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29. A nurse is caring for a client who is 48 hr postoperative following a small bowel resection. The client reports gas pains in the periumbilical area. The nurse should plan care based on which of the following factors contributing to this postoperative complication? Blood loss NPO status after surgery Nasogastric tube suctioning Impaired peristalsis of the intestines
Impaired peristalsis of the intestines Rationale: Normal bowel function is delayed for up to several days following a bowel resection. When peristalsis is absent or sluggish, intestinal gas builds up, producing pain and abdominal distention. The nurse should plan to assist the client to ambulate to promote peristalsis.
4. A nurse is using the I-SBAR communication tool to provide the client's provider with information about the client. The nurse should convey the client's pain status in which portion of the report? Assessment Background Situation Recommendation
Assessment Rationale: The nurse provides information about assessment findings in this portion of the report. This includes vital signs, pain assessment, and changes in assessment findings.
39. A nurse is caring for a client who has a terminal illness. Which of the following findings indicates that the client's death is imminent? Urinary retention Cold extremities Hypertension Tachycardia
Cold extremities Rationale: Cold extremities, first in the feet and then in the hands, are a physical change that occurs when a client's death is imminent.
50. A nurse on a telemetry unit is caring for a client who had a myocardial infarction. The client states "All this equipment is making me nervous." Which of the following responses should the nurse make? "You won't need the equipment very long." "All of this equipment can be frightening." "Why does the equipment bother you?" "Let me tell you about what each machine does."
"All of this equipment can be frightening." Rationale: This statement is therapeutic because the nurse is reflecting the client's statement. The client is feeling fearful, and this response shows that the nurse understands those feelings, which will encourage the client to communicate more.
14. A nurse is teaching a client who has lower extremity weakness how to use a four-point crutch gait. Which of the following instructions should the nurse include in the teaching? "Support the majority of your weight on the axillae." "Keep your elbows extended." "Bear weight on both of your legs." "Move both crutches forward at the same time."
"Bear weight on both of your legs." Rationale: The client has three points on the ground at all times. Therefore, he must be able to bear weight on both legs.
30. A nurse is planning to insert a nasogastric tube for a client after explaining the procedure. The client states, "You are not putting that hose down my throat." Which of the following statements should the nurse make? "I would try to get it over with because you won't get better without this tube." "You should talk to your provider about it." "Why don't you want the tube inserted?" "I can see that this is upsetting you."
"I can see that this is upsetting you." Rationale: The nurse is using the therapeutic communication techniques of reflecting and restating, which encourages communication by the client.
10. A nurse in a long-term care facility is admitting a client who is incontinent and smells strongly of urine. His partner, who has been caring for him at home, is embarrassed and apologizes for the smell. Which of the following responses should the nurse make? "A lot of clients who are cared for at home have the same problem." "Don't worry about it. He will get a bath, and that will take care of the odor." "It must be difficult to care for someone who is confined to bed." "When was the last time that he had a bath?"
"It must be difficult to care for someone who is confined to bed." Rationale: This response addresses the feelings of the partner by reflecting on her feelings. It facilitates therapeutic communication because it is nonjudgmental and encourages the partner to express her feelings.
48. An adolescent client in an outpatient mental health facility tells the nurse that it is hard to follow his treatment plans because his friends discourage him. Which of the following statements should the nurse make? "Don't worry, teenagers often have friends who give them bad advice." "I think you should stop seeing those friends since they discourage you from following your treatment plan." "Tell me more about how your friends discourage you." "Tell me where you met these friends."
"Tell me more about how your friends discourage you." Rationale: The nurse should ask an open-ended question that encourages the client to elaborate about the problems that he is having.
11. A nurse in a provider's office is assessing a client who has heart failure. The client has gained weight since her last visit and her ankles are edematous. Which of the following findings by the nurse is another clinical manifestation of fluid volume excess? Sunken eye balls Hypotension Poor skin turgor Bounding pulse
Bounding pulse Rationale: Bounding pulse is an expected finding of fluid volume excess.
21. A nurse is teaching a client who is postoperative how to use a flow-oriented incentive spirometer. Which of the following instructions should the nurse include? Blow into the spirometer to elevate the balls in the device. Cough deeply after each use. Clean the mouth piece with an alcohol swab after each use. Use the spirometer every 8 hr.
Cough deeply after each use. Rationale: Proper use of the incentive spirometer loosens secretions in the client's lungs. The client should cough deeply to facilitate removal of secretions from his lungs.
27. A nurse is applying an ice bag to the ankle of a client following a sports injury. Which of the following actions should the nurse take? Leave the bag in place for 45 min. Fill the bag two-thirds full with ice. Place the ice bag uncovered on the client's ankle. Tell the client that it is expected to feel numbness when the ice bag is in place.
Fill the bag two-thirds full with ice. Rationale: The nurse should fill the bag two-thirds full with ice, which makes it possible to mold the bag around the client's ankle.
23. A nurse is providing teaching about food choices to a client who has a prescription for a clear liquid diet. Which of the following selections by the client indicates an understanding of the teaching? Cream of rice Cottage cheese Gelatin Ice cream
Gelatin Rationale: Foods allowed on a clear liquid diet are those that are clear and liquid at room temperature.
8. A nurse is planning to assess the abdomen of a client who reports feeling bloated for several weeks. Which of the following methods of assessment should the nurse use first? Inspection Auscultation Percussion Palpation
Inspection Rationale: According to evidence-based practice, the nurse should inspect the abdomen first by observing the contour of the abdomen, the condition of the skin, and the position of the umbilicus. Findings from this step of assessment are used by the nurse in the subsequent steps.
41. A nurse on a mental health unit is preparing to terminate the nurse-client relationship with a client who no longer requires care. Which of the following concepts should the nurse and client discuss in the termination phase of the relationship? Loss Trust Self-disclosure Risk-taking
Loss Rationale: At the close of a relationship, even one that is planned, loss is an expected feeling for both the client and the nurse. It is important for both the nurse and the client to terminate the relationship without feelings of guilt or anxiety.
34. A nurse is cqaring for a client who has a fecal impaction. Before digital removal of the mass, which of the following types of enemas should the nurse plan to administer to soften the feces? Carminative Hypertonic Oil retention Sodium polystyrene sulfate
Oil retention Rationale: The nurse should administer an oil retention enema prior to removal of a fecal impaction to soften the stool. This makes the procedure less painful for the client.
15. A nurse is planning to document care provided for a client. Which of the following abbreviations should the nurse use? BT for bedtime SC for subcutaneously PC for after meals HS for half-strength
PC for after meals Rationale: The nurse can use this abbreviation. It is an approved, not an error prone, abbreviation.
24. A nurse is performing a neurological assessment for a client. Which of the following examinations should the nurse use to check the client's balance? Two-point discrimination test Glasgow coma scale Babinski reflex Romberg test
Romberg test Rationale: When using the Romberg test, the nurse instructs the client to stand with his feet together and arms at sides, first with his eyes open and then with eyes closed. The inability to maintain balance is a positive Romberg test.
42. A nurse is caring for a client who has bilateral casts on her hands. Which of the following actions should the nurse take when assisting the client with feeding? Sit at the bedside while feeding the client. Order pureed foods. Make sure feedings are at room temperature. Offer the client a drink of fluid after every bite.
Sit at the bedside while feeding the client. Rationale: The nurse should avoid appearing to be in a hurry. Sitting at the bedside provides the client with the nurse's full attention during the feeding.
46. A nurse in the emergency department is caring for a client who has abdominal trauma. Which of the following assessment findings should the nurse identify as an indication of hypovolemic shock? Warm, dry skin Increased urinary output Tachycardia Bradypnea
Tachycardia Rationale: Due to the decrease in circulating blood volume that occurs with internal bleeding, the oxygen-carrying capacity of the blood is reduced. The body attempts to relieve the hypoxia by increasing the heart rate and cardiac output, along with increasing the respiratory rate.
17. An assistive personnel (AP) is assisting a nurse with the care of a female client who has an indwelling urinary catheter. Which of the following actions by the AP indicates a need for further teaching? The AP uses soap and water to clean the perineal area. The AP tapes the catheter to the client's inner thigh. The AP hangs the collection bag at the level of the bladder. The AP ensures that there are no kinks in the drainage tubing.
The AP hangs the collection bag at the level of the bladder. Rationale: The AP should place the drainage bag below the level of the bladder to ensure proper drainage by gravity.
33. A nurse is caring for a client who has a prescription for a vest restraint. Which of the following actions should the nurse take? Fasten the ties on the restraint to the side rails of the bed. Tie the restraint with a quick-release knot. Allow one finger's breadth between the restraint and the client's chest. Place the restraint under the client's clothing.
Tie the restraint with a quick-release knot. Rationale: The nurse should use a quick-release knot that can be untied easily in case the client's well-being requires quickly removing the restraints.
6. A nurse is providing discharge teaching to a client who is recovering from lung cancer. The provider instructed the client that he could resume lower-intensity activities of daily living. Which of the following activities should the nurse recommend to the client? Sweeping the floor Shoveling snow Cleaning windows Washing dishes
Washing dishes Rationale: Washing dishes requires a low level of activity and is appropriate for this client.
25. A nurse in a provider's office is reviewing the laboratory findings of a client who reports chills and aching joints. The nurse should identify which of the following findings as an indication that the client has an infection? WBC 15,000 mm3 Erythrocyte sedimentation rate (ESR) 15 mm/hr Urine pH 7.2 Urine specific gravity 1.0063
WBC 15,000 mm3 Rationale: This finding is above the expected reference range and is an indication of infection.
5. A nurse is caring for a client who is receiving IV therapy via a peripheral catheter. The nurse should identify that which of the following findings is an indication of infiltration? Redness at the infusion site Edema at the infusion site Warmth at the infusion site Oozing of blood at the infusion site
Edema at the infusion site Rationale: Edema due to fluid entering subcutaneous tissue is an indication of infiltration.
9. A nurse is explaining the use of written consent forms to a newly-licensed nurse. The nurse should ensure that a written consent form has been signed by which of the following clients? A client who has a prescription for a transfusion of packed red blood cells A client who is being transported for a radiography of the kidneys, ureters, and bladder A client who has a prescription for a tuberculin skin test A client who has a distended bladder and needs urinary catheterization
A client who has a prescription for a transfusion of packed red blood cells Rationale: Administration of blood is a procedure that carries risk; therefore, the client must sign a consent form prior to the procedure.
7. A nurse is caring for a client who has acute renal failure. Which of the following assessments provides the most accurate measure of the client's fluid status? Daily weight Blood pressure Specific gravity Intake and output
Daily weight Rationale: According to the evidence-based priority-setting framework, daily weight provides important information about the client's fluid status. A gain or loss of 1 kg (2.2 lb) indicates a gain or loss of 1 liter of fluid; therefore, weighing the client daily will provide the nurse with the most accurate fluid status measurement.
47. A nurse is reviewing the laboratory values for a client who has a positive Chvostek's sign. Which of the following laboratory findings should the nurse expect? Decreased calcium Decreased potassium Increased potassium Increased calcium
Decreased calcium Rationale: Calcium is necessary for nerve conduction and muscle contractions. When the client's total calcium level is below 8.4 mg/dL, tetany and muscle spasms may occur. The nurse should tap the facial nerve in front of the client's ear. If facial muscle twitching follows this stimulus, it is a positive Chvostek's sign and an indication of hypocalcemia.
3. A home health nurse is planning to provide health promotion activities for a group of clients in the community. Which of the following activities is an example of the nurse promoting primary prevention? Teaching clients to perform self-examinations of breasts and testicles Educating clients about the recommended immunization schedule for adults Teaching clients who have type 1 diabetes mellitus about care of the feet Recommending that clients over the age of 50 have a fecal occult blood test annually
Educating clients about the recommended immunization schedule for adults Rationale: Primary prevention includes health education about disease prevention. A&D:This activity is an example of secondary prevention. Secondary prevention focuses on measures that identify the early stages of a condition.
22. A nurse is teaching a client how to self-administer insulin. Which of the following actions should the nurse take to evaluate the client's understanding of the process within the pyschomotor domain of learning? Ask the client if he wants to self-administer his insulin. Have the client list the steps of the procedure Have the client demonstrates the procedure. Ask the client if he understands the purpose of insulin.
Have the client demonstrates the procedure. Rationale: Having the client demonstrate the procedure provides the nurse the ability to evaluate the client's understanding within the psychomotor domain of learning.
2. A nurse is caring for a client who, while sitting in a chair, starts to experience a seizure. Which of the following actions should the nurse take? Place a padded tongue blade in the client's mouth. Lower the client to the floor and place a pad under the client's head. Seek the help of a coworker and lift the client back into bed. Use an oropharyngeal airway to keep upper airway passages open.
Lower the client to the floor and place a pad under the client's head. Rationale: To reduce the risk of injury to the client, the nurse should lower the client to the floor and place a pillow or other soft object under the client's head.
20. A nurse is planning to perform passive range-of-motion exercises for a client. Which of the following actions should the nurse take? Repeat each joint motion five times during each session. Move the joint to the point of considerable resistance. Sit approximately 2 feet from the side of the bed closest to the joint being exercised. Exercise the smaller joints first.
Repeat each joint motion five times during each session. Rationale: To maintain the client's joint mobility the nurse should repeat each motion three to five times.
38. A nurse is planning care for a client who is postoperative and has a history of poor nutritional intake. Which of the following actions should the nurse include in the plan of care to promote wound healing? Limit total caloric intake to 25 kcal/kg of body weight. Provide an intake of 500 mg/day of vitamin E. Limit fluid intake to 20 mL/kg of body weight per day. Provide a protein intake of 1.5 g/kg of body weight per day.
Provide a protein intake of 1.5 g/kg of body weight per day. Rationale: A protein intake of 1 to 1.5 g/kg of body weight per day is necessary to maintain a positive nitrogen balance, which promotes wound healing.
26. A nurse is preparing to administer an intramuscular injection to a young adult client. Which of the following injection sites is the safest for this client? Vastus lateralis Dorsogluteal Deltoid Ventrogluteal
Ventrogluteal Rationale: According to evidence-based practice, the ventrogluteal site is the safest injection site for all adults because it contains thick gluteal muscles and it does not contain major nerves or blood vessels.
44. A nurse is planning care for a client who has a single-lumen nasogastric (NG) tube for gastric decompression. Which of the following actions should the nurse include in the plan of care? (Select all that apply.) Set the suction machine at 120 mm HG. Provide oral hygiene frequently. Measure the amount of drainage from the NG tube every shift. Secure the NG tube to the client's gown. Apply petroleum jelly to the client's nares.
-Provide oral hygiene frequently. -Measure the amount of drainage from the NG tube every shift. -Secure the NG tube to the client's gown. Rationale: -Provide oral hygiene frequently is correct. Frequent oral hygiene provides comfort for the client since mucous membranes easily become dry and uncomfortable when a client cannot drink fluids. -Measure the drainage from the NG tube every shift is correct. Measuring the drainage at least every shift helps the provider to calculate fluid loss and prescribe appropriate replacement therapy. -Secure the NG tube to the client's gown is correct. An unsecured NG tube can irritate the nares if the tube is pulled or caught on the bed or other equipment. The tube can also be dislodged if not secured appropriately.
37. A nurse is preparing to provide chest physiotherapy for a client who has left lower lobe atelectasis. Which of the following actions should the nurse plan to take? Place the client in Trendelenburg's position. Perform percussions directly over the client's bare skin. Use a flattened hand to perform percussions. Remind the client that chest percussions can cause mild pain.
Place the client in Trendelenburg's position. Rationale: The nurse should place the client in right side lying position in Trendelenburg's position to promote drainage from the client's left lower lobe.
19. A nurse is providing oral care for a client who is unconscious. Which of the following actions should the nurse take? Place the client in a lateral position with the head turned to the side before beginning the procedure. Use the thumb and index finger to keep the client's mouth open. Rinse the client's mouth with an alcohol-based mouth wash following the procedure. Cleanse the client's mucous membranes with lemon-glycerin sponges.
Place the client in a lateral position with the head turned to the side before beginning the procedure. Rationale: The nurse should place the client in a lateral position with the head turned to the side to reduce the risk of aspiration of fluids and secretions.
16. A nurse is responding to a parent's question about his infant's expected physical development during the first year of life. Which of the following information should the nurse include? A 2-month-old infant can turn from his abdomen to his back. A 10-month-old infant can pull up to a standing position. A 4-month-old infant can sit up without support. A 6-month-old infant can crawl on his hands and knees.
A 10-month-old infant can pull up to a standing position. Rationale: An 8 to 10-month-old infant can pull himself to a standing position.
45. A nurse is called away for an emergency while conversing with a client who is concerned about his medical diagnosis. The nurse returns to the client promptly, as promised. Which of the following ethical principles is the nurse demonstrating? Autonomy Fidelity Nonmaleficence Justice
Fidelity Rationale: The nurse is demonstrating the ethical principle of fidelity by keeping a promise that was made.
40. A nurse is caring for a client who is receiving a blood transfusion. The client reports flank pain and the nurse notes reddish-brown urine in the client's urinary catheter bag. The nurse recognizes these manifestations as which of the following types of transfusion reactions? Hemolytic Febrile Circulatory overload Sepsis
Hemolytic Rationale: A hemolytic reaction occurs when the client's blood is incompatible with the donor's blood. Chills, low back pain, hypotension, and tachycardia are indications of a hemolytic transfusion reaction.
13. A nurse in a provider's office is collecting information from an older adult client who reports that he has been taking acetaminophen 500 mg/day for severe joint pain. The nurse should instruct the client that large doses of acetaminophen could cause which of the following adverse effects? Constipation Gastric ulcers Respiratory depression Liver damage
Liver Damage Rationale: Acetaminophen in large doses can be toxic to the liver. Daily intake should be limited to less than 3 to 4 grams per day for healthy individuals and 2.4 grams per day for older adults and those with a history of liver impairment.
31. A nurse is preparing to administer a cleansing enema to a client. Which of the following actions should the nurse plan to take? Insert the rectal tube 15.2 cm (6 in). Wear sterile gloves to insert the tubing. Position the client on his left side. Hold the solution bag 91 cm (36 in) above the client's rectum.
Position the client on his left side. Rationale: Positioning is an important aspect of administering an enema. Having the client lie on his left side facilitates the flow of the enema solution into the sigmoid and descending colon.
36. A nurse is reviewing the correct use of a fire extinguisher with a client. Which of the following actions should the nurse direct the client to take first? Aim the hose at the base of the fire. Squeeze the handle of the extinguisher. Remove the safety pin from the extinguisher. Sweep the hose from side to side to dispense material.
Remove the safety pin from the extinguisher. Rationale: Evidenced-based practice indicates removing the safety pin from the extinguisher is the first action to take when using a fire extinguisher; therefore, this is the action the nurse should instruct the client to take first.
49. A nurse is reviewing measures to prevent back injuries with assistive personnel (AP). Which of the following instructions should the nurse include? Stand 3 feet from the client when assisting with lifting. Lock your knees when standing for long periods. Lift up to 22.6 kg (50 lbs) without the use of assistive devices. When lifting an object, spread your feet apart to provide a wide base of support.
When lifting an object, spread your feet apart to provide a wide base of support. Rationale: The AP should spread his feet apart because a wide base of support increases stability.
18. A newly licensed nurse is preparing to administer medications to a client. The nurse notes that the provider has prescribed a medication that is unfamiliar to her. Which of the following actions should the nurse take? Consult the medication reference book available on the unit. Ask a more experienced nurse for information about the medication. Call the client's provider and verify the prescription. Ask the client if she takes this medication at home.
Consult the medication reference book available on the unit. Rationale: A nurse must have knowledge about medications to administer them safely. The nurse should become familiar with the medication by looking it up it in the medication reference on the unit.
35. A nurse is providing education about cultural and religious traditions and rituals related to death for the assistive personnel on the unit. Which of the following information should the nurse include? "People who practice the Islamic faith pray over the deceased for a period of 5 days before burial." "People who practice the Hindu faith bury the deceased with their head facing north." "People who practice Judaism stay with the body of the deceased until burial." "People who are practicing the Buddhist faith have the female family members prepare the body following death."
People who practice Judaism stay with the body of the deceased until burial. Rationale: In the Jewish faith, a family member often stays with the body until burial occurs.
28. A client is being discharged home with oxygen therapy via a nasal cannula. Which of the following instructions should the nurse provide to the client and family? Use battery-operated equipment for personal care. Apply mineral oil to protect the facial skin from irritation. Remove the television set from the client's bedroom. Wear cotton clothing to avoid static electricity.
Wear cotton clothing to avoid static electricity. Rationale: The use of cotton clothing will limit the buildup of static electricity. Oxygen is a highly combustible gas. The use of oxygen in high concentrations has great combustion potential and readily fuels fire. Although it will not spontaneously burn or cause an explosion, it can easily cause a fire in a client's room if it contacts a spark.
12. A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following actions should the nurse take first after discovering that the client's wound has eviscerated? Cover the incision with a moist sterile dressing. Have the client lie on his back with his knees flexed. Call the client's surgeon. Reassure the client.
Cover the incision with a moist sterile dressing. Rationale: The nurse should apply the safety and risk reduction priority-setting framework when caring for this client. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. An open wound places the client at risk for peritonitis, and any exposed organ tissue could dry out. Therefore, covering the wound with a moist sterile dressing is the first action the nurse should take to protect the client.
43. A nurse is caring for a client who has Clostridium difficile and is in contact isolation. Which of the following actions should the nurse take? Wear gloves when changing the client's gown. Use alcohol-based sanitizer to cleanse the hands. Wear a mask when assisting the client with his meal tray. Place the client on complete bed rest.
Wear gloves when changing the client's gown. Rationale: The nurse should wear gloves when handling articles that have the potential to contaminate the hands when caring for a client who is in contact isolation.
32. A nurse on a surgical unit is receiving a client who had abdominal surgery from the postanesthesia care unit. Which of the following assessments should the nurse make first? Pain level Hydration status Airway Urinary output
Airway Rationale: The nurse should apply the ABC priority-setting framework when caring for this client. This framework emphasizes the basic core of human functioning and prioritizes having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these can indicate a threat to life. Therefore, this is the nurse's priority concern. When applying the ABC priority-setting framework, airway is always the highest priority because the airway must be clear and open for oxygen exchange to occur. Breathing is the second highest priority in the ABC priority-setting framework because adequate ventilatory effort is essential in order for oxygen exchange to occur. Circulation is the third highest priority in the ABC priority-setting framework because delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them; therefore, the nurse should first assess the client's airway.
1. A client who reports shortness of breath requests her nurse's help in changing positions. After repositioning the client, which of the following actions should the nurse take next? Encourage the client to take deep breaths. Observe the rate, depth, and character of the client's respirations. Prepare to administer oxygen. Give the client a back rub to help her relax.
Observe the rate, depth, and character of the client's respirations. Rationale: The nurse should apply the nursing process priority-setting framework when caring for this client. The nurse can use the nursing process to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's status, the nurse must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with knowledge to make an appropriate decision; therefore, the first action the nurse should take is to assess the client's respiratory status.