse is monitoring a client for adverse effects following the administration of an opioid. Which of the following effects should the nurse identify as an adverse effect of opioids? (Select all that apply) A. Urinary incontinence B. Diarrhea C. Bradypnea D. Orthostatic hypotension E. Nausea

2. C, D, E. CORRECT: When evaluating outcomes, the nurse should identify that the manifestations of adverse reaction to opioid medication include bradypnea, orthostatic hypotension, and nausea. A, B. Other manifestations include urinary retention, constipation, bradycardia, pruritus, and dizziness.

2. A nurse is caring for a client who is expected to die within 24 hr. The client's family asks the nurse what physical changes to expect. Which manifestations should the nurse include? (Select all that apply.) A. Increased urine output B. Warm extremities C. Decreased muscle tone D. Periods of apnea E. Bowel incontinence

2. C, D, E. CORRECT: When taking actions, the nurse should inform the client's family that physical changes that occur within 24 hr of death can include decreased muscle tone, irregular breathing with periods of apnea, and incontinence of the bowels and bladder.

2. A nurse is performing an integumentary assessment for a group of clients. Which of the followir g findings is the nurse's priority? A. Pallor B. Jaundice C. Cyanosis D. Erythema

2. C. CORRECT: When prioritizing a hypothesis, using the airway, breathing, circulation approach to client care, the nurse should identify that the priority finding is cyanosis. Cyanosis is a manifestation of hypoxia and can indicate impaired oxygenation. Therefore, cyanosis is the priority finding.

2. The nurse is teaching the newly licensed nurse strategies to reduce the risk for IV infections. What strategies should the nurse include?

2. When taking actions, the nurse should include to perform hand hygiene before and after handling I systems, change I sites according to the facility's policy (usually every 72 hr), remove catheters as soon as they are no longer clinically necessary to eliminate a portal of entry for pathogens, and use a sterile needle or catheter for each insertion attempt for safety and prevention of infection. The nurse should not disconnect IV tubing because this increases the risk of bacteria entering the system. The nurse should replace IV catheters or tubing when suspecting a break in surgical aseptic technique, and avoid writing on IV bags with pens or markers, because ink can contaminate the solution. Do not allow fluids to hang for more than 24 hr unless it is a closed system (pressure bags for hemodynamic monitoring). Wipe all ports with alcohol or an antiseptic swab before connecting IV lines or inserting a syringe to prevent the introduction of micro-organisms into the system.

2. A nurse in an acute care facility is caring for a client who is having difficulty sleeping at night. What actions should the nurse take to promote sleep?

2. When taking actions, the nurse should try to provide a quiet hospital environment and limit waking the client during the night to reduce interruptions in the client's sleep. A soothing back rub and assisting the client in following their regular bedtime routine, such as taking a bath in the evening, might promote relaxation and sleep in the acute care facility.

4. A nurse is consoling the partner of a client who just died after a long battle with cancer. The grieving partner states, "I hate them for leaving me." What actions should the nurse take to facilitate mourning for the client's partner?

4. When taking actions, the nurse should assist the client's partner through the mourning process by using therapeutic communication to encourage the partner to express their feelings. The nurse should ask the client's partner whether they would like to talk to a spiritual leader to provide spiritual support and guidance. The nurse should provide education to the grieving individual about the grieving process and about emotions they can expect at this time to assist the client's partner through the mourning process.

3. A nurse is assessing a client's sensory function. The nurse asks the client to close their eyes. Match the nursing action to associated sensory function. 1. Ask the client to report when they feel a cotton ball on their skin. 2. Ask the client to report when they feel the movement of a tuning fork on their skin. 3. Reposition the client's arm and ask the client to report whether it is positioned up or down. 4. Trace a number on the client's palm with the blunt end of a pencil and ask them to identify it. ruranty aclion to A. Position B. Light touch C. Discrimination D. Vibration

3. A, 3 B, 1 C, 4 D; 2 When taking actions, the nurse should ask the client to close their eyes before assessing sensory function. The nurse should assess the client's sensation of light touch by lightly touching their skin with a cotton ball and then asking them to report when they feel the cotton ball on their skin. The nurse should assess the client's sensation of vibration by touching their skin with the handle of a vibrating tuning fork and then asking them to report when they feel the vibration. The nurse should assess the client's sensation of position by repositioning the client's arm and then asking them to report whether it is positioned up or down. The nurse should assess the client's sensation of discrimination by tracing a number on the client's palm with the blunt end of a pencil and then asking them to identify it.

3. A nurse is reviewing the electronic medical record of a client who has an electrolyte imbalance. Match the electrolyte imbalance to the associated risk factor. A. Hypernatremia B: Hyponatremia C. Hypocalcemia D. Hypercalcemia 1. Diabetes insipidus 2. Hypoparathyroidism 3. Hyperparathyroidism 4. Excessive water intake

3. A, 1 B, 4 C, 2 D, 3. When taking actions, the nurse should instruct risk factors for hypernatremia include diabetes insipidus and diarrhea. Risk factors for hyponatremia include excessive water intake and syndrome of inappropriate antidiuretic hormone. Risk factors for hypocalcemia include hypoparathyroidism and malabsorption. Risk factors for hypercalcemia include hyperparathyroidism and glucocorticoid use.

3. A nurse attempting to collect a capillary blood specimen via finger stick for blood glucose monitoring is unable to obtain an adequate drop of blood for the reagent strip. Which of the following actions should the nurse take first? A. Puncture another finger to obtain a capillary specimen. B. Test the urine with a urine reagent strip. C. Wrap the hand in a warm, moist cloth. D. Perform a venipuncture to obtain a venous sample.

3. A. Another finger can be punctured to obtain a capillary specimen; however, a less invasive intervention should be used first. B. A urine glucose can be obtained; however, the client's blood glucose level should be significantly elevated in order to detect glucose in the urine. A less invasive intervention should be used first. C. CORRECT: The nurse should take action and first use the least invasive intervention. Warming the client's finger with a warm moist cloth will promote blood flow in preparation for the next finger stick. D. A venipuncture might need to be requested for checking the blood glucose level; however, a less invasive intervention should be used first.

3. A nurse is discussing herbal remedies with a newly licensed nurse. Match the herbal remedy with the possible therapeutic effect. A. Antiemetic B. Increases physical endurance C. Enhances immunity D. Produces sleep E. Improves memory 1. Ginkgo biloba 2. Echinacea 3. Ginger 4. Ginseng 5. Valerian

3. A, 3; B, 4; C, 2; D, 5; E, 1 When taking actions, the nurse should instruct that ginger is used to reduce nausea, ginseng is used to increase physical endurance, echinacea is used to improve immunity, valerian is used to induce sleep, and ginkgo biloba is used to improve memory.

3. A nurse is collecting data from a client who is 5 days postoperative following abdominal surgery. The surgeon suspects an incisional wound infection and has prescribed antibiotic therapy for the nurse to initiate after collecting wound and blood specimens for culture and sensitivity. Which of the following findings should the nurse expect? (Select all that apply.) A. Increase in incisional pain B. Fever and chills C. Reddened wound edges D. Increase in serosanguineous drainage E. Decrease in thirst

3. A, B, C. CORRECT: When recognizing cues, the nurse should expect the client to have pain and tenderness at the wound site, fever and chills, and reddened or inflamed wound edges with an incisional infection. D. The nurse should expect the client to have purulent drainage with an incisional infection. E. The nurse should not expect changes in thirst as an indication of an incisional infection.

3. A nurse is assessing a client who reports insomnia. Which of the following findings can contribute to the client's insomnia? (Select all that apply.) A. Irregular schedule B. Stress C. Warm bath D. Alcohol intake E. Morning walk

3. A, B, D. CORRECT: When analyzing cues, the nurse should identify that an irregular schedule, stress and anxiety, and alcohol intake can contribute to impaired sleep. The nurse should instruct the client to try to maintain a regular bedtime routine, find ways to reduce stress, such as yoga or meditation, and limit alcohol and beverages to 4 hr before bedtime.

3. A nurse is auscultating a client's lungs. Which of the following findings are expected? (Select all that apply). A. High pitched musical sounds B. Expiration is longer than inspiration over the trachea upon auscultation. C. Soft, breezy, low- pitched sounds D. Medium pitched blowing sounds

3. A. A high-pitched musical sound upon auscultation indicates wheezing which is an adventitious or unexpected. B. CORRECT: Expiration that is longer than inspiration over the trachea upon auscultation is an expected bronchial sound. C. CORRECT: Soft, breezy, low- pitched sounds are vesicular sounds which are best heard over the periphery of the lungs and are expected. D. CORRECT: Medium-pitched blowing sounds upon auscultation are bronchovesicular and are expected.

3. A nurse is caring for a client who has a new diagnosis of type 2 diabetes mellitus. Which of the following nursing interventions for stress, coping, and adherence to the treatment plan should the nurse initiate at this time? (Select all that apply.) A. Suggest coping skills for the client to use in this situation. B. Allow the client to provide input in the treatment plan. C. Assist the client with time management, and address the client's priorities. D. Provide extensive instructions on the client's treatment regimen. E. Encourage the client in the expression of feelings and concerns.

3. A. Although it can seem helpful to suggest specific coping skills for the client, it is best to allow the client to discuss coping skills that have worked in the past. B. CORRECT: The nurse should identify that allowing the client to contribute to the treatment plan allows for greater adherence to the plan. C. CORRECT: Helping the client to prioritize is an intervention that can reduce levels of stress for the client because, many times, time management is extremely difficult in times of stress. D. While it is necessary to provide complete information on treatment plans, simplifying treatment regimens as much as possible allows for greater adherence to the treatment plan. E. CORRECT: By using effective communication techniques, encouraging the client to verbalize feelings is an intervention for stress, coping, and adherence that allows the client to reduce stress, validate emotions, and start planning for valid concerns.

4. A nurse is teaching a client who reports stress urinary incontinence. What instructions should the nurse include?

4. When taking actions, the nurse should instruct the client to maintain adequate fluid intake, empty the bladder completely with each void, avoid bladder irritants, such as caffeine and alcohol, and perform pelvic muscle exercises (Kegel) 3 to 4 times each day.

3. A nurse is caring for a client who is having difficulty breathing. The client is lying in bed and is already receiving oxygen therapy via nasal cannula. Which of the following interventions is the nurse's priority? A. Increase the oxygen flow. B. Assist the client to Fowler's position. C. Promote removal of pulmonary secretions. D. Obtain a specimen for arterial blood gases.

3. A. There might be a need to increase the client's oxygen flow, as hypoxia can be the cause of a client's difficulty breathing. However, another action is the priority. B. CORRECT: The priority action to be taken when using the airway, breathing, circulation (ABC) approach to care delivery is to relieve dyspnea (difficulty breathing). Fowler's position facilitates maximal lung expansion and thus optimizes breathing. With the client in this position, the cause of the client's dyspnea can better assessed and determined. C. There might be a need to suction the client's airway or encourage expectoration of pulmonary secretions. However, another action is the priority, D. Check the client's oxygenation status. However, another action is the priority.

3. A nurse is caring for a school-age child who is sitting in a chair. To facilitate effective communication, which of the following actions should the nurse take? A. Touch the child's arm. B. Sit at eye level with the child. C. Stand facing the child. D. Stand with a relaxed posture.

3. A. Touching can intimidate the child and block communication. B. CORRECT: Being at the same eye level as the child facilitates communication. C. Standing can appear domineering and intimidating, even with a relaxed posture. D. Standing can appear domineering and intimidating, even with a relaxed posture.

3. A nurse is caring for a client who weighs 80 kg (176 lb) and is 1.6 m (5 ft 3 in) tall. Calculate the body mass index (BMI) and determine whether this client's BMI indicates a healthy weight, underweight, overweight, or obese.

3. BMI = weight (kg) + height (m2). Step 1: Client's weight (kg) and height (m) = 80 kg and 1.6 m. Step 2: 1.6 × 1.6 = 2.56 m2. Step 3: 80 ÷ 2.56 = 31.25. A BMI greater than 30 identifies obesity.

3. A nurse is caring for a client who is receiving morphine via a patient-controlled analgesia (PCA) infusion device after abdominal surgery. Which of the following statements indicates that the client knows how to use the device? A. "I'll wait to use the device until it's absolutely necessary." B. "I'll be careful about pushing the button too much so I don't get an overdose." C. "I should tell the nurse if the pain doesn't stop while I am using this device." D. "I will ask my adult child to push the dose button when I am sleeping."

3. C. CORRECT: When evaluating outcomes, the nurse should identify that the client understands the purpose of a PCA infusion by their statement, "I should tell the nurse if the pain doesn't stop while I am using this device". This indicates that while the client knows that the device is used for pain control, but if it does not adequately control their pain, the nurse can notify the provider to modify the PCA settings to ensure adequate pain control. A, B, D. The client should be reminded that using the PCA at the first indications of pain will achieve better pain management and that the PCA has a timing control or lockout mechanism, which enforces a preset minimum interval between medication doses, so the client cannot •self-administer another dose of medication until that time interval has passed, even if the button is pressed.

3. A nurse is preparing to administer diazepam to a client. Prior to administering the medication, which of the following actions is the nurse's priority? A. Teach the client about the purpose of the medication. B. Give the medication at the prescribed administration time. C. Identify the client's medication allergies. D. Document the client's anxiety level.

3. C. CORRECT: When prioritizing hypothesis, the nurse should identify that the greatest risk to this client is injury from an allergic reaction. The priority action is to identify the client's allergies prior to medication administration.

4. The nurse is reviewing the medical record of the client. The nurse should identify which of the following findings is a risk factor for the development of hypocalcemia? (Select all that apply.) A. Bariatric surgery B. Diarrhea C. Thyroid cancer D. Diabetes mellitus E. Hyperlipidemia

4. A, B, C. CORRECT: When analyzing data, the nurse should identify that risk factors for hypocalcemia include a past medical history of bariatric surgery and thyroid cancer, and current report of diarrhea due to inadequate absorption of calcium.

4. The nurse is educating the client about ways to improve sleep. Which of the following recommendations should the nurse include? (Select all that apply.) A. Practice muscle relaxation techniques. B. Exercise each morning. C. Take two 30 min naps each day. D. Avoid heavy meals before bedtime. E. Limit fluid intake at least 1 hr before bedtime.

4. A, B, D. CORRECT: When taking actions, the nurse should instruct the client to practice muscle relaxation techniques to promote relaxation, reduce stress, and induce sleep. The nurse should instruct the client to exercise daily, at least 3 hr before bedtime, to promote sleep. A heavy meal before bedtime can cause indigestion which can disturb sleep.

4. A nurse in a provider's office is preparing to assess a client's skin as 1.art of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply.) A. Capillary refill less than 3 seconds B. 1+ pitting edema. in both feet C. Pale nail beds in one hand D. Thick skin on the soles of the feet E. 2+ pulses on the client's lower extremities

4. A, D, E. CORRECT: When analyzing cues, the nurse should identify that a capillary refill less than 3 seconds and 24 pulses in the client's lower extremities are expected indugs and indicate adequate peripheral circulation, Thick skin on the soles of the client's feet is an expected finding.

xercises. 4. A nurse is counseling a middle adult client who describes having difficulty dealing with several issues. Which of the following client statements should the nurse identify as the priority to assess further? A. "I am struggling to accept that my parents are aging and need so much help. B. "It's been so stressful for me to think about having intimate relationships." C. "I know I should volunteer my time for a good cause, but maybe l'm just selfish." D. "I love my grandchildren, but my

4. A. Adjusting to and caring for aging parents is nonurgent because it is an expected challenge during middle adulthood. There is another statement to identify as the priority. B. CORRECT: When using the urgent vs. nonurgent approach to client care, the counseling priority is the problem that reflects a lack of completion of the previous stage and progression to the current stage of development. According to Erikson, developing intimacy vs. isolation is a task of young adulthood. This middle adult is still struggling with this task and needs assistance in working through searching for and developing intimate relationships with others. C. Contributing to the community is nonurgent because it is an expected challenge during middle adulthood. There is another statement to identify as the priority. D. Questioning the ability to contribute to future generations is nonurgent because it is an expected challenge during middle adulthood. There is another statement to identify as the priority.

4. A nurse is performing mouth care for a client who is unconscious. Which of the following actions should the nurse take? A. Turn the client's head to the side. B. Place two fingers in the client's mouth to open it. C. Brush the client's teeth once per day. D. Inject a mouth rinse into the center of the client's mouth.

4. A. CORRECT: The nurse should turn the clients head toward the mattress so that the mouth is in a dependent position. This promotes drainage of secretions away from the throat and reduces the risk of aspiration. B. The nurse should avoid placing fingers in the client's mouth because the client might bite down on the nurse's fingers. C. The nurse should brush the client's mouth at least twice per day.

4. A nurse is instructing a young adult client about health promotion and illness prevention. Which of the following statements indicates understanding? A. "I already had my immunizations as a child, so I'm protected in that area." B. "It is important to schedule routine health care visits even if I am feeling well." C. "I will just go to an urgent care center for my routine medical care." D. "There's no reason to seek help if I am feeling stressed because it's just part of life."

4. A. For protection against a wide variety of communicable illnesses, encourage adults to obtain CDC-recommended immunizations throughout the lifespan. B. CORRECT: The nurse should identify that despite being in relatively good health, young adult clients should plan to participate in routine screenings and health care visits. C. Urgent care centers offer limited services, typically for acute injuries or problems that cannot wait until a primary care provider is available. Encourage clients to establish a relationship with a primary care provider to consult for nonurgent health problems. D. Although it is true that stress is inevitable, chronic stress can lead to severe health alterations. Young adults who have stress that is recurrent, or escalating should seek medical care.

4. A nurse is caring for a client who is recovering from a myocardial infarction and a cardiac catheterization. The client states, "I am concerned that things might be a little, you know, 'different' with my partner when I get home." Which of the following statements should the nurse make? A. "It sounds like something you should discuss with them when you get home." B. "It sounds like you are concerned about sexual functioning. Let's discuss your concerns." C. "Oh, I wouldn't be too concerned. Things will be fine as soon as we get you home." D. "Just make sure you take your medication as directed, and you should be fine.

4. A. The client has valid concerns... B. CORRECT: The nurse should acknowledge and allow the client to discuss their concerns regarding sexual functioning. The nurse should not give the client false reassurance. C. This statement is dismissing the client's feelings.. D. Giving the client a directive and telling them that they should be fine is not allowing the client to express their feelings and is displaying false reassurance, which is inappropriate because the client has valid concerns.

4. A nurse is talking with an adolescent who is having difficulty dealing with several issues. Which of the following issues should the nurse identify as the priority? A. "I kind of like this boy in my class, but he doesn't like me back." B. "I want to hang out with the kids in the science club, but the jocks pick on them." C. "I am so fat, I skip meals to try to lose weight." D. "My dad wants me to be a lawyer like him, but I just want to dance:

4. A. The client is at risk for developing an altered self-esteem due to rejection from their peers. However, another issue is the priority. It is common for adolescents, who are in the stage Erikson describes as identity vs. role confusion, to face the challenge of forming peer relationships and dating relationships. B. The client is at risk for developing an altered self-esteem due to rejection from their peers. However, another issue is the priority. It is common for adolescents, who are in the stage Erikson describes as identity vs. role confusion, to face the challenge of becoming part of a peer group and establishing a group identity. C. CORRECT: When analyzing cues while talking with an adolescent who is having difficulty dealing with several issues the nurse should identify that the greatest risk to the adolescent is injury due to an eating disorder. The priority issue is to provide counseling to promote body image and ensure proper nutrition. D. The client is at risk for devel

4. A nurse is caring for a 45-year-old client who is 2 days ostoperative following an appendectomy and has type diabetes mellitus. Their Hgb is 12 g/dL and BMI is 17.1. he incision is approximated and free of redness, with sant serous drainage on the dressing. The nurse should acognize that the client has which of the following risk ictors for impaired wound healing? (Select all that apply.) A. Age B. Chronic illness C. Low hemoglobin D. Malnutrition E. Poor wound

4. A. The client's age does not place them at an increased risk for impaired wound healing. B. CORRECT: When analyzing cues, the nurse should identify that diabetes mellitus is a chronic illness that places additional stress on the body's healing mechanisms. C. CORRECT: Hemoglobin is essential for oxygen delivery to healing tissues, and this client's hemoglobin level is low. D. CORRECT: A BMI of 17.1 indicates that the client is underweight and, therefore, malnourished. Deficiencies in essential nutrients delay wound healing. E. There is no indication that there have been any breaches in aseptic technique during wound care.

4. A nurse is teaching self-monitoring of blood glucose to a client who has diabetes mellitus. Which of the following instructions should the nurse include? (Select all that apply.) A. Perform blood glucose monitoring once daily at bedtime: B. Wipe the hand with an alcohol swab. C. Hold the hand in a dependent position prior to the puncture. D. Place the puncturing device perpendicular to the site. E. Prick the outer edge of the fingertip for the blood sample.

4. C, D, E. CORRECT: The nurse should take action by telling the client to hold the hand in a dependent position to increase blood flow to the fingers, hold the lancet perpendicular to the skin to ensure the correct piercing depth, and use the outer edge of the fingertip for blood sampling. The client can also use a heel, palm, arm, or thigh. A. Clients usually perform blood glucose monitoring as often as before each meal and at bedtime. Generally, the timing and frequency of blood glucose monitoring correlates with the client's medication schedule. Monitoring once a dav at bedtime does not provide enough information to monitor blood glucose control effectively. B. The dicershould wash the hand with warm water and soap. Alcohol can alter the blood glucose reading.

4. A nurse is teaching a newly licensed nurse about assessing clients who have hearing loss. Sort the following findings into conductive hearing loss or sensorineural hearing loss. A. The client speaks softly. B. The client speaks loudly. C. Weber test that indicates the tuning fork sound is heard better in the affected ear. D. Weber that indicates the tuning fork sound is heard better in the unaffected ear. E. Cerumen obstructs the ear canal. F. The client reports tinnitus.

4. CONDUCTIVE HEARING LOSS: A, C, E SENSORINEURAL HEARING LOSS: B, D, F When taking actions, the nurse should instruct the newly licensed nurse that findings associated with a conductive hearing loss include the Weber test indicates the tuning fork sound is heard better in the affected ear, cerumen obstructs the ear canal, and the client speaks softly. The nurse should instruct the newly licensed nurse that findings associated with a sensorineural hearing loss include the Weber test indicates the tuning fork sound is heard better in the unaffected ear, the client reports tinnitus, and the client speaks loudly.

4. Please sort the listed skills and techniques into the Effective category or the Ineffective category. A. Stereotyping B. Challenging C. Clarifying D. Approving E. Active Listening F. Asking for an explanation

4. EFFECTIVE: C, E INEFFECTIVE: A, B, D,F Effective therapeutic communication skills and techniques are silence, presenting reality, active listening, asking questions, open-ended questioning, clarifying techniques, offering general leads, broad opening statements, showing acceptance and recognition, focusing, giving information, summarizing, offering self, touch, and sharing feelings. Ineffective therapeutic communication skills and techniques include asking irrelevant personal questions, offering personal opinions, stereotyping, giving advice, giving false reassurance, minimizing feelings, changing the topic, asking "why" questions or for an explanation, challenging, offering value judgments, asking excessive probing questions, responding approvingly or disapprovingly, being defensive, testing, judging, offering sympathy, arguing, making automatic responses, and reacting with passive or aggressive responses.

5. A nurse is talking with an older adult client about improving nutritional status. Which of the following interventions should the nurse recommend? (Select all that apply.) A. Increase protein intake to increase muscle mass. B. Decrease fluid intake to prevent urinary incontinence. C. Increase calcium intake to prevent osteoporosis. D. Limit sodium intake to prevent edema. E. Increase fiber intake to prevent constipation.

5. A, C, D, E. CORRECT: The nurse should identify that older adults should increase protein intake to increase muscle mass and improve wound healing, increase calcium intake to reduce the risk for osteoporosis, limit sodium intake to reduce the risk for edema and hypertension, and increase fiber intake to prevent constipation.

5. A nurse is caring for a client who has a tracheostomy. Which of the following actions should the nurse take when providing tracheostomy care? (Select all that apply.) A. Apply the oxygen source loosely if the SpO2 decreases during the procedure. B. Use surgical asepsis to remove and clean the inner cannula. C. Clean the outer cannula surfaces in a circular motion from the stoma site outward. D. Replace the tracheostomy ties with new ties. E. Cut a slit in gauze squares to place beneath the tube holder.

5. A. CORRECT: Provide supplemental oxygen in response to any decline in oxygen saturation while performing tracheostomy care. B. CORRECT: Use a sterile disposable tracheostomy cleaning kit or sterile supplies and maintain surgical asepsis throughout this part of the procedure. C. CORRECT: Cleanse the exposed surfaces of the outer cannula and the area around and under the faceplate in a circular motion from the stoma site outward. Cleansing in this manner helps move mucus and contaminated material away from the stoma for easy removal. D. Replace the tracheostomy ties if they are wet or soiled. There is a risk of tube dislodgement with replacing the ties, do not replace them routinely, E. Use a commercially-prepared tracheostomy dressing with a slit in it. Cutting gauze squares can loosen lint or gauze fibers the client could aspirate.

5. A nurse is preparing to insert an NG tube for a client who requires gastric decompression. Which of the following actions should the nurse perform before beginning the procedure? (Select all that apply) A. Review a signal the client can use if feeling any distress. B. Lay a towel across the client's chest. C. Administer oral pain medication. D. Obtain a Dobhoff tube for insertion. E. Have a petroleum-based lubricant available.

5. A. CORRECT: The nurse should generate solutions and establish a means for the client to communicate that they need to stop the procedure before inserting an NG tube. B. CORRECT: The nurse should also place a disposable towel across the client's chest to provide for a clean environment and protect the client's gown from becoming soiled. C. The nurse should identify that because the purpose of the procedure is to remove stomach contents, the procedure would also remove the oral pain medication. D. The nurse should plan to use the prescribed type of tube for gastric decompression, which is a Salem sump, Miller- Abbott, or Levin. A Dobhoff tube is for feeding. E. The nurse should plan to use a water-based lubricant to reduce complications from aspiration.

5. A nurse is providing denture care for a client. Which of the following actions should the nurse take? A. Using a gauze pad to grasp and pull forward and downward to remove the upper denture B. Storing the dentures overnight in a labeled denture cup filled with a solution of water and mouth wash C. After brushing the dentures, rinsing them in hot water D. Donning sterile gloves prior to performing denture care

5. A. CORRECT: The nurse should use gauze to remove the client's dentures because dentures can be slippery and the gauze helps to ensure a firm grip. B. The nurse should store the dentures overnight in a labeled denture cup but should fill the cup with tepid water. C. After brushing the dentures, the nurse should rinse them in tepid water because hot water can cause the dentures to warp and cold water can cause the dentures to crack. D. The nurse should don clean gloves prior to performing denture care to reduce the risk of infection.

A nurse in a provider's office is preparing to auscultate and percuss a client's abdomen as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply.) A. Tympany B. High-pitched clicks C. Borborygmi D. Friction rubs E. Bruits

5. A. CORRECT: Tympany is the expected drumlike percussion sound over the abdomen. It indicates air in the stomach. B. CORRECT: Typical bowel sounds are high-pitched clicks and gurgles occurring about 35 times/min. C. Borborygmi are unexpected loud, growling sounds that indicate increased gastrointestinal motility. Possible causes include diarrhea, anxiety, bowel inflammation, and reactions to some foods. D. Friction rubs result from the rubbing together of inflamed layers of the peritoneum and are unexpected findings. E Bruits indicate narrowed blood vessels and are unexpected findings.

5. A nurse is caring for a client who is at risk for developing pressure injury. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? (Select all that apply.) A. Keep the head of the bed elevated 30° B. Massage the client's bony prominences frequently. C. Apply cornstarch liberally to the skin after bathing. D. Have the client sit on a gel cushion when in a chair. E. Reposition the client every 3 hr while in bed.

5. A. CORRECT: When generating solutions, the nurse should Identify that slightly elevating the head of the client's bed helps to reduce shearing forces that could tear sensitive skin on the sacrum, buttocks, and heels. B. Deep tissues can be traumatized when massaging the skin over bony prominences. C. Cornstarch and powder can abrade the client's sensitive skin. D. CORRECT: The nurse should also have the client sit on a gel, air, or foam cushion to redistribute weight away from Ischial areas, E. The nurse should reposition the client at least every 2 hr, Frequent position changes are important in preventing skin breakdown, but every 3 hr is not frequent enough.

5. A nurse on a medical-surgical unit is caring for a group of clients. Sort the following clients to those at risk for Hypovolemia or those at risk for Hypervolemia. A. A client who has nasogastric suctioning B. A client who is taking diuretics C. A client who has syndrome of inappropriate antidiuretic hormone D. A client who has cirrhosis

5. HYPOVOLEMIA: A, B; HYPERVOLEMIA: C, D; When analyzing data, the nurse should identify that a client who has nasogastric suctioning and a client who is taking diuretics are at risk for hypovolemia due to excess fluid loss. A client who has syndrome of inappropriate antidiuretic hormone is at risk for hypervolemia due to an excess secretion of ADH. A client who took a toxic dose of sodium bicarbonate antacids is at risk for hypervolemia due to excessive sodium intake.

5. A nurse is instructing an assistive personnel (AP) how to measure a client's respiratory rate. Which of the following statements should the nurse include? (Select all that apply.) A. "Place the client in semi-Fowler's position." B. "Have the client rest an arm across the abdomen." C. "Observe one full respiratory cycle и before counting the rate." D. "Count the rate for 30 sec if it is irregular." E. "Inform the client you are counting their respiratory rate."

5. A. CORRECT: When taking actions, the nurse should instruct the AP to place the client in semi-Fowler's position before counting their respiratory rate to promote ventilation. This position also allows the AP to visualize the client's chest and abdominal movements. B. CORRECT: The nurse should instruct the AP to have the client rest an arm across their abdomen to promote visualization of the client's chest and abdominal movements. C. CORRECT: The nurse should instruct the AP to observe the client for one full respiratory cycle before counting the rate to obtain an accurate measurement.

5. A charge nurse is teaching a newly licensed nurse about the care of a client who has methicillin-resistant Staphylococcus aureus (MRSA). Which of the following statements should the charge nurse identify as an indication that the newly licensed nurse understands the teaching? A. "I should obtain a specimen for culture and sensitivity after the first dose of an antimicrobial." B. "MRSA is usually resistant to vancomycin, so another antimicrobial will be prescribed." C. "I will protect others from exposure when I transport the client outside the room." D. "To decrease resistance, antimicrobial therapy is discontinued when the client is no longer febrile."

5. A. Obtain a specimen for culture and sensitivity prior to, not after, the initiation of antimicrobial therapy. B. MRSA is resistant to most antibiotics except vancomycin. C. CORRECT: When evaluating the outcomes of teaching to a newly licensed nurse, the charge nurse should identify that the statement, "I will protect others from exposure when I transport the client outside the room" indicates understanding of the teaching. With infections due to antibiotic-resistant bacteria, the nurse should protect everyone the client comes in contact with from transmission, especially when outside the isolation room. D. Discontinuing antimicrobial therapy prior to completing a full course of treatment increases the risk of producing resistant pathogens.

5. A nurse is caring for a client who requires a low-residue diet. The nurse should expect to see which of the following foods on the client's meal tray? A. Cooked barley B. Pureed broccoli C. Vanilla custard D. Lentil soup

5. A. Whole grains (barley and oats) are high in fiber and thus inappropriate components of a low-residue diet. B. Raw and gas-producing vegetables (broccoli and the cabbage in coleslaw) are high in fiber and thus inappropriate components of a low-residue diet. C. CORRECT: The nurse should identifv that a low-residue diet consists of foods that are low in fiber and easy to digest. Dairy products and eggs (custard and yogurt) are appropriate for a low-residue diet. D. Legumes (lentils and black beans) are high in fiber and thus inappropriate components of a low-residue diet.

5. A nurse is teaching a class about electrolyte imbalances. Match the electrolyte imbalance to the clinical manifestation. A. Hypocalcemia B. Hypomagnesemia C. Hypernatremia D. Hyperkalemia 1. Dry swollen tongue 2. Hypertension 3. Tingling around mouth 4. Muscle weakness

5. A: 3 B: 2 C: 1 D: 4 When taking actions, the nurse should instruct that manifestations of hypocalcemia can include numbness and tingling of extremities and around mouth; manifestations of hypomagnesemia can include hypertension, tachycardia, and muscle tremors; manifestations of hypernatremia can include dry, red, swollen tongue, muscle twitching, and hyperactive bowel sounds; and manifestations of hyperkalemia can include muscle weakness, irritability, cardiac dysrhythmias, decreased heart rate, and an irregular pulse.

5. A nurse is preparing to initiate a bladder-retraining program for a client who has urge incontinence. Which of the following actions should the nurse take? (Select all that apply.) A. Restrict the client's intake of fluids during the daytime. B. Have the client record urination times. C. Gradually increase the time of the client's urination intervals. D. Remind the client to try to hold urine until the next scheduled urination time. E. Restrict the client's coffee intake to 2 servings each day.

5. B, C, D. CORRECT: When taking actions, the nurse should instruct the client to keep track of urination times as a record of progress toward the goal of 4-hr intervals between urination. The nurse should instruct the client to gradually increase the urination intervals and try to hold urine until the next scheduled urination time, to meet the goal of 4-hr intervals between urination.

5. A nurse is instructing a client who has narcolepsy. Which of the following client statements indicates an understanding of the instructions? A. "I will add plenty of carbohydrates to my meals." B. " will take a short nap when I feel sleepy." C. "I will increase the heat in my office, so I stay warm." D. "I will limit alcohol intake to one drink per day."

5. B. CORRECT: When evaluating outcomes, the nurse should identify that the client statement to take short naps when they are feeling drowsy indicates an understanding of the teaching. Taking a planned daytime nap might reduce the risk of falling asleep at an inopportune time, such as when driving or at work. The nurse should also instruct the client to eat high protein meals, perform regular exercise, and avoid activities that might cause drowsiness, such as being in a warm environment and drinking alcohol.

5. A nurse is reviewing instructions with a client who has a new prescription for hearing aids. Which of the following client statements indicates an understanding of the instructions? A. "I will clean the ear molds of my hearing aids with rubbing alcohol each day." B. "I will use hairspray to keep my hair away from my hearing aids." C. " will take the batteries out of my hearing aids when I take them off at night." D. "I will soak my hearing aids in warm water once each week."

5. C. CORRECT: When evaluating outcomes, the nurse should identify that the client statement to take the batteries out of the hearing aids at night indicates an understanding of the teaching. To conserve battery power, the client should turn off the hearing aids and remove the batteries when not in use.

5. A nurse is preparing to perform postmortem care for a client. The family wishes to view the body. Which of the following actions should the nurse take? A. Make sure the body is lying completely flat. B. Remove dentures from the client. C. Place a clean gown on the client's body. D. Remove all equipment from the client's bedside. E. Dim the lights in the client's room.

5. C. CORRECT: When taking actions, the nurse should demonstrate respect to the client by washing soiled areas of the client's body and covering the client with fresh linens and a clean gown. D. CORRECT: The nurse should remove all equipment and supplies from the client's bedside to provide a calm, uncluttered environment. E. CORRECT: Dimming the lights provides a peaceful atmosphere for the family.

5. The nurse is caring for the client who is receiving IV therapy. Which of the following actions should the nurse plan to take first? A. Obtain a specimen for culture. B. Apply a warm compress. C. Administer analgesics. D. Discontinue the infusion.

5. D. CORRECT: When prioritizing hypothesis, the nurse should identify the greatest risk to this client is further injury to the irritated vein. The nurse should stop the infusion and remove the catheter to reduce the risk of further injury.

5. A nurse is discussing complementary and alternative therapies they can incorporate into their practice without the need for specialized licensing or certification with a group of newly licensed nurses. Sort the following therapies into either those that require a specialized licensed or those that do not require a specialized license. A. Acupuncture B. Chiropractic medicine C. Guided imagery D. Humor E. Therapeutic communication

5. REQUIRES SPECIALIZED LICENSED: A, B; DOES NOT REQUIRE SPECIALIZED LICENSE: C, D, E When taking actions, the nurse should include that acupuncture and chiropractic medicine are alternative therapies that require a specialized licensing or certification. Guided imagery, humor, and therapeutic communication are alternative therapies nurses can incorporate into their practice without the need for specialized licensing or certification.

6. A nurse is caring for a client who has a fractured femur and a blood pressure of 140/94 mm Hg. Which of the following actions should the nurse take first? A. Request a prescription for an antihypertensive medication. B. Ask the client if they are having pain. C. Instruct the client about a low-sodium diet. D. Return in 30 min to recheck the client's blood pressure.

6. B. CORRECT: When taking actions using the nursing process, the first action that the nurse should take is ask the client if they are experiencing pain. Pain can cause an elevated blood pressure. Therefore, the priority action is to evaluate the client for pain.

8. During an abdominal examination, a nurse in a provider's office determines that a client has abdominal distention. The protrusion is at midline, the skin over the area is taut, and the nurse notes no involvement of the flanks. Which of the following possible causes of distention should the nurse suspect? A. Fat B. Fluid C. Flatus D. Hernias

8. A. With fat, there are rolls of adipose tissue along the sides, and the skin does not look taut. B. With fluid, the flanks also protrude, and when the client turns onto one side, the protrusion moves to the dependent side. C. CORRECT: With flatus, the protrusion is mainly midline, and there is no change in the flanks. D. With hernias, protrusions through the abdominal muscle wall are visible, especially when the client flexes the abdominal muscles.

9. A nurse is caring for a client who asks what their Snellen eye test results mean. The client's visual acuity is 20/30. Which of the following responses should the nurse make? A. "Your eyes see at 20 feet what visually unimpaired eyes see at 30 feet." B. "Your right eye can see the chart clearly at 20 feet, and your left eye can see the chart clearly at 30 feet." C. "Your eyes see at 30 feet what visually unimpaired eyes see at 20 feet. D. "Your left eye can see the chart clearly at 20 feet, a

9. A. CORRECT: The first number is the distance (in feet) the client stands from the chart. The second number is the distance at which a visually unimpaired eye can see the same line clearly. B. Each eye has its own visual acuity, which includes both numbers. C. The numerator of visual acuity results is a constant. It does not change with a client's ability to see clearly. D. Each eye has its own visual acuity, which includes both numbers.

9. During a cardiovascular examination, a nurse in a provider's office places the diaphragm of the stethoscope on the left midclavicular line at the fifth intercostal space. Which of the following data is the nurse attempting to auscultate? (Select all that apply.) A. Ventricular gallop B. Closure of the mitral valve C. Closure of the pulmonic valve D. Apical heart rate E. Murmur

9. A. To auscultate a ventricular gallop (an 53 sound), place the bell of the stethoscope at each of the auscultatory sites. B. CORRECT: To auscultate the closure of the mitral valve, place the diaphragm of the stethoscope over the apex, or apical/mitral site, which is on the left midclavicular line at the fifth intercostal space. C. To auscultate the closure of the pulmonic valve, place the diaphragm of the stethoscope over the aortic area, which is just to the right of the sternum at the second intercostal space. D. CORRECT: To auscultate the apical heart rate, place the diaphragm of the stethoscope over the apex of the heart, which is on the left midclavicular line at the fifth intercostal space. F To auscultate a murmur, place the bell of the stethoscope at various auscultatory sites.

1. The nurse is performing a cranial nerve assessment on the client. Match the assessment method to the associated cranial nerve. A. X Vagus Nerve B. XI Spinal accessory nerve C. XII Hypoglossal nerve D. IX Glossopharyngeal nerve 1. Sticking out the tongue 2. Checking speech for hoarseness 3. Identifying a sour taste at the back of the tongue 4. Shrugging the shoulders

A. X vagus nerve 2. Checking speech for hoarseness B. XI spinal accessory nerve 4. Shrugging shoulders C. XII hypoglossal nerve 1. Sticking out the tongue D. IX glossopharyngeal nerve 3. Identifying a sour taste at the back of the tongue

1. A nurse is teaching a class about skin lesions. Match the following lesions with the associated skin condition. 1. Acne 2. Warts 3. Psoriasis 4. Herpes simplex 5. Freckle A. Scale B. Pustule C. Macule D. Nodule E. Vesicle

Scale - psoriasis Pustule - acne Macule - freckle Nodule - warts Vesicle - heroes simplex When recognizing cues, the nurse should instruct that acne is an example of a pustule, or a raised lesion filled with pus. Warts are an example of a nodule, or an elevated solid, firm lesion. Psoriasis is an example of scales, or areas of skin that flakes. Herpes simplex lesions are examples of vesicles, which are circumscribed fluid-filled skin elevations. Freckles are examples of macules, or flat areas of skin color change.

1. A nurse is instructing a class about the physical development of toddlers. Match the age of a toddler with the expected motor skill. 1. Walks up and down stairs 2. Stands on one foot 3. Builds a tower with two blocks A. 15 months B. 2 years C. 2.5 years

1. A, 3 B, 1 C, 2 When taking actions, the nurse should instruct that a 15-month-old toddler should be able to build a tower with two blocks. A 2-year-old toddler should be able to walk up and down stairs and by age 2.5, a toddler should be able to stand on one foot.

Application Exercises 1. A charge nurse is reviewing documentation with a group of newly licensed nurses. Which of the following legal guidelines should be followed when documenting in a client's record? (Select all that apply.) A. Cover errors with correction fluid, and write in the correct information. B. Put the date and time on all entries. C. Document objective data, leaving out opinions. D. Use as many abbreviations as possible. E. Wait until the end of the shift to document.

1. B., C. CORRECT: When taking actions, the nurse should ensure that the day and time confirm the recording of the correct sequence of events. The nurse should ensure that the documentation is factual, descriptive, and objective, without opinions or criticism. A. Correction fluid implies that the nurse might have tried to ha the previous documentation or deface the medical record. D. Too many abbreviations can make the entry difficult to understand. The nurse should minimize use of abbreviations and use only those the facility approves. E. Documentation should be current. Waiting until the end of the shift can result in data omission.

1. The ostomy nurse is providing preoperative education for the client who is scheduled for a sigmoid colostomy. The nurse should identify that which of the following client statements is an indication that the client is ready to learn? A. " will not look at my incision after the surgery." B. "Will you give me pain medicine after the surgery?" C. "Can you tell me about how long the surgery will take?" D. "I can't remember what my doctor told me about the surgery."

1. C. CORRECT: When recognizing cues, the ostomy nurse should identify that asking a concrete question about the procedure indicates that the client is ready to learn about the surgery.

2. A nurse notes that an oncoming nurse smells of alcohol and seems unsteady. Which of the following actions should the nurse take? A. Report the oncoming nurse to the board of nursing. B. Confront the oncoming nurse. C. Notify the oncoming supervisor. D. Ask an assistive personnel (AP) if they smelled alcohol on the oncoming nurse's breath.

2. A. The nurse should report the observation to the oncoming supervisor whose duty is to ensure that a thorough investigation occurs, and if the facts indicate the nurse reported to work after drinking alcohol, reporting the nurse to the state board of nursing. B. The nurse should avoid confronting the oncoming nurse who might become hostile. C. CORRECT: The nurse's duty is to protect client safety. The nurse should report the observation to the oncoming supervisor whose duty is to ensure that a thorough investigation occurs, and if the facts indicate the nurse reported to work after drinking alcohol, report the nurse to the state board of nursing. D. The nurse should also avoid involving another person on the shift such as the AP.

2. The ostomy nurse is preparing to educate the client about caring for the new colostomy. Place the following actions the ostomy nurse should take in the correct order. A. Ask the client to explain how to care for their colostomy. B. Determine what the client knows about colostomies C. Select instructional materials about colostomy care to give to the client. D. Demonstrate how to care for the colostomy.

2. B, C, D, A When taking actions, the ostomy nurse uses the nursing process to educate the client about caring for the colostomy. The first action the nurse should take is to determine what the client knows about colostomies. The ostomy nurse can base the education for the client on preexisting knowledge. The second action the ostomy nurse should take using the nursing process is to plan to use instructional materials to educate the client about colostomy care. The third action the ostomy nurse should take using the nursing process is implementation. The ostomy nurse demonstrates how to care for the colostomy. The fourth action the ostomy nurse should take using the nursing process is evaluation. The ostomy nurse evaluates the client's understanding of how to care for their colostomy.

3. A nurse is reviewing the recommended immunization schedule for the parents of a 6-year-old child. Which immunizations does the nurse inform the parents are generally indicated for a school-age child? A. Varicella B. Influenza C. Shingles D. Hepatitis B E. Measles, mumps, rubella F. Rotavirus

3. A, B, D, E. CORRECT: When taking actions to review the recommended immunization schedule for school-age children, the nurse should inform the parents that immunizations for varicella, influenza, hepatitis B, and measles, mumps and rubella are appropriate for a school-age child.

3. A nurse educator is teaching staff members about facility protocol in the event of a tornado. Which of the following should the nurse include? (Select all that apply.) A. Open doors to client rooms. B. Place blankets over clients who are confined to beds. C. Move beds away from windows. D. Draw shades and close drapes. E. Instruct ambulatory clients in the hallways to return to their rooms.

3. B, C, D When taking action, the nurse should close all client doors to minimize the threat of flying glass and debris, place blankets over clients to protect them from shattering glass or flying debris, move all beds away from windows to protect clients from shattering glass or flying debris, draw shades and close drapes to protect clients against shattering glass, and instruct ambulatory clients to go to the hallways, away from windows, or other secure locations designated by the facility.

4. A nurse is performing a primary survey for a client who has a life-threating condition. In which order should the nurse perform the assessment? A. Check the client's level of consciousness B. Check the client's airway C. Check the client's exposure to adverse elements. D. Check the client's ventilation E. Check the client's circulation

4. B-check airway D-check ventilation E-check circulation A-check level of consciousness C-check exposure to adverse elements When taking action, the nurse should use the ABCDE principle. This stepwise approach is meant to ensure that life-threatening conditions are identified and treated early. A stands for airway, B stands for breathing (ventilation), C stands for circulation, D stands for disability (level of consciousness) and E stands for exposure (whether the client was exposed to extreme heat or cold).

4. A nurse is providing information to parents about nutrition for an infant. Which statements by the parents indicate their understanding of the information? A. "If we stop breastfeeding at 6 months, we can switch to whole milk." B. "If we use formula to feed our newborn, we will include extra water after feedings. C. "Our infant will be ready for solid foods at about 6 months.' D. "Our infant will need an iron supplement while breastfeeding."

4. C. CORRECT: When evaluating outcomes about the parents understanding of nutrition information for infants, the nurse recognizes that the statement, "Our infant will be ready for solid foods at about 6 months" indicates understanding that the infant is ohysiologically and developmentally ready for the introduction of solid foods at about 6 months of age.

4. An occupational health nurse is caring for an employee who was exposed to an unknown dry chemical, resulting in a chemical burn. Which of the following interventions should the nurse include in the plan of care? A. Irrigate the affected area with running water. B. Wash the affected area with antibacterial soap. C. Brush the chemical off the skin and clothing. D. Leave the clothing in place until emergency personnel arrive.

4. C. CORRECT: When taking action, the nurse should not apply water to a dry chemical exposure because it could activate the chemical and cause further harm. The nurse should wash the skin with antibacterial soap in the event of a biological exposure, use a brush to remove the chemical off the skin and clothing, and plan to remove the client's clothing following decontamination. © NCLEX® Connection: Safety and Infection Control, Accident/ Error/Injury Prevention

Applica 1. A charge nurse is discussing the levels of critical thinking with a newly licensed nurse. Match the following interventions with the appropriate critical thinking level. A. A nurse follows a facility's procedure manual to change an IV dressing. B. A nurse repositions a client's arm to improve the infusion of an IV. C. A nurse increases an IV rate on a client who has hypotension. 1. Basic 2. Complex 3. Commitment

1. A, 1 B, 2 C, 3 When analyzing cues, the nurse should identify that nursing interventions that involve concrete thinking, based on rules, such as following a facility's procedure manual to change an IV dressing, is an example of basic critical thinking. Complex critical thinking involves analyzing data and using creativity to problem-solve, such as repositioning a client's arm to promote IV infusion. Commitment critical thinking involves using expert knowledge and experience to problem-solve while assuming responsibility, such as increasing an IV rate on a client who has hypotension.

1. A goal for a client who has difficulty with self-feeding due to rheumatoid arthritis is to use adaptive devices. The nurse caring for the client should initiate a referral to which of the following members of the interprofessional care team? A. Social worker B. Certified nursing assistant C. Registered dietitian D. Occupational therapist

1. A. A social worker can coordinate community services to help the client, but not specifically with self-feeding devices. B. A certified nursing assistant can help the client with feeding, but does not typically procure adaptive devices for the client. C. A registered dietitian can help with educating the client about meeting nutritional needs, but cannot help with the client's physical limitations. D. CORRECT: The nurse should identify that an occupational therapist can assist clients who have physical challenges to use adaptive devices and strategies to help with self-care activities. A certified nursing assistant can help the client with feeding but does not typically procure adaptive devices for the client.

1. A nurse is caring for multiple clients during a mass casualty event. Which of the following clients is the nurse's priority? A. A client who has partial-thickness and full-thickness burns to the face, neck and chest. B. A client who received crush injuries to the chest and abdomen and is expected to die C. A client who has a 4-inch laceration to the head D. A client who has a fractured fibula and tibia

1. A. CORRECT: A client who has burns to the face, neck, and chest is at risk for airway obstruction and requires immediate intervention for survival. Using the survival approach to client care, the nurse should give priority to this client (Emergent Category: Class I). B. A client who has crush injuries to the chest and abdomen and is expected to die (Category IV Expectant) has a minimal chance of survival. The nurse should provide comfort care, but this client is not the nurse's priority. C. A client who has a laceration to the head does not have an immediate threat to life and can wait for treatment (Nonurgent Category: Class III). D. A client who has major fractures does not have an immediate threat to life and can wait for treatment (Urgent (Delayed) Category: Class II).

1. A nurse in a health clinic is caring for a 21-year-old client who tells the nurse that their last physical exam was in high school. Which of the following health screenings should the nurse expect the provider to perform for this client? A. Testicular examination B. Blood glucose C. Fecal occult blood D. Prostate-specific antigen

1. A. CORRECT: The nurse should identify that starting at puberty, the client should have examinations for testicular cancer, along with blood pressure and body mass index and cholesterol measurements. Testicular cancer is most common in males 15 to 34 years of age. B. Blood glucose testing begins at age 45. C. Testing for fecal occult blood usually begins at age 45. D. Testing for prostate-specific antigen usually begins at age 55.

1. A nurse observes an assistive personnel (AP) reprimanding a client for not using the urinal properly. The AP tells the client that diapers will be used next time the urinal is used improperly. Which of the following torts is the AP committing? A. Assault B. Battery C. False imprisonment D. Invasion of privacy

1. A. CORRECT: When recognizing cues, the nurse should identity that the AP is threatening the client; therefore, the AP is committing assault. The AP's threats could make the client become fearful and apprehensive. B. Battery is actual physical contact without the client's consent. Because the AP has only verbally threatened the client, battery has not occurred. C. Unless the AP restrains the client, there is no false imprisonment involved. D. Invasion of privacy involves disclosing information about a client to an unauthorized individual.

1. A nurse is talking with the caregiver of a 4-year-old child who reports that the child is waking up at night with nightmares. Which of the following interventions should the nurse suggest? A. Offer the child a large snack before bedtime. B. Allow the child to watch an extra 30 min of TV in the evening. C. Have the child go to bed at a consistent time every day. D. Increase physical activity before bedtime.

1. A. Eating a large snack, especially one that is heavy or has a Nigh sugar content, is likely to provide stimulation that will make it more difficult for the child to fall asleep. This will not alleviate the child's nightmares. B. Watching TV is likely to provide stimulation that will make it more difficult for the child to fall asleep. This will not alleviate the child's nightmares. C. CORRECT: When taking action while talking to the caregiver of a 4-year-old child who reports that the child is waking up at night with nightmares, the nurse should encourage the caregiver to have the child go to bed at a consistent time every night to promote a bedtime routine. It is also helpful to bathe the child or read a story every night before bed to promote consistency, which should provide reassurance and ensure the child gets adequate sleep. D. Increasing physical activity is likely to provide stimulation that will make it more diffeuls for the child to fall asleep. This will not alleviate th

1. A nurse is caring for a client who decides not to have surgery despite significant blockages of the coronary arteries. The nurse understands that this client's choice is an example of which of the following ethical principles? A. Fidelity B. Autonomy C. Justice D. Nonmaleficence

1. A. Fidelity is the fulfillment of promises. The nurse has not made any promises; this is the client's decision. B. CORRECT: The nurse identifies that in this situation, the client is exercising their right to make their own personal decision about surgery, regardless of others' opinions of what is "best" for them. This is an example of autonomy. C. Justice is fairness in care delivery and in the use of resources. Because the client has chosen not to use them, this principle does not apply. D. Nonmaleficence is a commitment to do no harm. In this situation, harm can occur whether or not the client has surgery. However, because they choose not to, this principle does not apply.

1. A nurse is reviewing hand hygiene techniques with a group of assistive personnel (AP). Which of the following instructions should the nurse include when discussing handwashing? (Select all that apply.) A. Apply 3 to 5 mL of liquid soap to dry hands. B. Wash the hands with soap and water for at least 15 seconds. C. Rinse the hands with hot water. D. Use a clean paper towel to turn off hand faucets. E. Allow the hands to air-dry after washing.

1. A. The APs should apply alcohol rubs to dry hands. When washing hands with soap and water, the As should wet the hands first before applying soap for handwashing. B. CORRECT: It takes 15 seconds to remove transient flora from the hands. For soiled hands, the recommendation is 2 minutes. C. The APs should use warm- not hot- water to minimize the removal of protective skin oils. D. CORRECT: If the sink does not have foot or knee pedals, the As should turn off the water with a clean paper towel and not with their hands. E. The APs should dry their hands with a clean paper towel. This helps prevent chapped skin.

1. A nurse is caring for a client who fell at a nursing home. The client is oriented to person, place, and time and can follow directions. Which of the following actions should the nurse take to decrease the risk of another fall? (Select all that apply.) A. Place a belt restraint on the client when they are sitting on the bedside commode. B. Keep the bed in its lowest position with all side rails up. C. Make sure that the client's call light is within reach. D. Provide the client with nonskid fo

1. A. The nurse should identify that restraining the client places a liability risk for false imprisonment. B. Ensuring full side rails for this client puts the client at risk for a fall because they might attempt to climb over the rails to get out of bed. C. CORRECT: Making sure that the call light is within reach enables the client to contact the nursing staff to ask for assistance and prevents the client from falling out of bed while reaching for the call light. D. CORRECT: Nonskid footwear keeps the client from slipping E. CORRECT: A fall-risk assessment serves as the basis for a plan of care that can then individualize for the client.

1. A nurse educator is reviewing proper body mechanics during employee orientation. Which of the following statements should the nurse identify as an indication that an attendee understands the teaching? (Select all that apply.) A. "My line of gravity should fall outside my base of support." B. "The lower my center of gravity, the more stability I have. C. "To broaden my base of support, I should spread my feet apart." D. "When I lift an object, I should hold it as close to my bodv as possible."

1. A. To reduce the risk of falling, the line of gravity should fall within the base of support, not outside it. B. CORRECT: The new employee should identify that being closer to the ground lowers the center of gravity, which leads to greater stability and balance. C. CORRECT: Spreading the feet apart increases and widens the base of support. D. CORRECT: Holding an object as close to the body as possible helps avoid displacement of the center of gravity and thus prevents injury and instability. E. To promote stability, move the rear leg back when pulling on an object.

A nurse is discussing the purpose of regulatory agencies during a staff meeting . Which of the following tasks should the nurse identify as the responsibility of state licensing boards? A. Monitoring evidence - based practice for clients who have a specific diagnosis B. Ensuring that health care providers comply with regulations C. Setting quality standards for accreditation of health care facilities D. Determining whether medications are safe for administration to clients

1. A. Utilization review committees have the responsibility of monitoring for appropriate diagnosis and treatment according to evidence-based practice for diagnosis and treatment of hospitalized clients. B. CORRECT: State licensing boards are responsible for ensuring that health care providers and agencies comply with state regulations. C. The Joint Commission has the responsibility of setting quality standards for accreditation of health care facilities. D. The U.S. Food and Drug Administration has the responsibility of determining whether medications are safe for administration to clients.

1. A nurse is preparing an in-service program about delegation. Which of the following are components of the five rights of delegation? (Select all that apply.) A. Right place B. Right supervision and evaluation C. Right direction and communication D. Right documentation E. Right circumstances

1. B, C, E. CORRECT: When taking action, the nurse should instruct that right supervision and evaluation, right direction and communication, and right circumstances are included in the five rights of delegation. Right task and right person are also included in the five rights of delegation. The five rights of delegation are used to ensure client care is delegated in a safe and effective manner.

2. A nurse is caring for a client who has a history of falls. Which of the following actions is the nurse's priority? A. Complete a fall-risk assessment B. Educate the client and family about fall risks. C. Eliminate safety hazards from the client's environment. D. Make sure the client uses assistive aids in their possession.

2. A. CORRECT: The nurse should identify that the first action to take using the nursing process is to assess or collect data from the client. Therefore, the priority action is to determine the client's fall risk. This will work as a guide in implementing appropriate safety measures. B. The nurse should educate the client and family about fall risk factors so they can help promote client safety, but this is not the priority action. C. The nurse should eliminate safety hazards from the client's environment to help reduce the risk for falls, but this is not the priority action. D. Aids, such as eyeglasses, hearing aids, canes, and walkers, should be accessible to reduce the client's risk for falls, but this is not the priority action.

2. A nurse is caring for a group of clients on a medical-surgical unit. For which of the following client care needs should the nurse initiate a referral for a social worker? (Select all that apply.) A. A client who has terminal cancer requests hospice care in the home. B. A client asks about community resources available for older adults. C. A client states, "I would like to have my child baptized before surgery." D. A client requests an electric wheelchair for use after discharge. E. A client

2. A. CORRECT: The nurse should initiate a referral for a social worker to provide information and assistance in coordinating hospice care for a client. B. CORRECT: The nurse should initiate a referral for a social worker to provide information and assistance in coordinating care for community resources available for clients. C. The nurse should initiate a referral for spiritual support staff it a client requests specific religious sacraments or prayers. D. CORRECT: The nurse should initiate a referral for a social worker to assist the client in obtaining medical equipment for use after discharge. E. The nurse should provide client teaching for concerns regarding the use of a nebulizer. If additional information is needed, initiate a referral for a respiratory therapist.

toddler with the expected motor skill. A. 15 months 1. Walks up and down stairs B. 2 years 2. Stands on one foot C. 2.5 years 3. Builds a tower with two blocks 2. A parent tells a nurse that their 2-vear-old toddler has temper tantrums and says "no" every time the parent tries to help them get dressed. The nurse should identify the toddler is manifesting which of the following stages of development? A. Trying to increase independence B. Developing a sense of trust C. Establishing a new identity

2. A. CORRECT: When recognizing cues, the nurse should identify that the toddler is expressing a desire for independence by challenging those in authority. Toddlers become easily frustrated and express this frustration by a temper tantrum.

2. A nurse is receiving a provider's prescription by telephone for morphine for a client who is reporting moderate to severe pain. Which of the following nursing actions are appropriate? (Select all that apply.) A. Repeat the details of the prescription back to the provider. B. Have another nurse listen to the telephone prescription. C. Obtain the provider's signature on the prescription within 24 hr. D. Decline the verbal prescription because it is not an emergency situation. E. Tell the charge

2. A. CORRECT: When taking actions, the nurse should repeat the medication's name, dosage, time or interval route, and any other pertinent information back to the provider and receive document confirmation. B. CORRECT: The nurse should have another nurse listen to the telephone prescription as a safety precaution to help prevent medication errors due to miscommunication. C. CORRECT: The provider must sign the prescription within the time frame the facility specifies in its policies (generally 24 hr). D: The nurse should identify that unrelieved pain can become an emergency situation without the appropriate pain management interventions. E. There is no need to inform the charge nurse every time a nurse receives a medication prescription, whether by telephone, verbally or in the medical record. by telephone, verbally, or in the medical record.

2. A nurse offers pain medication to a client who is postoperative prior to ambulation. The nurse understands that this aspect of care delivery is an example of which of the following ethical principles? A. Fidelity B. Autonomy C. Justice D. Beneficence

2. A. Fidelity is the fulfillment of promises. Unless the nurse has specifically promised the client a pain-free recovery, which is unlikely, this principle does not apply to this action. B. Autonomy is the right to make personal decisions, even when they are not necessarily in the person's best interest. In this situation, the nurse is delivering responsible client care. This principle does not apply. C. Justice is fairness in care delivery and in the use of resources. Pain management is available for all clients who are postoperative, so this principle does not apply. D. CORRECT: The nurse should identify that beneficence is action that promotes good for others, without any self-interest. By administering pain medication before the client attempts a potentially painful exercise like ambulation, the nurse is taking a specific and positive action to help the client.

2. When entering a client's room to change a surgical dressing, a nurse notes that the client is coughing and sneezing. Which of the following actions should the nurse take when preparing the sterile field? A. Keep the sterile field at least 6 ft away from the client's bedside. B. Instruct the client to refrain from coughing and sneezing during the dressing change. C. Place a mask on the client to limit the spread of micro-organisms into the surgical wound. D. Keep a box of facial tissues nearby

2. A. It would be difficult to maintain a sterile field away from the bedside. But more importantly, this might not have any effect on the transmission of some micro-organisms. B. The client might be unable to refrain from coughing and sneezing during the dressing change. C. CORRECT: Placing a mask on the client prevents contamination of the surgical wound during the dressing change. D. Keeping tissues close by for the client to use still allows contamination of the surgical wound.

2. A nurse is explaining the various types of health care coverage clients might have to a group of nurses. Which of the following health care financing mechanisms should the nurse include as federally funded? (Select all that apply.) A. Preferred provider organization (PPO) B. Medicare C. Long-term care insurance D. Exclusive provider organization (EPO) E.. Medicaid

2. A. PPOs, long-term care insurance, and EPOs are privately funded. B. CORRECT: Medicare and Medicaid are federally funded health insurance programs. C. PPOs, long-term care insurance, and EPOs are privately funded. D. PPOs, long-term care insurance, and EPOs are privately funded. E. CORRECT: Medicare and Medicaid are federally funded health insurance programs.

2. A nurse is planning diversionary activities for preschoolers on an inpatient pediatric unit. Which of the following activities should the nurse include? (Select all that apply.) A. Hide and seek B. Pulling wheeled toys C. Putting puzzles together D. Using musical toys E. Playing with puppets F. Coloring with crayons

2. A. Playing hide and seek is a high energy activity and should not be included in the activities. Many children who are hospitalized have low energy levels. B. Pulling or pushing toys helps toddlers develop large muscles and coordination. C. CORRECT: Putting puzzles together helps a preschooler develop fine motor and cognitive skills. D. CORRECT: Playing with musical toys helps a preschooler develop fine motor skills and coordination E. CORRECT: Playing with puppets helps a preschooler develop oral language and actively use their imagination. F. CORRECT: Using crayons to color on paper or in coloring books helps a preschooler develop fine motor skills and coordination.

2. A nurse at a provider's office is talking about routine screenings with a 45-year-old female client who has no specific family history of cancer or diabetes mellitus. Which of the following client statements indicates that the client understands how to proceed? A. "I'll need a colonoscopy in 5 years." B. "For now, I should continue to have a clinical breast exam each year." C. "Because the doctor just did a Pap smear, I'll come back next year for another one." D. "I had my blood glucose test

2. A. The nurse should identify that the female client who has no specific family or personal history of colorectal cancer should have a colonoscopy every 10 years beginning at age 45. B. CORRECT: The female client who is between the ages of 40 and 49 should have a clinical breast exam annually, and they should consult with their provider about the frequency of mammograms. C. The female client who is between the ages of 30 and 65, with no family or personal history of cervical cancer, should have either a Pap smear and human papilloma virus test every 5 years, or a Pap test every 3 years. D. The client who is age 45 should have a blood alucose test at least every 3 years. Unless there is a specific family or personal history of diabetes mellitus, annual blood glucose determinations are not necessary.

2. A nurse educator is providing education on infant safety to a group of guardians. Which of the following statements by a guardian indicates an understanding of the teaching? A. "I should line the crib with bumper pads." B. "I will make sure the crib slats are no more than 3 inches apart." C. "| should place the baby on their back when sleeping. D. "I should place the baby in a vehicle safety seat facing forward in the back seat of the car."

2. C. CORRECT: When taking action, the nurse should instruct the guardian of an infant to place the infant on their backs to sleep to safeguard against sudden unexpected infant death syndrome (SUIDs). Crib slats should be no more than 6 cm (2.4in) apart to prevent the infant from slipping through the slats, and bumper pads should not be used to line the crib to reduce the risk of SUIDs. When placing the infant in a motor vehicle, the infant should be placed in a federally approved car seat that is rear facing in the back seat of the vehicle.

2. As part of the admission process, a nurse at a long-term care facility is gathering a nutrition history for a client who has dementia. Which of the following components of the nutrition evaluation is the priority for the nurse to determine from the client's family? A. Body mass index B. Usual times for meals and snacks C. Favorite foods D. Difficulty swallowing

2. D. CORRECT: When recognizing cues, the greatest risk to this client related to a nutrition-related evaluation is from difficulty swallowing, or dysphagia. It puts the client at risk for aspiration, which can be life-threatening. It is important to calculate body mass index to determine the client's weight status and related risks. However, there is a higher priority. It is important to know and try to follow the meal schedule the client follows at home. However, there is a higher priority. It is important to know which foods are the client's favorites in case it becomes difficult to get the client to consume adequate nutrients. However, there is a higher priority.

2. A nurse is caring for a client who has an infection. Sort the manifestations the nurse would expect to find if the infection is Localized or Systemic. A. Fever B. Malaise C. Edema D. Pain or tenderness E. Increase in pulse and respiratory rate

2. LOCALIZED: C-edema D-pain or tenderness SYSTEMIC: A-fever B-malaise E-increase in pulse and respiratory rate When recognizing cues, the nurse identifies edema and pain or tenderness as manifestations of a localized infection, because they are limited to a specific area of the body. The nurse identifies fever, malaise, and increased heart and respiratory rates as manifestations of a systemic infection that is affecting multiple parts of the body.

3. A charge nurse is discussing critical thinking attitudes with a newly licensed nurse. Match the following nursing actions with the critical thinking attitude. 1. Creativity 4. Perseverance 2. Risk-taking 5. Responsibility 3. Fairness 4. Perseverance 5. Responsibility A. Caring for a client in a nonjudgmental manner B. Checking a client's medical record for allergies before administering a medication C. Taking a calculated chance to find a solution to a client's problem D. Using imagination

3. A, 3 B, 5 C, 2 D, 1 E, 4 When recognizing cues, the charge nurse should identify that caring for a client in a nonjudgmental manner demonstrates the critical thinking attitude of fairness. Fairness is using a nonjudgmental, objective approach in looking at clients and situations. Checking a client's medical record for allergies before administering a medication demonstrates the critical thinking attitude of responsibility. The nurse is responsible for administering medications in a safe manner and according to standards of practice. Checking the medical record for allergies helps ensure safety. Taking a calculated chance to find a solution to a client's problem demonstrates the critical thinking attitude of risk-taking. Risk-taking is a calculated approach to solving a problem that is not responding to traditional methods. Using imagination to find a unique solution to solve a client's problem demonstrates the critical thinking attitude of creativity. Continuing to work to solve a p

3. A nurse is discussing occurrences that require completion of an incident report with a newly licensed nurse. Which of the following should the nurse include in the teaching? (Select all that apply). A. Medication error B. Needlesticks C. Conflict with provider and nursing staff D. Omission of prescription E. Missed specimen collection of a prescribed laboratory test

3. A, B, D. CORRECT: When taking actions, the nurse should include the necessity to complete an incident report regarding a medication error, complete an incident report regarding a needlestick, and complete an incident report following an omission of a prescription. C. The nurse should report a conflict with a provider and nursing staff to the charge nurse or nurse manager. E. The nurse should report missed specimen collection of a prescribed laboratory test to the charge nurse or nurse manager.

3. A nurse manager is developing strategies to care for the increasing number of clients who have obesity. Which of the following actions should the nurse include as a primary health care strategy? A. Collaborating with providers to perform obesity screenings during routine office visits B. Ensuring the availability of specialized beds in rehabilitation centers for clients who have obesity C. Providing specialized intraoperative training in surgical treatments for obesity D. Educating acute care

3. A. CORRECT: Obesity screenings at office visits is an example of primary health care. Primary health care emphasizes health promotion and disease control, is often delivered during office visits, and includes screenings. B. Care that is provided in a rehabilitation center as an example of restorative health care. C. Specialized and highly technical care is an example of tertiary health care. D. Education about postoperative complications for acute care nurses is an example of secondary health care.

4. The ostomy nurse is educating the client about how to empty their ostomy pouch. Which of the following actions by the client indicates that psychomotor learning has taken place? A. The client states how often the ostomy pouch should be emptied. B. The client demonstrates emptying the ostomy pouch. C. The client writes the steps of how to empty the ostomy pouch on a piece of paper. D. The client states they understand how to empty their ostomy pouch.

4. B. CORRECT: When evaluating outcomes, the ostomy nurse should identify that the client demonstrating that they can empty the ostomy pouch indicates psychomotor learning has taken place. The psychomotor domain of learning involves performing a physical task.

3. A nurse is caring for a client who had a stroke and is scheduled for transfer to a rehabilitation center. Which of the following tasks are the responsibility of the nurse at the transferring facility? (Select all that apply.) A. Ensure that the client has possession of their valuables. B. Confirm that the rehabilitation center has a room available at the time of transfer. C. Assess how the client tolerates the transfer. D. Give a verbal transfer report via telephone. E. Complete a transfer fo

3. A. CORRECT: The nurse should identify that it is important that both the transferring and receiving nurse account for all of the client's valuables at the time of transfer. B. CORRECT: On the day of the transfer, the transferring nurse should confirm that the receiving facility is expecting the client and that the room is available. It is the responsibility of the nurse at the receiving facility to assess the client upon arrival to determine how they tolerated the transfer. D. CORRECT: The transferring nurse should provide the nurse at the receiving facility with a verbal transfer report in person or via telephone. E. CORRECT: The transferring nurse should complete any documentation for the transfer, including a transfer form and the client's medical records.

3. A nurse manager is reviewing guidelines for preventing injury with staff nurses. Which of the following instructions should the nurse manager include? (Select all that apply.) A. Request assistance when repositioning a client. B. Avoid twisting your spine or bending at the waist. C. Keep your knees slightly lower than your hips when sitting for long periods of time. D. Use smooth movements when lifting and moving clients. E. Take a break from repetitive movements every 2 to 3 hr to flex and s

3. A. CORRECT: The nurse should identify that to reduce the risk of injury, at least two staff members should reposition clients. B. CORRECT: Twisting the spine or bending at the waist (flexion) increases the risk for injury. C. When sitting for long periods of time, it is essential to keep the knees slightly higher, not lower, than the hips to decrease strain on the lower back. D. CORRECT: Using smooth movements instead of sudden or jerky muscle movements helps prevent injury. E. It is important to take a break every 15 to 20 min, not every 2 to 3 hr, from repetitive movements to flex and stretch joints and muscles.

3. A client who is postoperative following knee arthroplasty is concerned about the adverse effects of the medication prescribed for pain management. Which of the following members of the interprofessional care team can assist the client in understanding the medication's effects? (Select all that apply.) A. Provider B. Certified nursing assistant C. Pharmacist D. Registered nurse E. Respiratory therapist

3. A. CORRECT: The provider must be knowledgeable about any medication prescribed for the client, including its actions, effects, and interactions. B. It is not within the scope of a certified nursing assistant's duties to counsel a client about medications. C. CORRECT: A pharmacist must be knowledgeable about any medication dispensed for the client, including its actions, effects, and interactions. D. CORRECT: A registered nurse must be knowledgeable about any medication administered, including its actions, effects, and interactions. E. Although some analgesics can cause respiratory depression, requiring assistance from a respiratory therapist, it is not within this therapist's scope of practice to counsel the client about medications prescribed by the provider.

3. A nurse manager is reviewing with nurses on the unit in the care of a client who has had a seizure. Which of the following statements by a nurse requires further instruction? A. "I will place the client on their side." B. "I will go to the nurses' station for assistance." C. "I will note the time that the seizure begins." D. "I will prepare to insert an airway."

3. A. During a seizure, the client should be placed in a side. lying position to allow for drainage of secretions and to prevent the tongue from occluding the airway. B. CORRECT: The nurse should identify that during a seizure, the client should not be left alone, and the call light system should be activated to summon assistance. C. The nurse should note the time the seizure begins, and track how long the seizure lasts. D. Place nothing in the client's mouth except an oral airway, if necessary. A tongue blade can cause injury and airway obstruction.

3. A nurse is instructing a group of newly licensed nurses about the responsibilities organ donation and procurement involve. When the nurse explains that all clients waiting for a kidney transplant have to meet the same qualifications, the newly licensed nurses should understand that this aspect of care delivery is an example of which of the following ethical principles? A. Fidelity B. Autonomy C. Justice D. Nonmaleficence

3. A. Fidelity is the fulfillment of promises. Because donor organs are a scarce resource compared with the numbers of potential recipients who need them, no one can promise anyone an organ. Thus, this principle does not apply. B. Autonomy is the right to make personal decisions, even when they are not necessarily in the person's best interest. No personal decision is involved with the qualifications for organ recipients. C. CORRECT: The nurse should identify that justice is fairness in care delivery and in the use of resources. By applying the same qualifications to all potential kidney transplant recipients, organ procurement organizations demonstrate this ethical principle in determining the allocation of these scarce resources. D. Nonmaleficence is a commitment to do no harm. In this situation, harm can occur to organ donors and to recipients. The requirements of the organ procurement organizations are standard procedures and do not address avoidance of harm or injury.

3. A nurse has removed a sterile pack from its outside cover and placed it on a clean work surface in preparation for an invasive procedure. Which of the following flaps should the nurse unfold first? A. The flap closest to the body B. The right side flap C. The left side flap D. The flap farthest from the body

3. A. The flap closest to the body is the innermost flap and the last one to unfold. B. Unfold the side flap that is closest to the top of the package before the one underneath it; however, there is another flap to unfold first. C. Unfold the side flap that is closest to the top of the package before the one underneath it; however, there is another flap to unfold first. D. CORRECT: The priority goal in setting up a sterile field is to maintain sterility and thus reduce the risk to the client's safety. Unless the nurse pulls the top flap (the one farthest from their body) away from the body first, there is a risk of touching part of the inner surface of the wrap and thus contaminating it.

3. A nurse is caring for a young adult at a college health clinic. Which of the following actions should the nurse take first? A. Give the client information about immunization against meningitis. B. Tell the client to have a TB skin test every 2 years. C. Determine the client's health risks. D. Teach the client about exercise recommendations.

3. A. The nurse should plan to give the client information on the meningococcal vaccine as part of the primary disease prevention; however, there is another action the nurse should take first. B. The nurse should recommend TB screening depending on the client's occupation and exposure to TB as part of secondary disease prevention; however, there is another action the nurse should take first. C. CORRECT: The first action that should be taken using the nursing process is assessment. Talk with the client first to determine what risk factors the client might have before initiating the health promotion and disease prevention measures. D. The nurse should instruct the client about exercise and activity recommendations as part of health promotion; however, there is another action the nurse should take first.

3. A nurse is providing preoperative teaching for a client who is scheduled for surgery the next week. The client tells the nurse, "I plan to prepare my advance directives before I come to the hospital." Which of the following statements made by the client indicates an understanding of advance directives? A. "I'd rather have my brother make my decisions for me, but I know it must be my spouse.' B. "I know they won't go ahead with the surgery unless I fill out the form." C. "I plan to tell them I

3. A. When analyzing cures, the nurse should recognize that the client can designate any competent adult to be their health care proxy. It does not have to be their spouse. B. The hospital staff cannot refuse care based on the lack of advance directives. The client has the right to decide and specify which medical procedures they want when a life-threatening situation arises. C. CORRECT: The hospital staff cannot refuse care based on the lack of advance directives. The client has the right to decide and specify which medical procedures they want when a life-threatening situation arises. D. However, they should give his primary care provider a copy of the document for their records.

3. A nurse is delegating the ambulation of a client who had a knee arthroplasty 2 days ago to an AP. Which of the following information should the nurse share with the AP? (Select all that apply.) A. The client's roommate ambulates independently. B. The client ambulates wearing slippers over antiembolic stockings. C. The client uses a front-wheeled walker when ambulating. D. The client had pain medication 30 min ago. E. The client is allergic to codeine. F. The client ate 50% of breakfast this m

3. B, C, D. CORRECT: When taking actions, the nurse should provide right direction and communication to ensure the AP can complete this assignment safely. The nurse should share information with the AP to make sure the client wears stockings and slippers and uses a front-wheeled walker while ambulating. The AP should know that the client might be feeling the effects of the pain medication.

3. A nurse is contributing to the plan of care for a client who is being admitted to the facility with a suspected diagnosis of pertussis. Which of the following interventions should the nurse suggest?? (Select all that apply.) A. Place the client in a room that has negative air pressure of at least six exchanges per hour. B. Wear a mask when providing care within 3 ft of the client. C. Place a surgical mask on the client if transportation to another department is unavoidable. D. Use sterile glo

3. B, C, E When generating solutions for a client who has pertussis, the nurse should suggest using droplet precautions when caring for this client, including wearing a mast when within 3 feet when caring for the client to protect against inhalation of small droplets and placing a surgical mask on the client when transporting them to contain respiratory droplets. The nurse should also suggest wearing a gown when care may involve contamination from respiratory secretions.

3. A nurse is reviewing the Centers for Disease Control and Prevention's (CDC) immunization recommendations with the guardians of preschoolers. Which of the following vaccines should the nurse include in this discussion? (Select all that apply.) A. Haemophilus influenzae type B B. Varicella C. Polio D. Hepatitis A E. Seasonal influenza

3. B, C, E. CORRECT: When taking action while reviewing the Centers for Disease Control and Prevention's (CDC) immunization recommendations with the parents of preschoolers, the nurse should include the following vaccinations in the discussion: varicella, polio, and seasonal influenza. A. The CDC recommends Haemophilus influenzae type B immunizations during infancy, but not generally beyond 15 months of age. D. The CDC recommends hepatitis A immunizations during infancy, but not generally beyond 23 months of age.

3. A nurse is reviewing the recommended immunization schedule for parents of an infant. Which immunizations does the nurse inform the parents are recommended within the first year? (Select all that apply.) A. Varicella B. Human papillomavirus (HPV) C. Meningococcal D. Hepatitis B E. Diphtheria F. Rotavirus

3. D, E, F. CORRECT: When taking actions to review the recommended immunization schedule for infants, the nurse should inform the parents that hepatitis B, diphtheria, and rotavirus immunizations are recommended within the first year.

4. A client who had a cerebrovascular accident has persistent problems with dysphagia. The nurse caring for the client should initiate a referral with which of the following members of the interprofessional care team? (Select all that apply.) A. Social worker B. Certified nursing assistant C. Occupational therapist D. Speech-language pathologist E. Physical therapist

4. C, D. CORRECT: The nurse should identify that a speech. language pathologist and an occupational therapist can initiate specific therapy for clients who have difficulty with feeding due to swallowing difficulties. A. A social worker can coordinate community services to help the client, but not specifically with dysphagia. B. A certified nursing assistant can help the client with feeding but cannot assess and treat dysphagia. E. A physical therapist can assist clients who have motor challenges to improve abilities with self-care and work but cannot assess and treat dysphagia.

4. A nurse is evaluating education provided to the guardians of a 10-year-old child about nutrition. Sort the statements made by the guardians into Indicates Understanding or Indicates Additional Teaching Is Needed. A. "Our child eats at a different time than we do so we can eat whatever we want." B. "Our child skips lunch sometimes, but we think it's okay as long as we eat a healthy breakfast and dinner. C. "We reward school achievements with a point system instead of pizza or ice cream." D. "W

4. INDICATES UNDERSTANDING: C, E INDICATES ADDITIONAL TEACHING IS NEEDED: A, B, D When evaluating outcomes related to nutrition education with the family of a school-age child, the nurse should recognize that the guardians understand the education provided by expressing that they use a point system instead of food for rewards and calorie counting for a school-age child is not appropriate. The nurse recognizes that additional teaching is needed about modeling healthy eating behaviors, preventing the child from skipping meals, and selecting healthier options from fast food restaurants.

4. A charge nurse is observing a newly licensed nurse care for a client who is postoperative and reports pain. Match the actions of the newly licensed nurse with the nursing process. 1. Assessment/ 3. Planning Data Collection 4. Implementation 2. Analysis/Diagnosis/ 5. Evaluation Data Collection A. The newly licensed nurse documents that the client's pain is causing the client to take shallow breaths and could lead to complications such as atelectasis. B. The newly licensed nurse administered th

4. A, 2 B, 4 C, 1 D, 5 E, 3 The charge nurse is recognizing cues when identifying that the newly licensed nurse is using the steps of the nursing process when caring for the client who is postoperative and reports pain. The newly licensed nurse uses the assessment/data collection step of the nursing process when asking the client to rate the severity of pain on a scale of 0 to 10 scale. Documenting that the client's pain is causing the client to take shallow breaths and could lead to complications such as atelectasis is part of the analysis/diagnosis/data collection step of the nursing process. The newly licensed nurse clusters and interprets data to determine a conclusion. The newly licensed nurse is using the planning step of the nursing process when determining the client is due to receive the pain medication and prepares to administer a dose to the client. Administering the pain medication to the client is part of the implementation step of the nursing process. The newly licensed n

4. A charge nurse is discussing critical thinking attitudes with a newly licensed nurse. Match the following nursing actions with the critical thinking attitude. 1. Confidence 4. Discipline 2. Integrity 5. Curiosity 3. Humility A. Showing honesty when caring for clients B. Using a head-to-toe approach to conduct a physical examination on a client C. Speaking with certainty to a client when instructing them about a new diet D. Asking questions to obtain more information about a client's problem E

4. A, 2 B, 4 C, 1 D, 5 E, 3 When recognizing cues, the charge nurse should identify that showing honesty when caring for clients demonstrates the critical thinking attitude of integrity. Integrity is caring for clients truthfully and ethically. Using a head-to-toe approach to conduct a physical examination on a client demonstrates the critical thinking attitude of discipline. Discipline involves using a systematic approach to collecting data and making decisions. Speaking with certainty to a client when instructing them about a new diet demonstrates the critical thinking attitude of confidence. A confident nurse believes in their own abilities. Asking questions to obtain more information about a client's problem demonstrates the critical thinking attitude of curiosity. A curious nurse asks questions to explore and study a clinical situation. Identifying limitations of oneself when dealing with a clinical situation demonstrates the critical thinking attitude of humility. A nurse who has

4. A nurse is preparing the discharge summary for a client who has had knee arthroplasty and is going home. Which of the following information about the client should the nurse include in the discharge summary? (Select all that apply.) A. Advance directives status B. Follow-up care C. Instructions for diet and medications D. Most recent vital sign data E. Contact information for the home health care agency

4. A. Advance directive status is important in transfer documentation, when other care providers will take over a client's care. They are not an essential component of a discharge summary for a client who is returning to their home. B. CORRECT: When generating solutions, the nurse should identify that it is essential to include the names and contact information of providers and community resources the client will need after they return home. C. CORRECT: The client will need written information detailing home medication and dietary therapy. A client who has had knee arthroscopy typically requires analgesics, possibly anticoagulants, and dietary instructions for avoiding postoperative complications (constipation). D. Vital sign measurements are important in transfer documentation, when other care providers will take over a client's care. They are not an essential component of a discharge summary for a client who is returning home. E. CORRECT: It is essential to include the names and cont

4. A nurse observes smoke coming from under the door of the staff's lounge. Which of the following actions is the nurse's priority? A. Extinguish the fire. B. Activate the fire alarm. C. Move clients who are nearby. D. Close all open doors on the unit.

4. A. Although extinguishing the fire is part of the protocol for responding to a fire, it is not the priority action. B. Activating the fire alarm is part of the protocol for responding to a fire; however, it is not the priority action. C. CORRECT: The nurse should identify that the greatest risk to this client is injury from the fire. Therefore, the priority intervention is to rescue the clients. Protect and move clients in close proximity to the fire. D. Although containing the fire by closing doors and windows is part of the protocol for responding to a fire, it is not the priority action.

4. A nurse has prepared a sterile field for assisting a provider with a chest tube insertion. Which of the following events should the nurse recognize as contaminating the sterile field? (Select all that apply.) A. The provider drops a sterile instrument onto the near side of the sterile field. B. The nurse moistens a cotton ball with sterile normal saline and places it on the sterile field. C. The procedure is delayed 1 hr because the provider receives an emergency call. D. The nurse turns to s

4. A. As long as the provider has not reached over the sterile field (by placing the instrument on a near portion of the field), the field remains sterile. B. CORRECT: Fluid permeation of the sterile drape or barrier contaminates the field. C. CORRECT: Prolonged exposure to air contaminates a sterile field. D. CORRECT: Turning away from a sterile field contaminates the field because the nurse cannot see if a piece of clothing or hair made contact with the field. E. The 1-inch border at the outer edge of the sterile field is not sterile. Unless the client reached farther into the field, the field remains sterile

4. A nurse is explaining the various levels of health care services to a group of newly licensed nurses. Which of the following examples of care or care settings should the nurse classify as tertiary care? (Select all that apply.) A. Intensive care unit B. Oncology treatment center C. Burn center D. Cardiac rehabilitation E. Home health care

4. A. CORRECT: Tertiary health care involves the provision of specialized and highly technical care (the care nurses deliver in intensive care units). B. CORRECT: Tertiary health care involves the provision of specialized and highly technical care, such as the care nurses deliver in intensive care units, an oncology treatment center, and a burn center. C. CORRECT: Tertiary health care involves the provision of specialized and highly technical care, such as the care nurses deliver in intensive care units, an oncology treatment center, and a burn center. D. Cardiac rehabilitation and home health care are examples of restorative care. E. Cardiac rehabilitation and home health care are examples of restorative care.

4. A nurse is assigned to care a client who has tuberculosis. The nurse understands that the intent of this tracking is which of the following? A. To track information that poses a threat to the public B. To provide appropriate antibiotics at no cost the client C. To assist the Joint Commission with its goals for client safety D. To aid in obtaining personal protective equipment for the facility

4. A. CORRECT: The Centers for Disease Control and Prevention monitors certain illnesses and diseases that can pose a threat to the public. The purpose of this activity is to limit the spread of the diseases.

4. A nurse at a health department is planning strategies related to heart disease. Which of the following activities should the nurse include as part of primary prevention? A. Providing cholesterol screening B. Teaching about a healthy diet C. Providing information about antihypertensive medications D. Developing a list of cardiac rehabilitation programs

4. A. Cholesterol screening is an example of secondary prevention. B. CORRECT: Primary prevention encompasses strategies that help prevent illness or injury. This level of prevention includes health information about nutrition, exercise, stress management, and protection from injuries and illness. C. Taking medication to lower blood pressure is part of secondary prevention. D. Cardiac rehabilitation is an example of tertiary prevention.

4. A nurse questions a medication prescription as too extreme in light of the client's advanced age and unstable status. The nurse understands that this action is an example of which of the following ethical principles? A. Fidelity B. Autonomy C. Justice D. Nonmaleficence

4. A. Fidelity is the fulfillment of promises. The nurse is not addressing a specific promise when they determine the appropriateness of a prescription for the client. Thus, this principle does not apply. B. Autonomy is the right to make personal decisions, even when they are not necessarily in the person's best interest. No personal decision is involved when the nurse questions the client's prescription. C. Justice is fairness in care delivery and in the use of resources. In this situation, the nurse is delivering responsible client care and is not assessing available resources. This principle does not apply. D. CORRECT: The nurse should identify that nonmaleficence is a commitment to do no harm. In this situation, administering the medication could harm the client. By questioning it, the nurse is demonstrating this ethical principle.

4. A nurse is caring for a client who is receiving enteral tube feedings due to dysphagia. Which of the following bed positions should the nurse use for safe care of this client? A. Supine B. Semi-Fowler's C. Lateral Semi-prone Recumbent D. Trendelenburg

4. A. In the supine position, the client lies on their back with the head and shoulders elevated on a pillow. This angle will not prevent regurgitation. B. CORRECT: In the semi-Fowler's position, the client lies supine with the head of the bed elevated 15° to 45° (typically 30°. This position helps prevent regurgitation and aspiration by clients who have difficulty swallowing. This is the safest position for clients receiving enteral tube feedings. C. In the lateral semi-prone recumbent position, the client is on their side halfway between lateral and prone positions. This position is not safe because it promotes regurgitation. D. In the Trendelenburg position, the entire bed is tilted with the head of the bed lower than the foot of the bed. This position is not safe because it promotes regurgitation.

4. A nurse manager is discussing the HIPAA Privacy Rule with a group of newly hired nurses during orientation. Which of the following information should the nurse manager include? (Select all that apply.) A. A single electronic records password is provided for nurses on the same unit. B. Family members should provide a code prior to receiving client health information. C. Communication of client information can occur at the nurses' station. D. A client can request a copy of their medical record.

4. A. The HIPAA Privacy Rule requires the protection of clients electronic records. The rule states that electronic records must be password-protected and each staff person should use an individual password to access information. B. CORRECT: When taking actions, the nurse should identify that the HIPAA Privacy Rule states that information should only be disclosed to authorized individuals to whom the client has provided consent. Many hospitals use a code system to identify those individuals and should only provide information if the individual can give the code. C. CORRECT: The HIPAA Privacy Rule states that communication about a client should only take place in a private setting where unauthorized individuals cannot overhear it. A unit nurses' station is considered a private and secure location. D. CORRECT: The HIPAA Privacy Rule states that clients have a right to read and obtain a copv of thates thai cal record. E. CORRECT: The HIPAA Privacy Rule states that nurses can only photocop

4. A nurse on a medical-surgical unit has received change-of-shift reports on five clients. Understanding that a PN can perform each of the following tasks, sort the tasks the nurse should assign to the AP or the PN. A. Assist with updating the plan of care for a client who is postoperative B. Reinforce teaching with a client who is learning to walk using a quad cane C. Reapply a condom catheter for a client who has urinary incontinence D. Apply a sterile dressing to a pressure injury E. Perform

4. AP: C, E PN: A, B, D When taking actions, the nurse should identify that assisting with updating the plan of care for a client, reinforcing teaching a client, and applying a sterile dressing requires professional nursing knowledge and judgment and should be assigned to the PN. The application of a condom catheter and performing postmortem care are noninvasive, routine procedures that can be delegated to the AP.

4. The nurse is reviewing the use of transmission-based isolation precautions with a group of new nurses. Sort the following infectious diseases by the type of precautions required. (Contact, Droplet, Airborne) A. Tuberculosis B. SARS-CoV-2 (COVID-19) C. Influenza D. C. difficile E. MRSA

4. CONTACT: c-diff, MRSA DROPLET: influenza AIRBORNE: tuberculosis, COVID When taking actions to review transmission-based isolation precautions, the nurse discusses contact precautions for C. difficile and MRSA to prevent transmission of microorganisms from one client to another through direct or indirect contact The nurse discusses droplet precautions for influenza to prevent transmission of respiratory droplets greater than 5 microns. The nurse discusses airborne precautions for tuberculosis and SARS-CoV-2 to prevent transmission of respiratory droplets smaller than 5 microns.

5. The nurse is contributing to the plan of care for injury prevention for a school-age child. Match each safety issue to the instruction the nurse should suggest for the family to prevent injury related to that issue. 1. Provide approved flotation devices 2. Teach child to use low heat when cooking 3. Educate the child about 4. Encourage correct use of seat belts or child safety seats 5. Store firearms in locked cabinets A. Burns B. Poisoning C. Bodily harm D. Drowning E. Motor vehicle injury

5. A, 2 B, 3 C, 5 D, 1 E, 4 When generating solutions for injury prevention for a school-age child, the nurse should suggest teaching the child to cook using low heat on the stove to prevent injury from burns. The nurse should suggest educating the child about the dangers of illegal drugs and alcohol to prevent poisoning from ingestion. The nurse should suggest storing firearms in locked cabinets to protect the child from bodily harm caused by the discharge of a firearm. The nurse should suggest providing the child with approved flotation devices when swimming or boating to prevent drowning. The nurse should suggest that the child should be taught correct use of seat belts and child safety seats to protect against injury from a motor vehicle collision.

5. The nurse is contributing to the plan of care for injury prevention for an infant. Match each safety issue on the left to the instruction on the right the nurse should suggest for the family to prevent injury related to that issue. 1. Cover electrical outlets 2. Keep medications in locked cabinets 3. Remove pillows from the crib 4. Stay with the infant at all times while bathing them 5. Use clothes and toys without buttons 6. Place infant in rear-facing car seat A. Aspiration B. Suffocation

5. A, 5 B, 3 C, 1 D, 6 E, 4 F, 2 When generating solutions for injury prevention for an infant, the nurse should suggest covering electrical outlets to prevent injury from shocks or burns. The nurse should suggest storing medications in locked cabinets to prevent poisoning from ingestion. The nurse should suggest removing pillows and other soft, loose objects from the crib to prevent suffocation or strangulation. The nurse should suggest never leaving an infant unattended in a water source to prevent drowning. The nurse should suggest using clothes and toys without buttons to avoid a choking hazard if they are accidentally removed. The nurse should suggest that the infant is buckled into a rear-facing car seat to protect against injury from a motor vehicle collision.

5. A nurse is instructing a group of newly licensed nurses about how to know and what to expect when ethical dilemmas arise. Which of the following situations should the newly licensed nurses identify as an ethical dilemma? A. A nurse on a medical-surgical unit demonstrates signs of chemical impairment. B. A nurse overhears another nurse telling an older adult client that if he doesn't stay in bed, she will have to apply restraints. C. A family has conflicting feelings about the initiation of en

5. A Delivering client care while showing signs of a substance use disorder is a legal issue, not an ethical dilemma. B. A nurse who threatens to restrain a client has committed assault. This is a legal issue, not an ethical dilemma. C. CORRECT: The nurse should identify that making the decision about initiating enteral tube feedings is an example of an ethical dilemma. A review of scientific data cannot resolve the issue, and it is not easy to resolve. The decision will have a profound effect on the situation and on the client. D. The selection of a person to make health care decisions on a client's behalf is a legal decision, not an ethical dilemma.

5. A charge nurse is discussing the nursing process with a newly licensed nurse who is caring for a client. Match the following statements by the newly licensed nurse with each step of the nursing process. 1. Assessment/ 3. Planning Data Collection 4. Implementation 2. Analysis/Diagnosis/ 5. Evaluation Data Collection A. "I will determine the most important client problems that we should address." B. "I will review the past medical history in the client's medical record to obtain more informatio

5. A, 3 B, 1 C, 5 D, 2 E, 4 The charge nurse is recognizing cues when identifying that the newly licensed nurse is using the steps of the nursing process when caring for the client. The newly licensed nurse uses the assessment/data collection step of the nursing process when reviewing the past medical history on the client's medical record to obtain more information about the client. Reviewing objective and subjective client data to identify a potential client problem is part of the analysis/diagnosis/data collection step of the nursing process. The newly licensed nurse clusters and interprets data to determine a conclusion. The newly licensed nurse is using the planning step of the nursing process when prioritizing client problems. Administering prescribed medications to the client is part of the implementation step of the nursing process. The newly licensed nurse is using the evaluation step of the nursing process when asking the client if their nausea has resolved.

5. A nurse is acquainting a group of newly licensed nurses with the roles of the various members of the health care team they will encounter on a medical-surgical unit. When providing examples of the types of tasks certified nursing assistants (CNAs) can perform, which of the following client activities should the nurse include? (Select all that apply.) A. Bathing B. Ambulating C. Toileting D. Determining pain level E. Measuring vital signs

5. A, B, C, E. CORRECT: The nurse should identify that it is within the range of function for a CNA to provide basic care to clients, such as bathing, assisting with ambulation, assisting with toileting, and measuring and recording vital signs. D. Determining pain level is a task that requires the assessment skills of licensed personnel (nurses). It is outside the range of function for a CNA.

5. A nurse is wearing sterile gloves in preparation for performing a sterile procedure. Which of the following objects can the nurse touch without breaching sterile technique? (Select all that apply.) A. A bottle containing a sterile solution B. The edge of the sterile drape at the base of the field C. The inner wrapping of an item on the sterile field D. An irrigation syringe appropriately placed on the sterile field E. One gloved hand with the other gloved hand

5. A. A bottle of sterile solution is sterile on the inside and non-sterile on the outside. Place the solution in a sterile container on the field before putting on sterile gloves. B. The 1-inch border at the outer edge of the sterile field is not sterile. Do not touch it with sterile gloves. C. CORRECT: The inner wrappings of any objects dropped onto the sterile field are sterile. Touch them with sterile gloves. D. CORRECT: Any sterile objects dropped onto the sterile field during the setup are sterile. Touch the syringe with sterile gloves. E. CORRECT: One sterile gloved hand may touch the other sterile gloved hand because both are sterile.

5. A nurse is discussing restorative health care with a newly licensed nurse. Which of the following examples should the nurse include in the teaching? (Select all that apply) A. Home health care B. Rehabilitation facilities C. Diagnostic centers D. Skilled nursing facilities E. Oncology centers

5. A. CORRECT: Restorative health care involves intermediate follow-up care for restoring health and promoting self. care. Home health care, rehabilitation faollities, and skilled nursing facilities are types of restorative health care. B. CORRECT: Restorative health care involves intermediate follow-up care for restoring health and promoting self, care. Home health care, rehabilitation facilities, and skilled nursing facilises are types of restorative health care. C. Secondary health care includes the diagnosis and treatment of acute injury or liness. Diagnostic centers are a type of secondary health care. D. CORRECT: Restorative healóh care involves intermediate follow-up care for restoring health and promoting sell. care. Home health care, rehabilitation facilities, and skilled nursing facilities are types of restorative health care. E. Tertiary health care is specialized and highly technical care.

5. A nurse in a clinic is planning health promotion and disease prevention strategies for a client who has multiple risk factors for cardiovascular disease. Which of the following interventions should the nurse include? (Select all that apply.) A. Help the client see the benefits of their actions. B. Identify the client's support systems. C. Suggest and recommend community resources. D. Devise and set goals for the client. E. Teach stress management strategies.

5. A. CORRECT: The nurse should plan to assist the client to recognize the benefits of their health-promoting actions whit also overcoming barriers to implementing actions. B. CORRECT: The nurse should plan to collect information about who can help the client change unhealthy behaviors and then suggest steps to have friends and family to become involved and supportive. C. CORRECT: The nurse should plan to promote the client's use of any available community or online resources that can help the client progress toward meeting set goals. D. The nurse and the client should work together to devise and set mutually agreeable goals that are also realistic and achievable. E. CORRECT: The nurse should plan to teach that stress is a contributing factor to cardiovascular disease, as well as many other specific and systemic disorders.

5. A newly licensed nurse is considering strategies to improve critical thinking. Which of the following actions should the nurse take? (Select all that apply.) A. Find a mentor. B. Use a journal to write about the outcomes of clinical judgments. C. Review articles about evidence-based practice. D. Limit consultations with other professionals involved in a client's care. E. Make quick decisions when unsure about a client's needs. F. Organize client data using a concept map.

5. A. CORRECT: When taking actions to improve critical thinking, the newly licensed nurse should find a mentor to discuss client care and gain knowledge from the mentor's experience. B. CORRECT: Journaling about decision-making can assist the nurse with self-reflections and improve critical thinking skills. C. CORRECT: Learning new information about evidence-based practice improves the nurse's ability to think critically. D. Limit consultations with other professionals involved in a client's care. E. Make quick decisions when unsure about a client's needs. F. CORRECT: Creating a concept map improves critical thinking skills by organizing and connecting client data to identify possible clinical patterns and relationships.

5. A nurse is instructing a client who has COPD about using the orthopneic position to relieve shortness of breath. Which of the following statements should the nurse make? A. "Lie on your back with your head and shoulders supported by a pillow." B. "Have your head turned to the side while you lie on your stomach." C. "Have a table beside your bed so you can sit on the bedside and rest your arms on the table." D. "Lie on your side with your top arm resting on the bed and your weight on your hip.

5. A. Instructing the client to lie on their back with their head and shoulders supported by a pillow is describing the supine position, not the orthopneic position. B. Instructing the client to lie on their stomach with their head turned to the side is describing the prone position, not the orthopneíc position. C. CORRECT: The nurse should instruct the client to have a table beside the bed so they can sit on the bedside and rest their arms on the table. This is an accurate description for the orthopneic position. This position allows for chest expansion and is especially beneficial for clients who have COPD. D. Instructing the client to lie on their side with their top arm resting on the bed and their weight on their hip is describing the lateral or side-lying position, not the orthopneic position.

5. The ostomy nurse is educating the client about diet. Which of the following actions should the nurse take to evaluate the client's learning? A. Encourage the client to ask questions about their diet. B. Ask the client to list foods to include in their diet. C. Encourage the client to fill out an evaluation form about how the nurse presented the information about diet. D. Ask the client if they have additional resources for further instruction about their new diet.

5. B. CORRECT: When evaluating outcomes, the ostomy nurse should identify that having the client explain the information in their own words allows the nurse to evaluate what the client remembers, whether the client comprehends the information, and if further instruction is required.

5. A nurse on a medical-surgical unit is informed that a mass casualty event occurred in the community and that it is necessary to discharge stable clients to make beds available for injury victims. Which of the following clients should the nurse recommend for discharge? (Select all that apply.) A. A client who is dehydrated and receiving IV fluid and electrolytes B. A client who has a nasogastric tube to treat a small bowel obstruction C. A client who is scheduled for elective surgery D. A clie

5. C, D When generating solutions, the nurse should recognize that a client who is scheduled elective surgery and a client who has blood pressure of 135/85 mm Hg, which is within the reference range for prehypertension, are stable and should recommend for discharge. A client who is receiving IV fluid and electrolytes, a client who has a nasogastric tube, and a client who has an acute illness and is scheduled for surgery requires ongoing nursing care and are therefore unstable for discharge.

5. A nurse is reviewing nutritional guidelines with the parent of a 2-year-old toddler. Which of the following parent statements indicates an understanding of the teaching? A. "I will give my child popcorn because it is more nutritious than sweets." B. "I have to give my child whole milk until age 3 years." C. "I'll give my child 2 tablespoons of food for each serving." D. "It's okay for me to give my child a cup of apple juice with each meal."

5. C. CORRECT: When evaluating outcomes, the nurse should identify that the parent understands that a serving size for toddlers should be about 1 tbsp of solid food per year of age, so 2-year-olds should have about 2 tbsp of food per serving.

5. A charge nurse is assigning client care to an RN and a PN. Understanding that an RN can perform each of the following tasks, match the tasks the nurse should assign to the RN or the PN. A. Creating a plan of care for a client who is recovering following a stroke B. Assessing a pressure injury on a client who is on bed rest C. Providing nasopharyngeal suctioning for a client who has pneumonia D. Teaching a client who has asthma to use a metered-dose inhaler E. Administer enteral feeding to a c

5. RN: A, B, D PN: C, E, F When taking actions, the nurse should identify that creating a plan of care, assessing a pressure injury, and teaching a client requires professional nursing knowledge, skills, and judgment that is outside the scope of care of a PN and should be assigned to the RN. Providing nasopharyngeal suctioning, administering enteral feeding through a nasogastric tube, and inserting a urinary catheter is within the scope of practice of the PN.

6. A nurse educator is reviewing actions to take in the event of a bomb threat by phone to a group of new nurses. Which of the following statements by a nurse indicates understanding? A. "I will get the caller off the phone as soon as possible so I can alert the staff." B. "I will begin evacuating clients using the elevators." C. "I will not ask any questions and just let the caller talk." D. "I will listen for background noises."

6. D When evaluating outcomes, the nurse educator should identify that the teaching was effective by the new nurse's statement, "I will listen for background noises." In the event of a bomb threat, individuals should listen for background noises (church bells, train whistles, or other distinguishing noises) to try to identify the location of the caller; keep the caller on the line in order to trace the call and to collect as much information as possible; ask the caller about the location of the bomb and the time it is set to explode in order to gather as much information as possible; and avoid using the elevators so that they are free for the authorities to use. Clients should not be evacuated unless directed to by facility protocol.