Fundamentals for Nursing Exam 2: Lippincott Quiz Practice and Book Practice Questions

Which skills does the nurse teach a patient with a new colostomy before discharge from the hospital? (Select all that apply.) 1. How to change the pouch 2. How to empty the pouch 3. How to open and close the pouch 4. How to irrigate the colostomy 5. How to determine whether the ostomy is healing appropriately

1, 2, 3, 5

A nurse is teaching a patient to obtain a specimen for fecal occult blood testing using fecal immunochemical testing (FIT) at home. How does the nurse instruct the patient to collect the specimen? 1. Get three fecal smears from one bowel movement. 2. Obtain one fecal smear from an early-morning bowel movement. 3. Collect one fecal smear from three separate bowel movements. 4. Get three fecal smears when you see blood in your bowel movement.

3

Place the steps for an ileostomy pouch change in the correct order. 1. Close the end of the pouch. 2. Measure the stoma. 3. Cut the hole in the wafer to fit around the stoma and not leave skin exposed to the effluent. 4. Press the pouch in place over the stoma. 5. Remove the old pouch. 6. Trace the correct measurement onto the back of the wafer 7. Assess the stoma and the skin around it. 8. Cleanse and dry the peristomal skin.

5, 8, 7, 2, 6, 3, 4, 1

An obese client taking warfarin has dry skin due to decreased arterial blood flow. What should the nurse instruct the client to do? Select all that apply. A. Apply lanolin or petroleum jelly to intact skin. B. Encourage a reduced-calorie, reduced-fat diet. C. Inspect the involved areas daily for new ulcerations. D. Limit activities of daily living (ADLs). E. Use an electric razor to shave.

A, B, C, and E

Which statement by a staff nurse on the orthopedic floor indicates the need for further staff education? A. "The client is receiving physical therapy twice per day, so they don't need a continuous passive motion device." B. "Bleeding is a complication associated with the continuous passive motion device." C. "The continuous passive motion device can decrease the development of adhesions." D. "Monitoring skin integrity is important while the continuous passive motion device is in place."

A. "The client is receiving physical therapy twice per day, so they don't need a continuous passive motion device."

The nurse is assessing for oxygenation in a client with dark skin. Where will oxygenation be most evident on this client? A. buccal mucosa B. forehead C. nape of the neck D. skin

A. buccal mucosa

A nurse is caring for a client with status asthmaticus. Which medication should the nurse prepare to administer? A, an oral corticosteroid B. an inhaled beta2-adrenergic agonist C. an inhaled corticosteroid D. an I.V. beta2-adrenergic agonist

B. an inhaled beta2-adrenergic agonist

A client taking clozapine states, "I don't like feeling so sedated during the day. I can hardly keep my eyes open." Which response by the nurse would be most appropriate? A. "Try waking up an hour earlier to see if that helps." B. "Going to bed earlier at night might help." C. "Let's talk to your health care provider about taking most of the drug at bedtime." D. "Sleep as long as you need to, and nap fairly often."

C. "Let's talk to your health care provider about taking most of the drug at bedtime."

A client requests medication at 9 p.m. (2100) instead of 10 p.m. (2200) so that the client can go to sleep earlier. Which type of nursing intervention is required? A. interdependent B. intradependent C. independent D. dependent

C. independent

The toddler with nephrotic syndrome exhibits generalized edema. Which measure should the nurse institute for this child with impaired skin integrity related to edema? A. Apply powder to skinfolds. B. Apply lotion on opposing skin surfaces. C. Ambulate every shift while awake. D. Separate opposing skin surfaces with soft cloth.

D. Separate opposing skin surfaces with soft cloth.

For healing by secondary intention, a client's wound has been packed with medicated dressings. The nurse assesses the wound. Which finding indicates wound healing? A. The skin around the wound is edematous. B. The wound drainage is serous. C. The tissue surrounding the wound is red and hot. D. The granulation tissue is at the wound edges.

D. The granulation tissue is at the wound edges.

A client in acute respiratory distress is brought to the emergency department. After endotracheal (ET) intubation and initiation of mechanical ventilation, the client is transferred to the intensive care unit. Before suctioning the ET tube, the nurse hyperventilates and hyper oxygenates the client. What is the rationale for these interventions? A. They help prevent pulmonary edema. B. They help prevent subcutaneous emphysema. C. They help prevent pneumothorax. D. They help prevent cardiac arrhythmias.

D. They help prevent cardiac arrhythmias.

A client receiving external radiation to the left thorax to treat lung cancer has a nursing diagnosis of Risk for impaired skin integrity. Which intervention should be part of this client's care plan? A. removing thoracic skin markings after each radiation treatment B. applying talcum powder to the irradiated areas daily after bathing C. wearing a lead apron during direct contact with the client D. avoiding using deodorant soap on the irradiated areas

D. avoiding using deodorant soap on the irradiated areas

Which is the appropriate nursing intervention for a client with pruritus caused by medications used to treat cancer? A. administration of antihistamines B. steroids C. silk sheets D. medicated cool baths

D. medicated cool baths

The health care provider (HCP) prescribes pulse assessments through the night for a school- age child with rheumatic fever who has a daytime heart rate of 120 bpm. The nurse explains to the mother that this is to evaluate if the elevated heart rate is caused by which factor? A. a warmer daytime environment B. normal variations in day and evening hours C. the morning digitalis dose D. routine activity during waking hours

D. routine activity during waking hours

During the administration of a warm tap-water enema, a patient complains of cramping abdominal pain that he rates 6 out of 10. What nursing intervention should the nurse do first? 1. Stop the instillation. 2. Ask the patient to take deep breaths to decrease the pain. 3. Tell the patient to bear down as he would when having a bowel movement. 4. Continue the instillation; then administer a pain medication

1

Which symptoms are warning signs of possible colorectal cancer according to the American Cancer Society guidelines? (Select all that apply.) 1. Change in bowel habits 2. Blood in the stool 3. A larger-than-normal bowel movement 4. Fecal impaction 5. Muscle aches 6. Incomplete emptying of the colon 7. Food particles in the stool 8. Unexplained abdominal or back pain

1, 2, 6, 8

Which instructions do you include when educating a person with chronic constipation? (Select all that apply.) 1. Increase fiber and fluids in the diet. 2. Use a low-volume enema daily. 3. Avoid gluten in the diet. 4. Take laxatives twice a day. 5. Exercise for 30 minutes every day. 6. Schedule time to use the toilet at the same time every day. 7. Take probiotics 5 times a week.

1, 5, 6

Which nursing actions do you take when placing a bedpan under an immobilized patient? (Select all that apply.) 1. Lift the patient's hips off the bed and slide the bedpan under the patient. 2. After positioning the patient on the bedpan, elevate the head of the bed to a 45-degree angle. 3. Adjust the head of the bed so that it is lower than the feet, and use gentle but firm pressure to push the bedpan under the patient. 4. Have the patient stand beside the bed, and then have him or her sit on the bedpan on the edge of the bed. 5. Make sure the patient has a nurse call system in reach to notify the nurse when he or she is ready to have the bedpan removed.

2, 5

A nurse is taking a health history of a newly admitted patient with a diagnosis of possible fecal impaction. Which question is the priority to ask the patient or caregiver? 1. Have you eaten more high-fiber foods lately? 2. Have you taken antibiotics recently? 3. Do you have gluten intolerance? 4. Have you experienced frequent, small liquid stools recently?

4

The nurse is documenting care of a client who is restrained in bed with bilateral wrist restraints. Following assessment of the restraints, what should the nurse's documentation include? Select all that apply. A. capillary refill B. skin integrity C. need for medication D. nutrition and hydration needs E. continued need for restraints

A, B, D, E

A client who was transferred from a long-term care facility is admitted with dehydration and pneumonia. Which nursing interventions can help prevent pressure ulcer formation in this client? Select all that apply. A. Perform range-of-motion exercises. B. Use commercial soaps to keep the skin dry. C. Tuck bed covers tightly into the foot of the bed. D. Reposition the client every 2 hours. E. Encourage the client to eat a well-balanced diet.

A, D, E

A nurse assigned to a client with emphysema is providing shift report. Which nursing interventions would be appropriate to include? Select all that apply. A. Administer low-flow oxygen as needed. B. Teach the use of postural drainage and chest physiotherapy. c. Maintain fluid intake at fluid maintenance standards. D. Encourage alternating client activity with rest periods. E. Teach diaphragmatic, pursed-lip breathing. F. Maintain the client in a supine position as much as possible.

A. Administer low-flow oxygen as needed. B. Teach the use of postural drainage and chest physiotherapy. D. Encourage alternating client activity with rest periods. E. Teach diaphragmatic, pursed-lip breathing.

The nurse is removing the client's staples from an abdominal incision when the client sneezes and the incision splits open, exposing the intestines. What should the nurse do first? A. Cover the abdominal organs with sterile dressings moistened with sterile normal saline. B. Have all visitors and family leave the room. C. Call the surgeon to come to the client's room immediately. D. Press the emergency alarm to call the resuscitation team.

A. Cover the abdominal organs with sterile dressings moistened with sterile normal saline.

A 13-year-old male was kidnapped and held for ransom by two criminals. His parents asked to have him admitted to the adolescent psychiatric unit. He is sleep-deprived, filthy, alternating between sobbing and making threats to kill his captors, suspicious, and easily startled. He signs a no harm contract and then asks to go to sleep. What is the best initial plan for this client? A. Develop trust and allow him to talk about his memories and feelings. B. Encourage him to talk with the police about the crime details. C. Help him and his parents prepare for the future trial. D. Discourage him from making threats toward his captors.

A. Develop trust and allow him to talk about his memories and feelings.

A young adult is admitted to the emergency department after an automobile accident. The client has severe pain in the right chest from contact with the steering wheel. What should the nurse do first? A. Maintain adequate oxygenation. B. Maintain adequate circulating volume. C. Reduce the client's anxiety. D. Decrease chest pain.

A. Maintain adequate oxygenation.

A client with acute respiratory distress syndrome (ARDS) has fine crackles at lung bases, and the respirations are shallow at a rate of 28 breaths/min. The client is restless and anxious. In addition to monitoring the arterial blood gas results, what should the nurse do? Select all that apply. A. Monitor serum creatinine and blood urea nitrogen levels. B. Administer a sedative. C. Keep the head of the bed flat. D. Administer humidified oxygen. E. Auscultate the lungs.

A. Monitor serum creatinine and blood urea nitrogen levels. D. Administer humidified oxygen. E. Auscultate the lungs.

During a home visit to an older adult with mild dementia, the client's daughter reports that she has one major problem with her mother. She says, "She sleeps most of the day and is up most of the night. I can't get a decent night's sleep anymore." Which suggestions should the nurse make to the daughter? Select all that apply. A. Promote relaxation before bedtime with a warm bath or relaxing music. B. Ask the client's health care provider for a strong sleep medicine. C. Have the daughter encourage the use of caffeinated beverages during the day to keep her mother awake. D. Establish a set routine for rising, hygiene, meals, short rest periods, and bedtime. E. Engage the client in simple, brief exercises or a short walk when she gets drowsy during the day.

A. Promote relaxation before bedtime with a warm bath or relaxing music. D. Establish a set routine for rising, hygiene, meals, short rest periods, and bedtime. E. Engage the client in simple, brief exercises or a short walk when she gets drowsy during the day.

A diabetic client with peripheral vascular disease is ordered to wear knee-high elastic compression stockings continuously until discharge. Which would be the priority after the stockings are applied? A. Remove elastic stockings once per day and observe lower extremities. B. Teach the client isotonic leg exercises. C. Elevate the client's legs while out of bed. D. Order a second pair of stockings to be rotated each day.

A. Remove elastic stockings once per day and observe lower extremities.

The nurse has placed the intubated client with acute respiratory distress syndrome (ARDS) in prone position for 30 minutes. Which factors would require the nurse to discontinue prone positioning and return the client to the supine position? Select all that apply. A. The SpO2 and PO2 have decreased. B. The face has increased skin breakdown and edema. C. The client has increased secretions requiring frequent suctioning. D. The family is coming in to visit. E. The client is tachycardic with drop in blood pressure.

A. The SpO2 and PO2 have decreased. B. The face has increased skin breakdown and edema. E. The client is tachycardic with drop in blood pressure.

A client with ascites and peripheral edema is at risk for impaired skin integrity. To prevent skin breakdown, what should the nurse do? A. Use an alternating air pressure mattress. B. Elevate the lower extremities. C. Institute range-of-motion (ROM) exercise every 4 hours. D. Massage the abdomen once a shift.

A. Use an alternating air pressure mattress.

A client has had an incisional cholecystectomy. Which of the following nursing interventions has the highest priority in postoperative care for this client? A. Using incentive spirometry every 2 hours while awake. B. Promoting incisional healing. C. Maintaining a weight-reduction diet. D. Performing leg exercises every shift.

A. Using incentive spirometry every 2 hours while awake.

The partner of a 22-year-old client dies in a drunk-driving accident. The client complains of difficulty eating, sleeping, and working. The reaction is considered: A. a crisis caused by traumatic stress. B. a crisis of anticipated life transitions. C. a pathologic response to grief. D. a non-crisis situation.

A. a crisis caused by traumatic stress.

An older adult woman who is usually meticulous about her appearance and dress arrives today for her 23rd day of radiation therapy. She appears disheveled and emotionally labile, and her responses to the usual questions are a little inappropriate. Her heart rate is 124 bpm, her respirations are 32 breaths/min, and her skin is cold and clammy. Based on these findings, the nurse should further assess the client for which condition? A. delirium B. schizophrenia C. panic disorder D. depression

A. delirium

A nurse is caring for a client who has a tracheostomy and temperature of 103° F (39.4° C). Which intervention will most likely lower the client's arterial blood oxygen saturation? A. endotracheal suctioning B. use of a cooling blanket C. encouragement of coughing D. incentive spirometry

A. endotracheal suctioning

Which should be the nursing priority of care for a client exhibiting signs and symptoms of coronary artery disease? A. enhance myocardial oxygenation B. educate the client about their symptoms C. decrease anxiety D. administer sublingual nitroglycerin

A. enhance myocardial oxygenation

The nurse is teaching a client with heart failure how to avoid complications and future hospitalizations. The client has understood the instruction when the client identifies which potential complications? Select all that apply. A. having to sleep sitting up in a reclining chair B. weight gain of 2 lb (0.9 kg) or more in 1 day C. high intake of sodium for breakfast D. weight loss of 2 lb (0.9 kg) in 1 day E. becoming increasingly short of breath at rest

A. having to sleep sitting up in a reclining chair B. weight gain of 2 lb (0.9 kg) or more in 1 day E. becoming increasingly short of breath at rest

Which nutritional deficiency may delay wound healing? A. lack of vitamin C B. lack of vitamin E C. lack of calcium D. lack of vitamin D

A. lack of vitamin C

After having a blood sample drawn, a 5-year-old child insists that the site be covered with a bandage. When the parent tries to remove the bandage before leaving the office, the child screams that all the blood will come out. The nurse encourages the parent to leave the bandage in place and tells the parent that the child's reaction is based on which factor? A. lacking understanding of body integrity B. fearing another procedure C. expressing severe pain D. attempting to regain control

A. lacking understanding of body integrity

A client is being treated for left lower lobe pneumonia. In what position should the nurse position the toddler to maximize oxygenation? A. left lateral B. supine C. right lateral D. prone

A. left lateral

A client with chronic obstructive pulmonary disease (COPD) is intubated and placed on continuous mechanical ventilation. Which equipment is most important for the nurse to keep at this client's bedside? A. manual resuscitation bag B. water-seal chest drainage set-up C. oxygen analyzer D. tracheostomy cleaning kit

A. manual resuscitation bag

The client returns from surgery for a below-the-knee amputation with the residual limb covered with dressings and a woven elastic bandage. At first, the bandage was dry. Now, 30 minutes later, the nurse notices a small amount of bloody drainage. The nurse should first: A. mark the area of drainage. B. change the dressing. C. reinforce the dressing. D. notify the health care provider.

A. mark the area of drainage.

A client is scheduled for cardiac catheterization the next morning. The physician ordered temazepam, 30 mg by mouth at bedtime, for sedation. Before administering the drug, the nurse should know that: A. sedatives reduce excitement; hypnotics induce sleep. B. sedatives don't depress respirations; hypnotics do. C. sedatives cause predictable responses; hypnotics cause unpredictable ones. D. sedatives interact with few drugs; hypnotics interact with many.

A. sedatives reduce excitement; hypnotics induce sleep.

After administering a prescribed medication to a client who becomes restless at night and has difficulty falling asleep, which nursing action is most appropriate? A. sitting quietly with the client at the bedside until the medication takes effect B. reading to the client with the lights turned down low C. engaging the client in interaction until the client falls asleep D. encouraging the client to watch television until the client feels sleepy

A. sitting quietly with the client at the bedside until the medication takes effect

A client has had a cast applied to the arm. When discharging the client, the nurse should tell the client to: A. smell the cast for foul odors. B. use powder on the skin around the cast. C. apply a heating pad to the arm for 24 hours after the injury. D. use a padded ruler to reach inside and rub under the cast.

A. smell the cast for foul odors.

What should the nurse teach family caregivers when a patient has fecal incontinence because of cognitive impairment? 1. Cleanse the skin with antibacterial soap, and apply talcum powder to the buttocks. 2. Initiate bowel or habit training program to promote continence. 3. Help the patient to toilet once every hour. 4. Use sanitary pads in the patient's underwear.

2

The patient states, "I have diarrhea and cramping every time I have ice cream. I am sure this is because the food is cold." Based on this assessment data, which health problem does the nurse suspect? 1. A food allergy 2. Irritable bowel syndrome 3. Increased peristalsis 4. Lactose intolerance

4

A client has a wound with a drain. When performing wound cleansing around the drain, the nurse should cleanse in which direction? A. in a widening circle around the drain, outward from the center B. from the superior portion of the wound to the inferior C. laterally, from the distal area to the center D. laterally, from one side of the wound to the opposite side

A. in a widening circle around the drain, outward from the center

The cyanosis that accompanies bacterial pneumonia is primarily caused by which of the following? A. Pleural effusion. B. Decreased oxygenation of the blood. C. Inadequate peripheral circulation. D. Decreased cardiac output.

B. Decreased oxygenation of the blood.

When teaching the diabetic client about foot care, what should the nurse instruct the client to do? A. Cut toenails at angles. B. Buy shoes a half size larger. C. Avoid going barefoot. D. Use heating pads for sore feet.

C. Avoid going barefoot.

A client with jaundice has pruritus and areas of irritation from scratching. What measures can the nurse suggest the client use to prevent skin breakdown? Select all that apply. A. Avoid lotions containing calamine. B. Rub the skin when it itches with knuckles instead of nails. C. Add baking soda to the water in a tub bath. D. Increase sodium intake in diet. E. Massage skin with alcohol. F. Keep nails short and clean.

B, C, F

To reduce the risk of pressure ulcer formation, which activity should the nurse teach the client who is wheelchair-bound as a result of a spinal cord injury? A. Eat a high-carbohydrate diet. B. Bathe daily. C. Shift your weight every 15 minutes. D. Move from the bed to the wheelchair every 2 hours.

C. Shift your weight every 15 minutes.

The nurse is teaching the client with a platelet disorder about signs of bleeding. What statement from the client indicates the client has understood the teaching? A. "Petechiae are large, red skin bruises." B. "Ecchymoses are large, purple skin bruises." C. "Purpura is an open cut on the skin." D. "Abrasions are small pinpoint red dots on the skin."

B. "Ecchymoses are large, purple skin bruises."

A client is admitted to the hospital with a diagnosis of a pulmonary embolism. Which problem should the nurse address first? A. difficulty breathing B. nonproductive cough C. impaired gas exchange D. activity intolerance

C. impaired gas exchange

A nurse is preparing to perform complex abdominal wound care. Which action should the nurse take while performing this task? A. Position the client on the far side of the bed. B. Position the overbed table away from the bed. C. Keep the side rails up. D. Raise the bed to approximately waist level.

D. Raise the bed to approximately waist level.

The parent of a preschool-age child has been told the child has sleep terrors. Which statement should the nurse include when teaching the parents about sleep terrors? A. "The dreams are real to the child." B. "Intervention is required only if it is necessary to protect the child." C. "Getting the child back to sleep may be difficult." D. "Sleep terrors require psychological counseling."

B. "Intervention is required only if it is necessary to protect the child."

The nurse is beginning the shift and is assessing the oxygen exchange on a neonate. The nurse reviews the medical record for pulse oximetry reading for the last 8 hours. The pulse oximetry reading at 1530 is 75% taken on the infant's right wrist. What should the nurse do first? A. Reassess the oximetry reading in 30 minutes. B. Administer oxygen via mask. C. Draw blood gases for oxygen and carbon dioxide levels. D. Obtain a pulse oximeter reading in a lower extremity.

B. Administer oxygen via mask.

The nurse is caring for a lethargic but arousable preschooler who is a victim of a near-drowning accident. What should the nurse do first? A. Prepare for intubation. B. Administer oxygen. C. Start an IV infusion. D. Institute rewarming.

B. Administer oxygen.

A client receiving radiation therapy for lung cancer is having difficulty sleeping. What should the nurse do first when teaching the client about promoting sleep? A. Request the health care provider prescribe a sleeping pill. B. Suggest the client stop drinking coffee until the therapy is completed. C. Tell the client to stop watching television before bed. D. Ask the client about usual sleep patterns.

D. Ask the client about usual sleep patterns.

The parent of an 11-month-old infant reports to the nurse that the infant sleeps much less than other children. The parent asks the nurse whether the infant is getting sufficient sleep. What should be the nurse's initial response? A. Instruct the parent to decrease the infant's daytime sleep to increase nighttime sleep. B. Inform the parent that the infant's growth and development are age-appropriate, so sleep isn't a concern. C. Reassure the parent that each infant's sleep needs are individual. D. Ask the parent for more information about the infant's sleep patterns.

D. Ask the parent for more information about the infant's sleep patterns.

A 39-year-old multigravid client at 39 weeks' gestation admitted to the hospital in active labor has been diagnosed with class II heart disease. Which measure will the nurse encourage to ensure cardiac emptying and adequate oxygenation during labor? A. Breathe slowly after each contraction. B. Request local anesthesia for vaginal birth. C. Avoid the use of analgesics for the labor pain. D. Remain in a side-lying position with the head elevated.

D. Remain in a side-lying position with the head elevated.

A nurse administers albuterol, as ordered, to a client with emphysema. Which finding indicates that the drug is producing a therapeutic effect? A. Heart rate of 100 beats/minute B. Dilated and reactive pupils C. Urine output of 40 ml/hour D. Respiratory rate of 22 breaths/minute

D. Respiratory rate of 22 breaths/minute

A girl in second grade with no remarkable medical history experiences a generalized tonic-clonic seizure in the classroom. Immediately after the seizure, the nurse arrives and notices that the child has been incontinent of urine and is difficult to arouse. Which action would be most appropriate at this time? A. Ask the teacher if the child has had any urinary problems. B. Awaken the child every 3 to 5 minutes to assess mentation. C. Perform a complete neurologic check every 3 to 5 minutes. D. Stay with the child, and allow her to sleep in a side-lying position.

D. Stay with the child, and allow her to sleep in a side-lying position.

The client, who is taking fluoxetine 20 mg at bedtime, tells the nurse the drug is interfering with his sleep. What conclusion should the nurse make? A. The client's symptoms of depression seem to be getting worse. B. The client is on the wrong medication. C. The dosage is too high. D. The client should take fluoxetine in the morning.

D. The client should take fluoxetine in the morning.

A client with peripheral artery disease has chronic, severe bilateral pretibial and ankle edema the client is on complete bed rest. To maintain skin integrity, what should the nurse do? A. Administer pain medication. B. Maintain hygiene. C. Ensure fluid intake of 3,000 ml per 24 hours. D. Turn the client every 1 to 2 hours.

D. Turn the client every 1 to 2 hours.

A client diagnosed with major depression has sleep and appetite disturbances, a flat affect and is withdrawn. The client has been taking fluvoxamine 50 mg twice daily for 5 days. Which client behavior is most important to report to the next shift? A. client spending the entire evening in her room B. client's flat affect C. client's interacting with a visitor D. client sleeping from 2300 hours to 0600 hours

D. client sleeping from 2300 hours to 0600 hours

A 5-year-old child is brought to the emergency department after being stung multiple times on the face by yellow jackets. Which symptom of anaphylaxis requires priority medical intervention? A. diffuse facial urticaria B. respiratory rate of 20 breaths/minute C. blood pressure of 95/50 mm Hg D. heart rate less than 60 beats/minute

D. heart rate less than 60 beats/minute

A child with asthma has a heart rate of 160 bpm and a respiratory rate of 36 breaths/minute. The child appears restless and anxious and is given albuterol via nebulizer. Which finding would indicate that the nebulizer treatment has been effective? A. nonproductive cough B. pulse oximeter reading of 91% C. expiratory wheezing D. increase in peak expiratory flow rate

D. increase in peak expiratory flow rate

In a client with amyotrophic lateral sclerosis (ALS) and respiratory distress, which finding is the earliest sign of reduced oxygenation? A. decreased level of consciousness (LOC) B. increased blood pressure C. decreased heart rate D. increased restlessness

D. increased restlessness

A mother who gave birth some three hours ago asked the nurse why her baby is so difficult to keep awake. The nurse informs the mother that this behavior indicates A. a physiologic abnormality. B. probable hypoglycemia. C. normal progression into a period of neonatal reactivity. D. normal progression into the sleep cycle.

D. normal progression into the sleep cycle.

The nurse is caring for a client with an exacerbation of ulcerative colitis. The nurse should instruct the client to: A. maintain a high-fiber diet. B. use antidiarrheal medications regularly. C. avoid lifting more than 5 pounds (2.3 kg). D. obtain frequent rest periods.

D. obtain frequent rest periods.

A client is receiving moderate sedation while undergoing bronchoscopy. Which assessment finding should the nurse attend to immediately? A. respiratory rate of 13 breaths/min B. absent cough and gag reflexes C. blood-tinged secretions D. oxygen saturation of 90%

D. oxygen saturation of 90%

The nurse is providing care for a client with a tracheotomy whose pulse oximeter has recently alarmed, showing the oxygen saturation to be 77%. The nurse has repositioned the client and applied supplemental oxygen, interventions that have raised the oxygen levels to 80% and somewhat decreased work of breathing. The client is not in immediate distress, and level of consciousness remains high. The nurse should page which practitioner? A. physical therapist B. occupational therapist C. physician D. respiratory therapist

D. respiratory therapist

A nurse is providing care for a pregnant client. The client asks the nurse how she can best deal with her fatigue. The nurse should instruct her to: A. tell her not to worry because the fatigue will go away soon. B. take sleeping pills for a restful night's sleep. C. take prenatal vitamins. D. try to get more rest by going to bed earlier.

D. try to get more rest by going to bed earlier.

When a central venous catheter dressing becomes moist or loose, what should a nurse do first?

Remove the dressing, clean the site, and apply a new dressing.

What is the primary goal of nursing care during the emergent phase after a burn injury?

Replace lost fluids

Two nurses are working the night shift on a medical unit. The first nurse completes an initial shift assessment on assigned clients. One hour later, the second nurse finds the first nurse asleep in the lounge. The first nurse remains asleep for the next 4 hours and then wakes up to do client rounds. What should the second nurse do in this situation? A. Nothing; the first nurse's patients did not call for assistance. B. Discuss the situation with the first nurse, including the safety implications of sleeping on the job. C. Cover by assessing the first nurse's patients hourly. D. Ask the nurse on the day shift to report the situation to the nurse manager.

B. Discuss the situation with the first nurse, including the safety implications of sleeping on the job.

What intervention should the nurse include in the plan of care for a child with a fracture in skeletal traction to prevent osteomyelitis? A. Maintain the child in reverse isolation. B. Encourage the child to eat nutritious foods. C. Administer prophylactic antibiotics as prescribed. D. Protect the child from visitors with colds.

B. Encourage the child to eat nutritious foods.

An unconscious client with multiple injuries arrives in the emergency department. What should the nurse do first? A. Stop bleeding from open wounds. B. Establish an airway. C. Determine the identity of the client. D. Check for a neck fracture.

B. Establish an airway.

A client is admitted to the hospital with a diagnosis of suspected pulmonary embolism. Prescriptions include oxygen 2 to 4 L/min per nasal cannula, oximetry at all times, and IV administration of 5% dextrose in water at 100 mL/h. The client has increasing dyspnea and has a respiratory rate of 32 breaths/minute. The oxygen flow rate is set at 2 L/min. What should the nurse do first? A. Call the health care provider (HCP) immediately. B. Increase the oxygen flow rate from 2 to 4 L/min. C. Obtain a sample for arterial blood gas analysis. D. Provide reassurance to the client.

B. Increase the oxygen flow rate from 2 to 4 L/min.

The nurse teaches a client with heart failure to take oral furosemide in the morning. What is the expected outcome for taking this drug in the morning? The client will: A. Limit the excretion of electrolytes. B. Obtain more sleep. C. Avoid concentrated urine. D. Prevent the risk of falling.

B. Obtain more sleep.

A client with right sided hemiparesis has limited mobility. Which action should the nurse include in the plan of care to help maintain skin integrity? A. Perform passive range-of-motion (ROM) exercises. B. Turn him regularly. C. Message bony prominences. D. Encourage fluid intake.

B. Turn him regularly.

Which action will be most helpful to the nurse when determining the need for oxygen therapy in a client with chronic obstructive pulmonary disease? A. Ask the client to tell the nurse when oxygen is needed. B. Use a pulse oximeter to determine oxygen saturation. C. Evaluate the client's hemoglobin level daily. D. Assess the client's fatigue level.

B. Use a pulse oximeter to determine oxygen saturation.

The client with dual diagnoses of major depression and alcohol abuse states, "I only drink when I cannot sleep." Which outcome is important for the client to achieve first? A. Describe dangerous effects when combining alcohol and antidepressant medication. B. Verbalize the desire to stop drinking alcohol. C. Verbalize negative effects of alcohol on the body. D. Describe adaptive methods of coping to induce sleep.

B. Verbalize the desire to stop drinking alcohol.

A nurse is changing a client's dressing. Which observation of the wound warrants immediate physician notification? A. Sutures in place B. Yellow, purulent drainage C. Pink granulation tissue D. Approximated wound edges

B. Yellow, purulent drainage

During morning assessment, a nurse assesses four clients. Which client is the priority for follow up? A. a 48-year-old client with chronic obstructive pulmonary disease with occasional atrial fibrillation B. a 73-year-old client who has pneumonia with coarse crackles, is receiving 2 L/minute of oxygen, and has an I.V. line C. a 42-year-old client who has left lower lobe pneumonia and an I.V. line D. an 84-year-old client with heart failure who's on telemetry and 2 L/minute of oxygen

B. a 73-year-old client who has pneumonia with coarse crackles, is receiving 2 L/minute of oxygen, and has an I.V. line

For a client with an endotracheal (ET) tube, which nursing action is the most important? A. providing frequent oral hygiene B. auscultating the lungs for bilateral breath sounds C. monitoring serial blood gas values every 4 hours D. turning the client from side to side every 2 hours

B. auscultating the lungs for bilateral breath sounds

The nurse is instructing the client with chronic obstructive pulmonary disease to do pursed-lip breathing. What is the expected outcome of this exercise? A. improved oxygen intake B. better elimination of carbon dioxide C. deeper diaphragmatic breathing D. stronger intercostal muscles

B. better elimination of carbon dioxide

A client who had an exploratory laparotomy 3 days ago has a white blood cell (WBC) differential with a shift to the left. The nurse instructs unlicensed assistive personnel (UAP) to report which clinical manifestation of this laboratory report? A. redness around the incision B. elevated temperature C. swelling around the incision D. purulent wound drainage

B. elevated temperature

The nurse is instructing the unlicensed assistive personnel (UAP) about how to prevent plantar flexion (foot drop) for a client on complete bed rest. The UAP should: A. place a trochanter roll along the side of the ankle. B. encourage active range of motion to unaffected extremities. C. place a bed cradle at the foot of the bed. D. massage lotion onto the feet daily.

B. encourage active range of motion to unaffected extremities.

The nurse is assessing a client who has a chronic mental illness. What early signs of relapse should the nurse monitor for? Select all that apply. A. suicidal or homicidal threats B. increase in social isolation and withdrawal C. decrease in sleep and self-care D. more fears and suspiciousness E. obvious delusions and hallucinations

B. increase in social isolation and withdrawal C. decrease in sleep and self-care D. more fears and suspiciousness

Assessment of a school-age child with Guillain-Barré syndrome reveals absent gag and cough reflexes. Which problem should receive the highest priority during the acute phase? A. impaired swallowing related to neuromuscular impairment B. ineffective breathing pattern related to neuromuscular impairment C. fluid volume deficits related to total urinary incontinence D. impaired physical mobility related to paralysis

B. ineffective breathing pattern related to neuromuscular impairment

A nurse is caring for a child who was involved in a bus accident on the way home from preschool. Several people were killed in the accident. When talking with the child's parents about normal reactions to a traumatic event, the nurse should tell them that A. they should allow their child to watch television programs about the accident. B. it is normal for the child to want to sleep with them at night. C. they should allow the child to eat and sleep when the child wants. D. they should immediately seek psychiatric care for the child.

B. it is normal for the child to want to sleep with them at night.

A 10-month-old infant with tetralogy of Fallot (TOF) experiences an cyanotic episode. To improve oxygenation during such an episode, the nurse should place the infant in which position? A. Fowler's B. knee-to-chest C. prone D. Trendelenburg's

B. knee-to-chest

A nurse is monitoring a client recovering from moderate sedation that was administered during a colonoscopy. Which finding requires the nurse's immediate attention? A. heart rate of 94 beats/minute B. oxygen saturation (SaO2) of 89% C. blood-tinged stools D. decreased cough and gag reflexes

B. oxygen saturation (SaO2) of 89%

A client who had an appendectomy for a perforated appendix returns from surgery with a drain inserted in the incisional site. The purpose of the drain is to: A. provide access for wound irrigation. B. promote drainage of wound exudates. C. minimize development of scar tissue. D. decrease postoperative discomfort.

B. promote drainage of wound exudates.

The nurse is assessing a group of older adults. Which client is at greatest risk for skin breakdown? A person who has: A. impaired hearing ability. B. reduced sensation of pressure. C. altered balance. D. impaired visual acuity.

B. reduced sensation of pressure.

Which intervention is essential when performing dressing changes on a client with a diabetic foot ulcer? A. applying a heating pad B. using sterile technique during the dressing change C. cleaning the wound with a povidone-iodine solution D. debriding the wound three times per day

B. using sterile technique during the dressing change

A client has an adrenal tumor and is scheduled for a bilateral adrenalectomy. During preoperative teaching, the nurse teaches the client how to do deep-breathing exercises after surgery. What should the nurse tell the client to do? A. "Raise your shoulders to expand your chest." B. "Sit in an upright position, and take a deep breath." C. "Hold your abdomen firmly with a pillow, and take several deep breaths." D. "Tighten your stomach muscles as you inhale, and breathe normally."

C. "Hold your abdomen firmly with a pillow, and take several deep breaths."

A client with a pulmonary embolus has the following arterial blood gas (ABG) values: pH, 7.49; partial pressure of arterial oxygen (PaO2), 60 mm Hg; partial pressure of arterial carbon dioxide (PaCO2), 30 mm Hg; bicarbonate (HCO3-) 25 mEq/L. What should the nurse do first? A. Encourage the client to deep-breathe and cough every 2 hours. B. Instruct the client to breathe into a paper bag. C. Administer oxygen by nasal cannula as ordered. D. Auscultate breath sounds bilaterally every 4 hours.

C. Administer oxygen by nasal cannula as ordered.

A client's burn wounds are being cleaned twice a day in a hydrotherapy tub. Which intervention should be included in the plan of care before a hydrotherapy treatment is initiated? A. Limit food and fluids 45 minutes before therapy to prevent nausea and vomiting. B. Apply a topical antibiotic cream to burns to prevent infection. C. Administer pain medication 30 minutes before therapy to help manage pain. D. Increase the IV flow rate to offset fluids lost through the therapy.

C. Administer pain medication 30 minutes before therapy to help manage pain.

On the day of surgery, a client has been breathing room air. The vital signs are normal, and the O2 saturation is 89%. What should the nurse do first? A. Lower the head of the bed. B. Notify the health care provider (HCP). C. Assist the client to take several deep breaths and cough. D. Administer oxygen by nasal cannula as prescribed at 2L per minute.

C. Assist the client to take several deep breaths and cough.

Which action should the nurse include when developing the plan of care for a neonate prior to surgical repair of a myelomeningocele? A. Apply thin layers of tincture of benzoin around the defect. B. Position the neonate on the side. C. Cover the defect with moist, sterile saline dressings. Leave the defect exposed to air.

C. Cover the defect with moist, sterile saline dressings.

A client is admitted to the acute psychiatric care unit after 2 weeks of increasingly erratic behavior. He has been sleeping poorly, has lost 8 lb (3.6 kg), is poorly groomed, exhibits hyperactivity, and loudly denies the need for hospitalization. Which nursing intervention takes priority for this client? A. Providing adequate hygiene B. Administering a sedative as ordered C. Decreasing environmental stimulation D. Involving the client in unit activities

C. Decreasing environmental stimulation

A 22-year-old client exhibits memory loss, confusion, and wandering behavior. Which comment by the nurse would provide the best reality orientation for the client when she first awakens in the morning? A. "Do you remember who I am or what day it is today?" B. " There will be pancakes for breakfast this morning. After breakfast your partner will come for a visit" C. Good morning. This is your 2nd day in Memorial Hospital, and I'm your nurse for today. My name is Rachel." D. "Hello, did you sleep well? Which dress would you like to wear today, the yellow or the green one?"

C. Good morning. This is your 2nd day in Memorial Hospital, and I'm your nurse for today. My name is Rachel."

A nursing instructor is instructing a group of new nursing students. The instructor reviews that surgical asepsis will be used for which procedure? A. nasogastric tube irrigation B. colostomy irrigation C. IV catheter insertion D. instilling eye drops

C. IV catheter insertion

What should the nurse do to help a client prevent atelectasis and pneumonia after surgery? A. Encourage the client to drink 1,000 mL of fluids in 24 hours. B. Administer oxygen therapy as needed to maintain adequate oxygenation. C. Offer pain medication before having the client deep-breathe and use incentive spirometry. D. Instruct the client to cough, deep-breathe, and turn in bed once every 8 hours.

C. Offer pain medication before having the client deep-breathe and use incentive spirometry.

A nurse is performing a baseline assessment of a client's skin risk assessment. Which finding will most impact the goal of the plan of care? A. Family history of pressure ulcers B. Potential areas of pressure ulcer development C. Overall potential of developing pressure ulcers D. Presence of pressure ulcers on the client

C. Overall potential of developing pressure ulcers

A nurse is developing a care plan for a client with disseminated intravascular coagulation (DIC). Which nursing intervention should the nurse include? A. Provide mouth care every 4 hours with lemon-glycerin swabs. B. Administer meperidine (Demerol) I.M. as needed for pain. C. Place a pressure-reducing mattress on the client's bed. D. Administer aspirin daily as ordered.

C. Place a pressure-reducing mattress on the client's bed.

A primigravid client at 36 weeks' gestation tells the nurse that she has been experiencing insomnia for the past 2 weeks. Which suggestion would be most helpful? A. Drink a small glass of wine with dinner. B. Exercise for 30 minutes just before bedtime. C. Practice relaxation techniques before bedtime. D. Drink a cup of hot chocolate before bedtime.

C. Practice relaxation techniques before bedtime.

The nurse is assessing a client who is immobile and notes that an area of sacral skin is reddened, but not broken. The reddened area continues to blanch and refill with fingertip pressure. What should the nurse do next? A. Apply a moist-to-moist dressing, being careful to pack just the wound bed. B. Complete and document a Braden skin breakdown risk score for the client. C. Reposition the client off the reddened skin and reassess in a few hours. D. Consult with a wound-ostomy-continence nurse specialist.

C. Reposition the client off the reddened skin and reassess in a few hours.

The nurse is planning care for a group of clients. Which client should the nurse identify as needing the most assistance in accepting being ill? A. an 8-year-old boy who alternately cries for his mother and is angry with the nurse about being hospitalized after a bike accident B. a 45-year-old man who just suffered a severe myocardial infarction and talks to the nurse about concerns regarding resuming sexual relations with his wife C. a 60-year-old woman diagnosed with chronic obstructive pulmonary disease who refuses to wear an oxygen mask even though poor oxygenation makes her confused D. a 32-year-old woman diagnosed with depression related to lupus erythematosus who discusses her medication's adverse effects with the nurse

C. a 60-year-old woman diagnosed with chronic obstructive pulmonary disease who refuses to wear an oxygen mask even though poor oxygenation makes her confused

When planning care for a group of clients, the nurse notes that which client is most susceptible to infection? A. an 18-year-old with diabetes mellitus B. a 6-year-old with a simple fracture of the femur C. an 86-year-old with burns from using a heating pad D. a 42-year-old with a recent, uncomplicated appendectomy

C. an 86-year-old with burns from using a heating pad

When assessing a preschooler who has sustained a head trauma, the nurse notes that the child appears to be obtunded. Which finding supports this level of consciousness? A. no motor or verbal response to noxious (painful) stimuli B. remains in a deep sleep; responsive only to vigorous and repeated stimulation C. can be roused with stimulation D. limited spontaneous movement; sluggish speech

C. can be roused with stimulation

A nurse is caring for a client with panic disorder who has difficulty sleeping. Which nursing intervention would best help the client achieve healthy long-term sleeping habits? A. administering sleeping pills B. suggesting that the client talk with other clients until ready to sleep C. encouraging the client use relaxation exercises D. telling the client to play ping pong in the day room

C. encouraging the client use relaxation exercises

After teaching the mother of a 7-month-old diagnosed with bronchiolitis, the nurse determines that the teaching has been effective when the mother states she will immediately report which sign or symptom? A. temperature of 100° F (37.8° C) for 2 days B. clear nasal discharge for longer than 2 days C. longer periods of sleep than usual D. seven wet diapers a day

C. longer periods of sleep than usual

A client is receiving supplemental oxygen. When determining the effectiveness of oxygen therapy, which arterial blood gas value is most important? A. pH B. partial pressure of arterial carbon dioxide (PaCO2) C. partial pressure of arterial oxygen (PaO2) D. bicarbonate (HCO3-)

C. partial pressure of arterial oxygen (PaO2)

The nurse is teaching a client with emphysema how to do pursed-lip breathing. What is the expected outcome of using pursed-lip breathing? A. relief from shortness of breath B. increased oxygenation C. prolonged exhalation D. increased exercise tolerance

C. prolonged exhalation

A client is admitted to the orthopedic unit in balanced skeletal traction using a Thomas splint and Pearson attachment. The primary purpose of traction is to: A. prevent neurologic damage. B. control internal bleeding. C. realign fracture fragments. D. maintain skin integrity.

C. realign fracture fragments.

A 12-year-old child is sent home for pediculosis after being at camp for 1 week. The mother thinks others at camp have it. The mother asks the nurse how her son could have gotten pediculosis. How should the nurse reply? A. "He probably got it at basketball practice." B. "Usually the kids get it at camp in the pool." C. "Children at camp usually get it from the animals here." D. "Children who sleep close to someone who has it get it more easily."

D. "Children who sleep close to someone who has it get it more easily."