Fundamentals ATI Practice B

A nurse is preparing a heparin infusion for a client who was admitted to the facility with deep vein thrombosis. The prescription reads: 25,000 units of heparin in 0.9% sodium chloride 250 mL to infuse at 800 units/hr. At what rate should the nurse set the infusion pump? round to the nearest whole number

8 mL/hr

A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take? (select all that apply) a. place the client in a room with negative airflow pressure b. wear gloves when assisting the client with oral care c. limit each visitor to 2 hr increments d. wear a surgical mask when providing client care e. use antimicrobial sanitizer for hand hygiene

a,b,e

A nurse has accepted a verbal prescription "for three tenths of a milligram of levothyroxine IV stat" for a client who has myxedema coma. How should the nurse transcribe the dosage of this medication in the client's medical record? a. .3 mg b. 0.3 mg c. 0.30 mg d. 3/10 mg

b. 0.3 mg

A nurse is planning teaching for a group of adolescents who each recently had surgical placement of an ostomy. Which of the following methods should the nurse use as psychomotor approach to learning? a. role play b. group discussions c. question-answer meetings d. practice sessions

d. practice sessions Role play is a technique that promotes cognitive and affective learning. Group discussionsGroup discussions assist adolescents with cognitive and affective learning. Question-answer meetingsQuestion-answer meetings promote cognitive learning. Practice sessionsPractice sessions require psychomotor skills when learning.

A nurse is caring for a client who requires an informed consent for a surgical procedure. Which of the following actions is the nurse's responsibility? a. describe the procedure to the client b. witness the client's signature on the consent form c. inform the client of alternatives to the procedure d. tell the client which team members will assist with the procedure

b. witness the client's signature on the consent form The provider who is performing the procedure is responsible for describing the procedure to the client. Witness the client's signature on the consent form. The nurse is responsible for witnessing the client sign the consent form. The nurse should confirm that the client appears competent to give consent and that the client understands the procedure. Inform the client of alternatives to the procedure.The provider who is performing the procedure is responsible for informing the client about potential alternatives. Tell the client which team members will assist with the procedure.The provider is responsible for informing the client of the names and roles of the team members who will assist in performing the procedure.

A nurse is reviewing a client's medication prescription that reads, "digoxin 0.25 by mouth every day." Which of the following components of the prescription should the nurse verify with the provider? a. medication name b. route of administration c. medication dose d. frequency of administration

c. medication dose The prescription states that the medication name is digoxin; therefore, this component of the prescription does not require verification. Route of administration The prescription states that the route of administration is by mouth; therefore, this component of the prescription does not require verification. Medication dose In the prescription, the medication dose is not complete. The number 0.25 should be followed by a unit of measurement, such as mg, to clarify the amount the nurse should administer. Frequency of administration The prescription states that the frequency of administration is every day; therefore, this component of the prescription does not require verification.

A nurse is caring for a client who has a prescription for 5 units of regular insulin and 10 units of NPH insulin to mix together and administer subcutaneously. Determine the correct order of the steps for this procedure. a. inject 5 units of air into the bottle of regular insulin b. withdraw the correct dose of NPH insulin from the bottle c. inject 10 units of air into the bottle of NPH insulin d. withdraw the correct dose of regular insulin from the bottle

c,a,d,b The nurse should first inject air into the vial of NPH insulin without touching the needle to the solution. Next, the nurse should inject air into the vial of regular insulin and withdraw the correct amount of the regular insulin. Finally, the nurse should insert the needle into the NPH insulin vial and withdraw the correct amount of NPH insulin. The nurse should follow these steps to prevent contaminating the regular insulin with NPH insulin.

A nurse is planning care for a client who has vision loss. Which of the following interventions should the nurse include in the plan of care to assist the client with feeding? a. assign a staff member to feed the client b. provide small handled utensils for the client c. thicken liquids on the client's tray d. arrange food in a consistent pattern on the client's plate

d. arrange food in a consistent pattern on the client's plate The nurse should allow the client to feed themself when possible. Assigning a staff member to feed a client who has vision loss impairs autonomy and can impede the client's ability to perform self-care. Provide small-handled utensils for the client.Large-handled, adaptive utensils are easier for the client to grip and allow for greater independence during meals for clients who have vision loss. Thicken liquids on the client's tray.Clients who have dysphagia, not vision loss, require thickening of liquids to facilitate swallowing without choking. Arrange food in a consistent pattern on the client's plate. Consistency in preparing the client's plate helps to facilitate self-feeding for clients who have vision loss. Staff can describe the location of the food on the plate by using a clock pattern, allowing the client to have greater independence during meals.

A nurse is planning care for a client who has tuberculosis. The nurse should use which of the following pieces of personal protective equipment when providing care for the client? a. gown b. N95 respirator c. shoe covers d. surgical cap

b. N95 respirator

A nurse is caring for a client who has tuberculosis. which of the following actions should the nurse take? (SATA) -Place the client in a room with negative-pressure -Wear gloves when assisting the client with oral care -Limit each visitor to 2-hr increments -Wear a surgical mask when providing client care -Use antimicrobial sanitizer for hand hygiene

-Place the client in a room with negative-pressure -Wear gloves when assisting the client with oral care -Use antimicrobial sanitizer for hand hygiene Place the client in a room with negative-pressure airflow is correct. The nurse should place the client in a room with negative-pressure airflow to meet the requirements of airborne precautions.Wear gloves when assisting the client with oral care is correct. The nurse should wear gloves when assisting the client with oral care to meet the requirements of standard precautions, which the nurse must adhere to for all clients regardless of their diagnosis. The nurse should wear gloves whenever their hands might come in contact with a client's bodily fluids, such as saliva, and the mucous membranes in the mouth.Limit each visitor to 2-hr increments is incorrect. The nurse does not need to limit the client's visitors. However, the nurse should limit the client's presence outside the room and the client should wear a surgical mask when outside of the room.Wear a surgical mask when providing client care is incorrect. The nurse should wear an N95 respirator during client care to meet the requirements of airborne precautions.Use antimicrobial sanitizer for hand hygiene is correct. The nurse should use antimicrobial sanitizer for routine hand hygiene when caring for a client who has tuberculosis. Nurses should also wash their hands with soap and water when their hands are visibly soiled.

A nurse is preparing to obtain a lower extremity blood pressure and no longer palpates the popliteal pulse after 92 mmHg. Which of the following images displays the measurement in mm Hg to which the nurse should inflate the cuff when obtaining the blood pressure?

The nurse should inflate the blood pressure cuff 30 mm Hg beyond the point at which the nurse was last able to palpate the pulse. This image does not show the correct pressure reading.

The nurse is providing discharge teaching for a client who has a new prescription for a home oxygen concentrator. Which of the following instructions should the nurse provide to the client and his family? select all that apply. a. check the cord routinely for frays and tearing b. keep the unit at least 1.2 m (4 feet) away from a gas stove c. consider purchasing a generator for power backup d. observe for signs of hypoxia d. select synthetic clothing and bedding

a,c,d Check the cord routinely for frays or tearing is correct. Oxygen concentrators require electrical power. Safe use of this delivery system includes assessing the electrical function of the device; therefore, the nurse should instruct the client to routinely check the condition of the cord.Keep the unit at least 1.2 m (4 feet) away from a gas stove is incorrect. Safe use of home oxygen equipment includes keeping the unit at least 3.05 m (10 feet) away from open flames, such as from a fireplace or a gas stove, and at least 2.4 m (8 feet) away from other heat sources.Consider purchasing a generator for power backup is correct. Loss of electricity prevents the oxygen concentrator from functioning and could deprive the client of necessary oxygen. The nurse should also instruct the family to have the client placed on their municipality's priority list for restoring power after an outage occurs.Observe for signs of hypoxia is correct. The nurse should instruct the family to observe for and report signs of hypoxia, such as anxiety, worsening fatigue, dizziness, rapid pulse and respirations, pallor, and cyanosis. Even with supplemental oxygen, the client's status can worsen, resulting in the development of hypoxia.Select synthetic clothing and bedding is incorrect. Safe use of oxygen therapy includes choosing clothing and bedding made from material that does not generate static electricity; therefore, the nurse should instruct the client to select materials made from cotton.

A nurse is caring for a client who has a terminal diagnosis and whose health is declining. The client requests information about advance directives. Which of the following responses should the nurse make? a. "we can talk about advance directives, and I can also give you some brochures about them" b. "you should set up a time to talk with your provider about that" c. "let's discuss how you are feeling today, and we'll save the planning for when you are feeling a little better" d. "why do you want to discuss this without your partner here to plan this with you?"

a. "we can talk about advance directives, and I can also give you some brochures about them" "We can talk about advance directives, and I can also give you some brochures about them." With this statement, the nurse offers to provide the information the client needs in a direct and simple way. "You should set up a time to talk with your provider about that."The nurse is passing the responsibility of discussing this topic with the client to the provider, which dismisses the client's concerns. "Let's discuss how you are feeling today, and we'll save the planning for when you are feeling a little better."The nurse is rejecting the client's needs by postponing a discussion about what is important to the client. "Why do you want to discuss this without your partner here to plan this with you?"Clients might interpret "why" questions as accusatory, and they can provoke feelings of mistrust and resentment.

A nurse is caring for a client who has terminal liver cancer. Which of the following statements should the nurse identify as an indication that the client is experiencing spiritual distress? a. "what could i have done to deserve this illness?" b. "I blame medical science for not curing me" c. "where is my daughter at a time like this? d. "will i ever begin to feel in charge of my life again?"

a. "what could i have done to deserve this illness?" The client's terminal illness might prompt the client to review their life and question its meaning. A manifestation of the client's spiritual distress is asking why this illness is happening to them. "I blame medical science for not curing me."The basis of medicine is science, not spirituality. This statement does not reflect the client's conflict with spiritual beliefs. "Where is my daughter at a time like this?"This statement reflects conflict in family relationships, not with the client's spiritual beliefs. "Will I ever begin to feel in charge of my life again?"This statement reflects the client's feelings of powerlessness but does not indicate a conflict of a spiritual nature.

A nurse is teaching a client whose left leg is in a cast about using crutches. Which of the following statements should the nurse identify as an indication that the client understands the teaching? a. "when descending the stairs, I will first shift my weight to my right leg" b. "I should place my crutches 12 inches in front and to the side of each foot" c. "As I sit down, I will hold one crutch in each hand" d. "I will make sure the shoulder rests are snug against my armpits"

a. "when descending the stairs, I will first shift my weight to my right leg" To descend stairs, the client should first shift his body weight to his right, unaffected leg. "I should place my crutches 12 inches in front and to the side of each foot."The client should place his crutches 15 cm (6 in) in front and to the side of each foot. "As I sit down, I will hold one crutch in each hand."Just before sitting down, the client should hold both crutches by their hand bars in one hand. "I will make sure the shoulder rests are snug against my armpits." To avoid injury to the underlying nerves, the shoulder rests should be at least 2.5 to 5 cm (1 to 2 in) below the axillae.

A nurse is providing a peripheral vascular assessment for a client. When placing the bell of the stethoscope on the client's neck, the nurse hears the following sound. This sound indicates which of the following. (click on the audio button to listen to the clip) a. Narrowed arterial lumen b. Distended jugular veins c. Impaired ventricular contraction d. Asynchronous closure of the aortic and pulmonic valves

a. Narrowed arterial lumen Blowing sounds resulting from blood flowing through occluded or narrowed arteries are known as a bruit. Distended jugular veins Blood flowing through distended jugular veins does not produce a sound. Impaired ventricular contractionImpaired ventricular function produces extra heart sounds, either S3 or S4. These sounds are best heard over the aortic area of the heart. Asynchronous closure of the aortic and pulmonic valvesAsynchronous closure of the aortic and pulmonic valves is known as "splitting" of S2, so the nurse should hear two "dub" sounds during auscultation. This sound is best heard over the aortic area of the heart.

A nurse is caring for a group of clients on a medical-surgical unit. In which of the following situations does the nurse demonstrate the ethical principle of veracity? a. a client who is unaware of her recent cancer diagnosis asks the nurse if she has cancer, and the nurse responds affirmatively. b. a client who has a prescription for a nasogastric tube refuses it, and the nurse complies with the client's wishes c. a client who has a DNR order has a cardiac arrest, and the nurse does not perfrom CPR despite requests from the client's family d. a client who is about to undergo a painful procedure receives pain medication 30 minutes before the procedure that the nurse previously promised to administer

a. a client who is unaware of her recent cancer diagnosis asks the nurse if she has cancer, and the nurse responds affirmatively. Following the ethical principle of veracity, the nurse must tell the truth at all times and never deceive others. A client who has a prescription for a nasogastric tube refuses it, and the nurse complies with the client's wishes.When stopping a procedure that the client refuses, the nurse is following the ethical principle of autonomy and is recognizing the client's right to refuse treatment. A client who has a do-not-resuscitate (DNR) order has a cardiac arrest, and the nurse does not perform CPR despite requests from the client's family.A DNR order requires a request on the part of the client or the client's designated power of attorney for health care decisions. Enforcing a client's DNR order supports the ethical principle of autonomy by following the client's end-of-life wishes. A client who is about to undergo a painful procedure receives pain medication 30 min before the procedure that the nurse previously promised to administer.This is an example of the ethical principle of fidelity, which means keeping promises.

A nurse is preparing to delegate client care tasks to an assistive personnel(AP). Which of the following tasks should the nurse delegate? a. ambulating a client who is postop b. inserting an indwelling urinary catheter for a client c. demonstrating the use of an incentive spirometer to a client d. confirming that a client's pain has decreased after receiving an analgesic

a. ambulating a client who is postop Ambulating a client is within the range of function of an AP. The nurse can delegate tasks to the AP that do not require special skills, assessment, or teaching. Inserting an indwelling urinary catheter for a clientIndwelling urinary catheter insertion requires advanced nursing judgment and sterile technique. This task is outside the range of function of an AP. Demonstrating the use of an incentive spirometer to a clientClient education requires advanced nursing knowledge and is outside the range of function of an AP. Confirming that a client's pain has decreased after receiving an analgesicEvaluating a client's pain level requires advanced nursing judgment and is outside the range of function of an AP.

A nurse is administering IV fluids to a client. When monitoring for adverse effects, which of the following assessments should the nurse identify as priority? a. auscultate lung sounds b. measure urine output c. monitor blood pressure readings d. monitor electrolyte levels

a. auscultate lung sounds Auscultate lung sounds.The priority assessment the nurse should make when using the airway, breathing, circulation approach to client care is auscultating lung sounds to monitor for fluid volume excess, a complication of IV therapy. Manifestations of fluid volume excess include moist crackles in lung fields, dyspnea, and shortness of breath. Measure urine output.The nurse should measure urine output to monitor the renal function of a client who is receiving IV fluid; however, it is not the priority assessment. Monitor blood pressure readings. The nurse should monitor blood pressure readings to evaluate the hemodynamic stability of a client who is receiving IV fluids; however, it is not the priority assessment. Monitor electrolyte levels.The nurse should monitor electrolyte levels, especially sodium, to guide the planning of interventions to correct any imbalances in a client who is receiving IV fluids; however, it is not the priority assessment.

A nurse is admitting a client who has rubella. Which of the following types of transmission based precautions should the nurse initiate? a. droplet b. airborne c. contact d. protective environment

a. droplet Droplet precautions are a requirement for clients who have infections that spread via droplet nuclei that are larger than 5 microns in diameter, including influenza, rubella, meningococcal pneumonia, and streptococcal pharyngitis. Airborne precautions are a requirement for clients who have infections that spread via droplet nuclei that are smaller than 5 microns in diameter, including varicella, tuberculosis, and measles. Contact precautions are a requirement for clients who have infections that spread via direct contact with another person or contact with the environment, including vancomycin-resistant enterococci, methicillin-resistant Staphylococcus aureus, and scabies. Protective environment Clients who have a compromised immune system, such as those who have had an allogeneic hematopoietic stem cell transplant, require a protective environment.

A nurse is assessing an adult client who has been immobile for the past 3 weeks. For which of the following findings should the nurse intervene? a. erythema on pressure points b. lower-extremity pulse strength of 2+ c. fluid intake of 3,000 mL per day d. one bowel movement every other day

a. erythema on pressure points Erythema on pressure pointsErythema on pressure points requires prompt relief of pressure and additional measures to protect the skin from breakdown. Lower-extremity pulse strength of 2+A lower-extremity pulse strength of 2+ is an expected finding. Fluid intake of 3,000 mL per day. Clients should receive 2,000 to 3,000 mL of fluid per day. One bowel movement every other dayBowel movements less frequent than three times per week can indicate constipation and the need for intervention. However, a bowel movement every other day does not require intervention.

A nurse is preparing to administer 0.5 mL of oral single-dose liquid medication to a client. Which of the following actions should the nurse take? a. gently shake the container of medication prior to administration b. transfer the medication to a medicine cup c. place the client in the semi-Fowler's position prior to medication administration d. verify the dosage by measuring the liquid before administering it

a. gently shake the container of medication prior to administration The nurse should gently shake the liquid medication to ensure that the medication is mixed. Transfer the medication to a medicine cup.The nurse should not transfer prepackaged liquid medication to a medicine cup to reduce the risk of altering the premeasured dose. Place the client in a semi-Fowler's position prior to medication administration.The nurse should place the client in high-Fowler's position when administering an oral liquid medication to reduce the risk of aspiration. Verify the dosage by measuring the liquid before administering it.The nurse should not transfer prepackaged liquid medication to a measuring device to reduce the risk of altering the premeasured dose.

A nurse is caring for a client who is receiving pain medication through a patient-controlled analgesia(PCA) pump. Which of the following actions should the nurse take? a. instruct the family to refrain from pushing the button for the client while she is asleep b. inform the client that because she is on PCA, vital signs will be taken every 8 hours c. teach the client to avoid pushing the button until pain is above a 7 on a scale of 0-10 d. increase the basal rate and shorten the lock-out interval time if the client's pain level is too high

a. instruct the family to refrain from pushing the button for the client while she is asleep The nurse should instruct family members not to activate the button for the client while they are sleeping. Even though PCA pumps minimize the risk of overdose, toxic effects could still occur if the client receives more medication than necessary to control pain. Inform the client that because she is on PCA, vital signs will be taken every 8 hr.The nurse should monitor a client who is using a PCA pump every 1 to 2 hr during the first 12 hr. The client is at risk for respiratory depression as a result of opioid medication administration. Teach the client to avoid pushing the button until pain is above a 7 on a scale of 0 to 10.The nurse should instruct the client to activate the PCA pump when she needs it. It is inappropriate for the client to wait until pain escalates to any particular level of intensity before using the pump. Increase the basal rate and shorten the lock-out interval time if the client's pain level is too high.It is not within the scope of practice for the nurse to prescribe the rate and lock-out interval.

A charge nurse is observing a newly licensed nurse prepare a sterile field for a dressing change. Which of the following actions by the newly licensed nurse requires intervention by the charge nurse? a. the newly licensed nurse places the cap of a bottle of sterile solution on the sterile field b. the newly licensed nurse places sterile objects 2.5 cm (1 in) within the border of the field c. the newly licensed nurse holds the bottle of sterile saline outside the edge of the field when pouring d. the sterile field is positioned at the level of the newly licensed nurse's waist

a. the newly licensed nurse places the cap of a bottle of sterile solution on the sterile field The newly licensed nurse should place the cap with the sterile side up on a clean surface because the outer edges are unsterile and will contaminate the sterile field. The newly licensed nurse places sterile objects 2.5 cm (1 inch) within the border of the field.The edges of the sterile field are considered contaminated. Therefore, the nurse should place all sterile items inside the 2.5 cm (1 inch) border of the field. The newly licensed nurse holds the bottle of sterile saline outside the edge of the field when pouring. The newly licensed nurse should hold the bottle of sterile saline outside the edge of the field when pouring to prevent contaminating the field. The sterile field is positioned at the level of the newly licensed nurse's waist.An object that is below waist level is considered nonsterile. Positioning the table at waist level does not require intervention.

A nurse is teaching an older adult client who is at risk for osteoporosis about beginning a program of regular physical activity. Which of the following types of activity should the nurse recommend? a. walking briskly b. riding a bicycle c. performing isometric exercise d. engaging in high-impact aerobics

a. walking briskly Weight-bearing exercises are essential for maintaining bone mass, which helps to prevent osteoporosis. Walking engages older adult clients in this preventive and therapeutic strategy. Riding a bicycleCycling has no weight-bearing advantages; therefore, it does not help prevent osteoporosis. Performing isometric exercises Isometric exercises have no weight-bearing advantages; therefore, they do not help prevent osteoporosis. Engaging in high-impact aerobics High-impact aerobics can injure bones that have lost density; therefore, the nurse should not recommend these exercises for a client who is at risk for developing osteoporosis.

A nurse is admitting a client who has been having frequent tonic-clonic seizures. Which of the following actions should the nurse add to the client's plan of care? a. wrap blankets around all 4 sides of the bed b. apply restraints during seizure activity c. place the client in a supine position during seizure activity d. have a tongue depressor at the client's bedside

a. wrap blankets around all 4 sides of the bed

A nurse is discussing the use of herbal supplements for health promotion with a client. Which of the following client statements indicates an understanding of herbal supplement use? a."I can take echinacea to improve my immune system" b. "I can take feverfew to reduce my level of anxiety" c. "I can take ginger to improve my memory" d. "I can take ginkgo biloba to relieve nausea"

a."I can take echinacea to improve my immune system" Echinacea is taken to promote immunity and reduce the risk of infection. "I can take feverfew to reduce my level of anxiety."Feverfew is taken to promote wound healing and decrease inflammation associated with arthritis. Valerian and chamomile can be taken to reduce anxiety. "I can take ginger to improve my memory."Ginger is taken to relieve nausea and vomiting and aid in digestion. Ginkgo biloba can be taken to improve memory and reduce stress. "I can take ginkgo biloba to relieve nausea."Ginkgo biloba is taken to improve memory and reduce stress. Ginger can be taken to relieve nausea and vomiting and aid in digestion.

A nurse is caring for a client who reports difficulty falling asleep. Which of the following recommendations should the nurse make? a. "drink a cup of hot cocoa before bedtime" b. "maintain a consistent time to wake up each day" c. "exercise 1 hour before going to bed" d. "watch a television program in bed before going to sleep"

b. "maintain a consistent time to wake up each day" Cocoa contains caffeine, which is a stimulant that can interfere with sleep. "Maintain a consistent time to wake up each day." The client should maintain a consistent time for waking up and going to sleep. This helps to establish an internal sense of sleep and waking on a daily basis and helps to maintain it over time. This will help promote sleep for the client. "Exercise 1 hour before going to bed."Exercising within 2 hr of bedtime can interfere with sleep. "Watch a television program in bed before going to sleep."The client should avoid watching television in bed before going to sleep to reduce stimulation in order to promote rest.

A nurse is caring for a client who reports pain. When documenting the quality of the client's pain on an initial pain assessment, the nurse should record which of the following client statements? a. "I'm having mild pain" b. "the pain is like a dull ache in my stomach" c. "I notice that the pain gets worse after I eat" d. "the pain makes me feel nauseous"

b. "the pain is like a dull ache in my stomach" The client is describing the severity of the pain, not the quality of the pain. The nurse should use a pain scale to specify the intensity of the client's pain. "The pain is like a dull ache in my stomach." The client is describing the quality of the pain, which is how the pain feels in the client's own words. "I notice that the pain gets worse after I eat."The client is describing a factor that aggravates the pain, not the quality of the pain. "The pain makes me feel nauseous."The client is describing a manifestation that accompanies the pain, not the quality of the pain.

A nurse is planning care for a client who has tuburculosis. The nurse should use which of the following pieces of PPE when providing care for the client? a. gown b. N95 respirator c. Shoe covers d. Surgical cap

b. N95 respirator The nurse should wear a gown when providing care for a client who requires contact precautions to prevent the transmission of bacteria. N95 respirator.The nurse should wear an N95 respirator when providing care for a client who requires droplet precautions as a result of tuberculosis to prevent the transmission of bacteria. Shoe coversThe nurse should wear shoe covers when proving care for a client who is in the surgical suite to reduce the risk for contamination and potential infection. Surgical capThe nurse should wear a surgical cap when proving care for a client who is in the surgical suite to reduce the risk for contamination and potential infection.

A community health nurse is checking blood pressure for a group of clients at a community health screening. Which of the following clients is at an increased risk for hypertension? a. a client who is 52 years old b. a client who smokes one pack of cigarettes each day c. a client who walks for 30 minutes every day d. a client who drinks one glass of wine 3 times per week

b. a client who smokes one pack of cigarettes each day A client who is 52 years oldClients who are 60 years of age or older are at an increased risk for hypertension. A client who smokes one pack of cigarettes each day. A client who smokes one pack of cigarettes each day is at an increased risk for hypertension. A client who walks for 30 min every dayRegular physical exercise lowers the risk for developing hypertension. A client who drinks one glass of wine three times per weekAlthough heavy alcohol consumption can increase the risk for hypertension, drinking one glass of wine three times per week is not considered heavy consumption.

A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect? a. neck vein distention b. urine specific gravity 1.010 c. rapid heart rate d. blood pressure 144/82 mmHg

c. rapid heart rate Neck vein distension is a clinical manifestation of fluid volume excess. Urine specific gravity 1.010T ypically, a client's urine specific gravity is greater than 1.030 in the presence of fluid volume deficit. The expected reference range for urine specific gravity is 1.005 to 1.030. Rapid heart rate. Tachycardia indicates fluid volume deficit, which is an expected finding for a client who has had vomiting and diarrhea for 3 days. Blood pressure 144/82 mm HgHypotension is an expected finding for a client who has fluid volume deficit.

A nurse manager is overseeing the care activities on a unit. For which of the following situations should the nurse manager intervene due to a violation of HIPAA guidelines? a. a nurse who is caring for a client reviews the client's medical chart with a nursing student who is working with the nurse. b. a nurse asks a nurse from another unit to assist with documentation for a client c. a nurse who is caring for a client returns a call to a person appointed in the health care proxy to discuss the client's care d. a nurse discussed a client's status with the physical therapist who is caring for the client.

b. a nurse asks a nurse from another unit to assist with documentation for a client Any health care professional directly caring for a client should have access to the client's medical information; therefore, this is not a violation of HIPAA guidelines. A nurse asks a nurse from another unit to assist with documentation for a client. Only health care professionals directly caring for a client should have access to the client's medical information; therefore, this is a violation of HIPAA guidelines. A nurse who is caring for a client returns a call to the person appointed in the health care proxy to discuss the client's care. The person designated by the health care proxy document has a legal right to information about the client's care; therefore, this is not a violation of HIPAA guidelines. A nurse discusses a client's status with the physical therapist who is caring for the client. Any health care professional who is directly caring for a client may discuss medical information with other members of the health care team; therefore, this is not a violation of HIPAA guidelines.

A nurse has just inserted an NG tube for a client. Which of the following findings should the nurse expect to confirm correct tube placement? a. the tube aspirate has a pH of 7 b. an x-ray shows the end of the tube above the pylorus c. bowel sounds are present on auscultation d. the client reports relief of nausea

b. an x-ray shows the end of the tube above the pylorus Gastric aspirate from a client who has been fasting for several hours should have a pH of 4.0 or less. Intestinal fluid or fluid from the client's airway usually has a pH higher than 6.0. Therefore, a pH of 7.0 does not indicate gastric placement of an NG tube. An x-ray shows the end of the tube above the pylorus. An abdominal x-ray showing the end of the tube above the pylorus indicates gastric placement. Bowel sounds are present on auscultation.The presence of bowel sounds on auscultation reflects gastric motility, not gastric placement of the tube. The client reports relief of nausea.Correct placement of an NG tube can help relieve nausea, especially if the tube is intended for gastric decompression. However, this finding alone is not enough to confirm gastric placement.

A nurse is giving change of shift report about a client they admitted earlier that day who has pneumonia. Which of the following pieces of info is the priority for the nurse to provide? a. admitting diagnosis b. breath sounds c. body temperature d. diagnostic test results

b. breath sounds When using the airway, breathing, circulation approach to client care, the nurse should determine that the priority information to provide is the current status of the client's breath sounds. Knowing the client's admitting diagnosis is essential for planning care and following critical pathways; however, other information is the nurse's priority to provide. Body temperature Knowing the client's current body temperature is essential for planning care and following critical pathways; however, other information is the nurse's priority to provide. Knowing diagnostic test results is essential for planning care and following critical pathways; however, other information is the nurse's priority to provide.

A nurse is reviewing protocol in preparation for suctioning secretions from a client who has a new tracheostomy. Which of the following actions should the nurse plan to take? a. use resuscitation bag with 80% oxygen prior to the procedure b. select a suction catheter that is half the size of the lumen c. place the end of the suction catheter in water soluble lubricant d. adjust the wall suction apparatus to pressure of 170 mmHg

b. select a suction catheter that is half the size of the lumen The nurse should preoxygenate the client with 100% oxygen before suctioning to prevent hypoxemia. Select a suction catheter that is half the size of the lumen. The nurse should select a suction catheter that is half the size of the lumen to prevent hypoxemia and trauma to the mucosa. Place the end of the suction catheter in water-soluble lubricant.The nurse should lubricate the end of the suction catheter with sterile water or 0.9% sodium chloride irrigation solution to decrease trauma to the mucosa. Adjust the wall suction apparatus to a pressure of 170 mm Hg.The nurse should adjust the suction pressure to approximately 120 mm Hg and no higher than 150 mm Hg to prevent hypoxemia and trauma to the mucosa.

A nurse is caring for a client who has an NG tube and is receiving intermittent feedings through an open system. Which of the following actions should the nurse take first? a. rinse the feeding bag with water between feedings b. tell the client to keep the head of the bed elevated at least 30 degrees c. make sure the enteral formula is at room temperature d. wipe the top of the formula can with alcohol

b. tell the client to keep the head of the bed elevated at least 30 degrees The first action the nurse should take when using the airway, breathing, circulation approach to client care is to prevent aspiration of the enteral formula; therefore, the priority intervention is to keep the head of the bed elevated at least 30° to prevent reflux of the formula into the esophagus. The nurse should rinse the feeding bag with warm water to reduce the risk of bacterial growth; however, there is another action that is the priority. The nurse should make sure the enteral formula is at room temperature to prevent the cramping and discomfort that can result from instilling cold formula; however, there is another action that is the priority. The nurse should wipe the top of the formula can with alcohol to remove or disinfect any dirt or micro-organisms that could contaminate the formula; however, there is another action that is the priority.

A nurse is caring for a client who is refusing a blood transfusion for religious reasons. The client's partner wants the client to have the blood transfusion. Which of the following actions should the nurse take? a. ask the client to consider a direct donation b. withhold the blood transfusion c. request a consultation with the ethics committee d. ask the client's family to intervene

b. withhold the blood transfusion A direct donation still requires a blood transfusion and does not respect the client's wishes. Withhold the blood transfusion. The principle of autonomy ensures that a client who is competent has the right to refuse treatment. Request a consultation with the ethics committee.A client who is competent has the right to refuse treatment, regardless of the consequences. There is no need to involve the ethics committee. Ask the client's family to intervene.Clients who are competent have the right to consent to or refuse treatment.

A nurse in a surgical suite notes documentation on a client's medical record that he has a latex allergy. In preparation for the client's procedure, which of the following precautions should the nurse take? a. ensure sterilization of non-disposable items with ethylene oxide b. wrap monitoring cords with stockinette and tape them in place c. cleanse latex ports on IV tubing with chlorhexidine before injecting medication d. wear hypoallergenic latex gloves that contain powder.

b. wrap monitoring cords with stockinette and tape them in place Ensure sterilization of nondisposable items with ethylene oxide.Ethylene oxide can cause an allergic reaction in clients who have a latex allergy. The nurse should rinse any items that received this type of sterilization before use. Wrap monitoring cords with stockinette and tape them in place. Many monitoring devices and cords contain latex. The nurse should prevent any contact of these cords and devices with the client's skin by covering them with a nonlatex barrier material, such as stockinette, and using nonlatex tape to secure them. Cleanse latex ports on IV tubing with chlorhexidine before injecting medication.The nurse should use a stopcock for injecting medication. Cleansing a latex item will not remove the latex protein. Wear hypoallergenic latex gloves that contain powder.Hypoallergenic latex gloves contain latex and can still provoke an allergic response. Powder is especially harmful because it contains the latex protein. The nurse should make sure all members of the client-care staff wear nonlatex gloves.

A nurse in a clinic is caring for a middle adult client who states, "The doctor says that, since I am at an average risk for colon cancer, I should have routine screening. What does that involve?" Which of the following responses should the nurse make? a. "I'll get a blood sample from you and send it for a screening test." b. "beginning at age 60, you should have a colonoscopy" c. " you should have a fecal occult blood test every year" d. "the recommendation is to have a sigmoidoscopy every 10 years'

c. " you should have a fecal occult blood test every year" Blood tests do not detect colorectal cancer. One option for screening is a double-contrast barium enema every 5 years. "Beginning at age 60, you should have a colonoscopy."Colorectal cancer screening for clients who are at average risk begins at age 50. One option for screening is a colonoscopy every 10 years. "You should have a fecal occult blood test every year." Colorectal cancer screening for clients who are at average risk begins at age 50. One option for screening is a fecal occult blood test annually. "The recommendation is to have a sigmoidoscopy every 10 years."One option for screening is a flexible sigmoidoscopy every 5 years.

A nurse is caring for a client who requires 24 hr urine collection. Which of the following statements by the client indicates an understanding of the teaching? a. "I had a bowel movement, but I was able to save the urine" b. "I have a specimen in the bathroom from about 30 minutes ago" c. "I flushed what I urinated at 7 am and have saved all urine since" d. "I drink a lot, so I will fill up the bottle and complete the test quickly"

c. "I flushed what I urinated at 7 am and have saved all urine since" For a 24-hr urine collection, the client should collect urine that is free of feces. "I have a specimen in the bathroom from about 30 minutes ago."For a 24-hr urine collection, the client should place any urine in the container immediately and keep it on ice or in a refrigerator. "I flushed what I urinated at 7:00 a.m. and have saved all urine since." For a 24-hr urine collection, the client should discard the first voiding and save all subsequent voidings. "I drink a lot, so I will fill up the bottle and complete the test quickly."For a 24-hr urine collection, there is no specified amount. The collection takes place over a 24-hr period regardless of the total volume of urine collected.

A nurse enters a client's room and finds her on the floor. The client's roommate reports that the client was trying to get out of bed and fell over the side rail onto the floor. Which of the following statements should the nurse document about this incident? a. "incident report completed" b. "client climbed over the side rails" c. "client found lying on the floor" d. "client was trying to get out of bed"

c. "client found lying on the floor" An incident report is an internal document that is part of a facility's risk management system. The nurse should not document completion of an incident report in the client's medical record for the facility's protection in the event of litigation. "Client climbed over the side rails."Unless the nurse witnessed the client climbing over the bed's side rails, this statement is not an objective account of the nurse's findings. "Client found lying on floor." The nurse should include documentation of information that is descriptive and objective concerning what the nurse actually observed, without including any opinions or judgments about motives or cause. "Client was trying to get out of bed."Unless the nurse witnessed the client trying to get out of bed, this statement is not an objective account of the nurse's findings.

A nurse is calculating a client's fluid intake over the past 8 hr. Which of the following should the nurse plan to document on the client's intake and output record as 120 mL of fluid? a. 2 cups of soup b. 1 quart of water c. 8 oz of ice chips d. 6 oz of tea

c. 8 oz of ice chips 2 cups of soup. The nurse should understand that 2 cups of soup are equivalent to 480 mL of fluid. 1 quart of water. The nurse should understand that 1 quart of water is equivalent to 960 to 1,000 mL of fluid. 8 oz of ice chips. The nurse should document half of the volume of ice chips when calculating fluid intake to account for the air in between the chips. The nurse should understand that 4 oz of liquid water is equal to 120 mL of fluid. 6 oz of tea. The nurse should understand that 6 oz of tea is equal to 180 mL of fluid.

A nurse is caring for a client who is receiving fluid through a peripheral IV catheter. Which of the following findings at the IV site should the nurse identify as indicating infiltration? a. purulent exudate b. warmth c. skin blanching d. bleeding

c. skin blanching Purulent Exudate indicates infection, not infiltration. Warmth. Warmth indicates phlebitis, not infiltration. Skin blanching. Skin blanching, edema, and coolness at the IV site indicate infiltration. Bleeding. Bleeding can have a mechanical cause or can occur as the result of anticoagulation. It is not a sign of infiltration.

A nurse is preparing to transfer a client who can bear weight on one leg from the bed to a chair. After securing a safe environment, which of the following actions should the nurse take next? a. rock the client up to a standing position b. pivot on the foot that is the farthest from the chair c. assess the client for orthostatic hypotension d. apply gait belt to the client

c. assess the client for orthostatic hypotension The nurse should rock the client up to a standing position to generate momentum and reduce the nurse's workload in lifting the client up off the bed; however, there is another action that is the priority. Pivot on the foot that is the farthest from the chair.The nurse should pivot on the foot that is the farthest from the chair to give the client room to move; however, there is another action that is the priority. The nurse can also use their other knee to give the client's weak leg some support as the client moves to the chair. Assess the client for orthostatic hypotension.The first action the nurse should take when using the nursing process is to assess the client. The nurse should determine the client's risk for falling or fainting during the transfer by assisting the client to sit and dangle the feet on the side of the bed. The nurse should assess for dizziness and a significant drop in blood pressure before assisting the client to stand and transfer into the chair. Apply a gait belt to the client. The nurse should use a gait belt to help maintain the client's stability; however, there is another action that is the priority.

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following findings indicates that the catheter requires irrigation? a. urine has an unusual odor b. urine specific gravity is 1.035 c. bladder scan shows 525 mL of urine d. urine is positive for ketones

c. bladder scan shows 525 mL of urine Urine with an unusual odor can be a sign of infection; however, it is not an indication for irrigation. Urine specific gravity is 1.035.A urine specific gravity of 1.035 indicates that the urine is concentrated; however, it is not an indication for irrigation. Bladder scan shows 525 mL of urine. A client who has an indwelling urinary catheter should have a continuous urine flow without an accumulation of urine in the bladder; therefore, the nurse should irrigate the catheter to resolve any existing blockage. Urine is positive for ketones.Urine that is positive for ketones is a sign of diabetes mellitus with poor glucose control; however, it is not an indication for irrigation.

A nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions should the nurse take? a. wear sterile gloves when removing the old dressing b. warm the irrigation solution to 40.5(105 degrees farenheit) c. cleanse the wound from the center outward d. use a 20 mL syringe to irrigate the wound.

c. cleanse the wound from the center outward The nurse should wear clean gloves to remove the old dressing. Warm the irrigation solution to 40.5° C (105° F).The nurse should warm the irrigation solution to body temperature. Cleanse the wound from the center outward. The nurse should clean the wound from the center outward to prevent introduction of micro-organisms from the outer skin surface. Use a 20-mL syringe to irrigate the wound.The nurse should use a 35-mL syringe to irrigate the wound. Syringes that hold 30 to 60 mL of fluid create a safe but effective amount of pressure for wound irrigation.

A nurse in an acute care facility is preparing a discharge summary for a client who is transferring to a long-term care facility. Which of the following documentation should the nurse include? a. client flow sheet b. acuity ranges c. current medications d. incident reports

c. current medications Client flow sheet. It is not necessary to include the client's flow sheet in the discharge summary. Flow sheets contain routine client data recorded by the nurse. Acuity ratings. It is not necessary to include acuity ratings in the discharge summary. Acuity ratings help determine the amount and level of staffing a nursing unit requires. Current medications. The nurse should include the client's medications in the discharge summary to ensure client safety and continuity of care. Incident reports. The nurse should not include incident reports in the discharge summary. Incident reports are confidential, internal documents that are not part of the client's medical record.

A client who is non ambulatory notifies the nurse that his trash can is on fire. After the nurse confirms the fire, which of the following actions should the nurse take next? a. activate the emergency fire alarm b. extinguish the fire c. evacuate the client d. confine the fore

c. evacuate the client Activate the emergency fire alarm.According to the RACE mnemonic, the second action in response to a fire is to activate the alarm. Extinguish the fire.According to the RACE mnemonic, the fourth action in response to a fire is to attempt to extinguish the fire. Evacuate the client. According to the RACE mnemonic, the first action in response to a fire is to rescue the clients, moving them to a safe area. Confine the fire.According to the RACE mnemonic, the third action in response to a fire is to contain the fire by closing all the doors and windows in the area. The nurse should also turn off oxygen and electrical equipment in the area of the fire.

A nurse is performing a Romberg test during the physical assessment of a client. Which of the following techniques should the nurse use? a. touch the face with a cotton ball b. apply vibrating tuning fork to the client's forehead c. have the client stand with their arms at their sides and their feet together d. perform direct percussion over the area of the kidneys

c. have the client stand with their arms at their sides and their feet together The nurse should touch the client's corneas with a wisp of cotton and measure light touch and pain across the client's face to test cranial nerve V, the trigeminal nerve. Apply a vibrating tuning fork to the client's forehead.The nurse should apply a vibrating tuning fork to the client's head to perform the Weber test to identify sound lateralization when assessing hearing. Have the client stand with their arms at their sides and their feet together. Romberg test helps identify alterations in balance. The nurse should have the client stand with their arms at their sides and their feet together to observe for swaying and a loss of balance. Perform direct percussion over the area of the kidneys.The nurse should perform direct percussion over the area of the kidneys to evaluate them for inflammation.

A nurse is caring for a client who has recently started using a behind the ear hearing aid. Which of the following statements should the nurse identify as an indication that the client understands the use of this assistive device? a. "this type of hearing aid does not allow for fine tuning of volume" b. "I shouldn't have trouble keeping the hearing aid in place during exercise c. "I expect to hear a whistling sound when I first insert the hearing aid" d. "I will be sure to remove my hearing aid before taking a shower"

d. "I will be sure to remove my hearing aid before taking a shower" A behind-the-ear hearing aid allows for fine tuning of the volume of the device. It is useful for clients who have mild to severe hearing loss. "I shouldn't have trouble keeping the hearing aid in place during exercise."Physical activity can easily dislodge this type of hearing aid. "I expect to hear a whistling sound when I first insert the hearing aid."Whistling during insertion can be a sign that the hearing aid does not fit properly. A buildup of cerumen or fluid in the ear can also cause a whistling sound. "I will be sure to remove my hearing aid before taking a shower." Clients should remove any hearing devices before showering because exposure to water can damage them.

A nurse is planning an educational program for a group of older adults at a senior living center. Which of the following recommendations should the nurse include? a. "You should have an eye exam every 2 years" b. "You should receive a tetanus booster every 5 years" c. "You should have a fecal occult blood test every 2 years" d. "You should receive a pneumococcal immunization every 10 years"

d. "You should receive a pneumococcal immunization every 10 years" "You should have an eye examination every 2 years."Older adults should have an eye examination every year. "You should receive a tetanus booster every 5 years."Older adults should receive a tetanus booster every 10 years. "You should receive a shingles vaccine when you are 70 years old."The nurse should instruct older adult clients to receive a shingles vaccine when they are 60 years old. "You should receive a pneumococcal vaccine when you are 65 years old." The nurse should instruct older adult clients to receive one of the two pneumococcal vaccines when they are 65 years old. The vaccines can be given to clients who are 19 years of age and older and have certain conditions, such as chronic heart, lung, or liver disease, diabetes mellitus, and alcohol disease, or to those who smoke cigarettes.

A middle adult client tells the nurse, "I feel so useless now that my children do not need me anymore." Which of the following responses should the nurse make? a. "most people are happy when their children grow up and leave home" b. "you should be proud that your children are becoming independent" c. "maybe you should consider why you are feeling useless" d. "people in middle adulthood often find satisfaction in nurturing and guiding young people"

d. "people in middle adulthood often find satisfaction in nurturing and guiding young people" This is an automatic or stereotypical response that minimizes the client's feelings by implying that the client should respond like everyone else. "You should be proud that your children are becoming independent."This response conveys the nurse's approval of people who are proud of their children's independence, which implies that this is the only acceptable behavior in this situation. "Maybe you should consider why you are feeling useless."Clients might interpret "why" questions as accusatory, and they can elicit feelings of mistrust and resentment. With this response, the nurse is asking for an explanation instead of acknowledging the client's feelings. "People in middle adulthood often find satisfaction in nurturing and guiding young people." According to Erik Erikson, the task of middle adulthood is generativity versus self-absorption and stagnation. The focus of this task is on offering support and guidance to future generations. The nurse should explore opportunities for mastering the developmental tasks of this stage with the client, such as volunteering and mentoring young people.

A nurse is teaching a group of staff nurses about the use of essential oils for aromatherapy. The nurse should include in the teaching that this therapy might be contraindicated for which of the following clients? a. a client who has a history of physical abuse b. a client who has a permanent pacemaker c. a client who has ulcerative colitis d. a client who has asthma

d. a client who has asthma Mental health issues that affect sensitivity to touch, such as previous physical abuse, are a contraindication for therapeutic touch, not aromatherapy. A client who has a permanent pacemakerHaving an implanted electrical device is a contraindication for magnet therapy, not aromatherapy. A client who has ulcerative colitisUlcerative colitis is a contraindication for colonic detoxification, not aromatherapy. A client who has asthma. Some essential oils can cause bronchospasm; therefore, the nurse should consult the client's provider before using this therapy for a client who has asthma.

A nurse is caring for a client who has decreased mobility. Which of the following actions should the nurse take to decrease the client's risk of developing plantar flexion contractures? a. place a pillow under the client's knees b. position a trochanter toll under each of the client's hips c. advise the client to wear rubber-soled slippers d. apply an ankle-foot orthotic device to the client's feet

d. apply an ankle-foot orthotic device to the client's feet The nurse should place a pillow under the client's lower legs to prevent pressure on the heels. Position a trochanter roll under each of the client's hips.The nurse should place a trochanter roll under the client's buttocks and alongside the hips to prevent external rotation of the hips while the client is supine. Advise the client to wear rubber-soled slippers.The soles of the client's slippers have no impact on the alignment of the feet while in bed. Apply an ankle-foot orthotic device to the client's feet.MY ANSWERThe nurse should use a device to maintain dorsiflexion, such as an ankle-foot orthotic device or a foot board placed perpendicular to the mattress.

A nurse on a medical unit is preparing to discharge a client to home. Which of the following actions should the nurse take as part of the medication reconciliation process? a. seal unused medications from the facility in a plastic bag b. evaluate the client's ability to self-administer medications c. report an identified discrepancy to The Joint Commission. d. compare prescriptions with medications the client received while at the facility

d. compare prescriptions with medications the client received while at the facility The medication reconciliation process involves assessment and documentation. The nurse does not handle the client's medications. Evaluate the client's ability to self-administer medications.The medication reconciliation process involves identifying and addressing the duplication and omission of medications as well as checking for possible interactions among them. The nurse does not evaluate the client's self-administration capabilities during medication reconciliation. Report an identified discrepancy to The Joint Commission.The medication reconciliation process involves addressing and correcting discrepancies so that the client leaves the facility or other point of care with clear information in writing about what medications to take. While the facility might require tracking of identified discrepancies, reporting such an incident to The Joint Commission is not part of the reconciliation process for an individual client. Compare prescriptions with medications the client received while at the facility. When performing medication reconciliation, the nurse should create a current, accurate list of every medication the client is or should be taking. Part of the process is comparing the medications the client received at the facility with those the provider has prescribed for the client to take after discharge.

A nurse is assessing a client who received an IV fluid bolus for dehydration. Which of the following findings should the nurse identify as an indication of fluid volume excess? a. hypotension b. weak, thready pulse c. slow capillary refill d. distended neck veins

d. distended neck veins Hypotension is an indication of fluid volume deficit. Other indications of fluid volume deficit, or dehydration, are dry mucous membranes and sunken eyeballs. Weak, thready pulseA weak, thready pulse is an indication of fluid volume deficit. Other indications of fluid volume deficit, or dehydration, include an increased hematocrit and urine specific gravity. Slow capillary refillA decrease in capillary refill time is an indication of fluid volume deficit. Other indications of fluid volume deficit, or dehydration, include output of less than 30 mL/hr and dark yellow urine. Distended neck veins. Indications of fluid volume excess include distended neck veins, edema, tachycardia, crackles in the lungs, dyspnea, a bounding pulse, and an increase in blood pressure.

A nurse is preparing to administer multiple medications to a client who has an enteral feeding tube. Which of the following action should the nurse plan to take? a. dissolve each medication in 5 mL of sterile water b. draw up medications together in the syringe c. push the syringe plunger gently when feeling resistance d. flush the tube with 15 mL of sterile water

d. flush the tube with 15 mL of sterile water The caregiver is the client's financial power of attorney.Having a caregiver who is the client's financial power of attorney allows the caregiver to perform necessary financial transactions on the client's behalf. This it is not an indication of elder abuse. The client is in a wheelchair with the wheels locked.If the client uses a wheelchair, it is important to lock the wheels when the client is stationary to keep the client safe. Locking the wheels of a wheelchair is not an indication of elder abuse. The client reports receiving a full bath twice each week.Neglect is a form of abuse or mistreatment that is characterized by omission of necessary care. Although hygiene is an important part of care for all clients, a full bath is not necessary every day for older adults due to the adverse effects it can have on fragile skin. Therefore, a full bath twice each week is sufficient for effective care and is not an indication of neglect or elder abuse. The caregiver insists on remaining in the room. A caregiver who refuses to leave the room during an admission assessment can be an indication of potential mistreatment of the client who is receiving care. The nurse should evaluate the client for additional signs of potential mistreatment throughout the admission assessment.

A charge nurse is discussing the responsibility of nurses caring for clients who have Clostridium difficile infection. Which of the following information should the nurse include in the teaching? a. assign the client to a room with a negative airflow system b. use alcohol-based hand sanitizer when leaving the client's room c. clean contaminated surfaces in the client's room with a phenol solution d. have family members wear a gown and gloves when visiting

d. have family members wear a gown and gloves when visiting A client who has a Clostridium difficile infection requires a private room, but a negative airflow system is not necessary. Use alcohol-based hand sanitizer when leaving the client's room. The nurse should use soap and water for hand hygiene because alcohol-based hand sanitizer does not kill Clostridium difficile spores. Clean contaminated surfaces in the client's room with a phenol solution.The nurse should use a phenol solution to clean surfaces contaminated with bacteria and fungi. However, phenol does not kill Clostridium difficile spores. Chlorine bleach is an example of a disinfectant that kills spores. Have family members wear a gown and gloves when visiting.Nurses are responsible for ensuring that family members wear a gown and gloves to prevent the transmission of Clostridium difficile spores. Staff must also wear gowns and gloves.

A nurse is caring for a client who has limited mobility in his lower extremities. Which of the following actions should the nurse take to prevent skin breakdown? a. place the client in high-Fowler's position. b. increase the client's intake of carbohydrates c. massage reddened areas with unscented lotion d. have the client use a trapeze bar when changing position

d. have the client use a trapeze bar when changing position Place the client in high-Fowler's position.High-Fowler's position places additional pressure on the sacrum and the heels, increasing the risk for skin breakdown. Increase the client's intake of carbohydrates.Increased protein intake helps with tissue repair. However, for prevention, the client should consume a balanced diet with adequate fluid intake. There is no need to increase carbohydrate intake. Massage reddened areas with unscented lotion. Massage can cause capillary breakdown in subcutaneous tissues. Have the client use a trapeze bar when changing position.By using a trapeze bar to assist with repositioning and transferring, the client avoids the friction and shearing that result from sliding up and down in bed. Shearing is a risk factor for pressure-injury development.

A nurse is reviewing practice guidelines with a group of newly licensed nurses. Which of the following interventions should the nurse include that is within the RN scope of practice? a. insert an implanted port b. close a laceration with sutures c. place an endotracheal tube d. initiate an enteral feeding through a gastrostomy tube

d. initiate an enteral feeding through a gastrostomy tube Implanted ports and other central venous access devices require insertion by a physician, a surgeon, or an advanced practice nurse. Close a laceration with sutures.Surgeons and other physicians close wounds with sutures. Place an endotracheal tube. Physicians and clinicians with special training insert endotracheal tubes. Initiate an enteral feeding through a gastrostomy tube.It is within the RN scope of practice for nurses to initiate enteral feedings through nasoenteric, gastrostomy, and jejunostomy tubes.

A home health nurse is completing an admission assessment of an older adult client who has their caregiver present. Which of the following should the nurse identify as a potential indication of elder abuse? a. the caregiver is the client's financial power of attorney b. the client is in a wheelchair with the wheels locked c. the client reports receiving a full bath twice each week d. the caregiver insists on remaining in the room

d. the caregiver insists on remaining in the room The caregiver is the client's financial power of attorney.Having a caregiver who is the client's financial power of attorney allows the caregiver to perform necessary financial transactions on the client's behalf. This it is not an indication of elder abuse. The client is in a wheelchair with the wheels locked.If the client uses a wheelchair, it is important to lock the wheels when the client is stationary to keep the client safe. Locking the wheels of a wheelchair is not an indication of elder abuse. The client reports receiving a full bath twice each week.Neglect is a form of abuse or mistreatment that is characterized by omission of necessary care. Although hygiene is an important part of care for all clients, a full bath is not necessary every day for older adults due to the adverse effects it can have on fragile skin. Therefore, a full bath twice each week is sufficient for effective care and is not an indication of neglect or elder abuse. The caregiver insists on remaining in the room.A caregiver who refuses to leave the room during an admission assessment can be an indication of potential mistreatment of the client who is receiving care. The nurse should evaluate the client for additional signs of potential mistreatment throughout the admission assessment.