Fundamentals Practice

A nurse is assessing for cyanosis in a client who has dark skin. Which of the following sites should the nurse examine to identify cyanosis in this client? -Pinnae of he ears -Dorsal surface of the hand -Conjunctivae -Dorsal surface of the foot

Conjunctivae To assess skin color changes in clients who have dark skin, the nurse should examine body areas with minimal pigmentation, such as the sclerae, soles of the feet, conjunctivae, and mucous membranes.

A nurse is discussing the norming stage of the group development process with a student nurse. Which of the following statements by the student indicates understanding of the discussion? -"This stage involves constructive efforts on the part of the group members." -"This stage is when testing occurs to identify boundaries of interpersonal behaviors." -"Consensus evolves in this stage." -"Resistance is evident as subgroups form in this stage."

"Consensus evolves in this stage." Consensus occurs and cooperation develops during the norming stage of the group development process.

A nurse is discharging a client who came to the outpatient clinic with an ankle sprain. Which of the following statements should the nurse identify as an indication that the client understands the discharge instructions? -"I'll apply ice to my ankle today and tomorrow." -"I'll rewrap my ankle starting from the knee down." -"I'll bear weight on my ankle for 10 minutes every hour." -"I'll put a heating pad on my ankle at bedtime tonight."

"I'll apply ice to my ankle today and tomorrow." The RICE acronym outlines how to treat an ankle sprain: rest, ice, compression, elevation. The client should apply ice for the first 24 to 48 hr after the injury.

A nurse is caring for a client who has impaired mobility. Which of the following support devices should the nurse plan to use to prevent the client from developing plantar flexion contractures? -Trochanter roll -Sheepskin heel pad -Abduction pillow -Footboard

Footboard Plantar flexion contractures, or foot drop, develop when a client's unsupported feet are constantly in plantar flexion. The nurse should place the soles of the client's feet against a footboard, a flat wooden or plastic panel perpendicular to the bed, to keep them dorsiflexed and, therefore, prevent foot drop.

A nurse is removing personal protective equipment (PPE) after giving direct care to a client who requires isolation. Which of the following PPE items should the nurse remove first? -Gown -Gloves -Face shield -Mask

Gloves According to evidence-based practice, the nurse should remove the most contaminated item, the gloves, first.

A nurse is caring for an older adult client who states, "I am afraid that I may fall while walking to the bathroom during the night." Which of the following actions should the nurse take? -Limit the client's fluid intake in the evening. -Obtain a bedside commode for the client's use. -Leave a nightlight on in the client's room. -Put the side rails up and tell the client to call the nurse before voiding.

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

A nurse is preparing to obtain a blood specimen from a client by venipuncture. The client is receiving IV fluids through an IV catheter inserted in the basilic vein of the right forearm. Which of the following sites should the nurse plan to use to obtain the blood specimen? -Left upper arm -Right forearm -Foot -Left forearm

Left forearm This site is in the antecubital fossa, which allows for easy access and does not interfere with the client's IV catheter and infusion. The nurse should use this site to obtain a blood specimen.

A nurse is measuring a client for knee-high antiembolic stockings to help prevent venous stasis. Which of the following actions should the nurse take? -Measure from the heel to the gluteal fold. -Measure the length of the feet. -Measure from the heel to the popliteal space. -Measure the ankle circumference.

Measure from the heel to the popliteal space. If the stocking is too short, if could impair circulation at its upper end. If it is too long, it can bunch together, which would cause pressure and irritate the skin. Measuring the length from the feet to the popliteal space helps the nurse identify the right size stockings for the client's legs.

A nurse is assessing a client's peripheral circulation. In which of the following locations should the nurse palpate to assess the posterior tibial pulse? (Selectable areas, or "Hot Spots," are outlined in the artwork below. Select only the outlined area that corresponds to your answer.)

The posterior tibial pulse is located on the inner ankle, one-third of the way along a line between the tip of the medial malleolus (end of the tibia) and the point of the heel. It is most easily palpated about 2.5 cm higher, where it runs behind the medial malleolus.

A nurse is teaching a client about carbon monoxide poisoning. Which of the following statements should the nurse identify as an indication that the client needs further instruction? -"A high concentration of carbon monoxide can cause death." -"I can detect the presence of carbon monoxide by a metallic odor." -"I should purchase a carbon monoxide detector for my home." -"Breathing in carbon monoxide can cause headaches and nausea."

"I can detect the presence of carbon monoxide by a metallic odor." Carbon monoxide gas is odorless, tasteless, and colorless.

A nurse is instructing a client who has a new diagnosis of Raynaud's disease about preventing the onset of manifestations. Which of the following client statements should indicate to the nurse the need for additional teaching? -"I will wear gloves when removing food from the freezer." -"I will try to anticipate and avoid stressful situations when possible." -"I will complete the smoking cessation program I started." -"I will take my medications at the first sign of an attack."

"I will take my medications at the first sign of an attack." Taking medications at the onset of an episode of Raynaud's disease may help to reduce the severity of the manifestations, but it will not prevent the onset of vasoconstriction.

A nurse is reviewing a client's prescription for 1,000 mL of 5% dextrose in water IV to infuse over 8 hr. At 1400, the nurse observes that there is 500 mL of solution remaining in the client's current IV bag. At what time should the nurse administer the next bag of IV solution? -1500 -1600 -1700 -1800

1800 The IV will infuse at 125 mL/hr. The next bag of IV solution will need to be administered at 1800.

A nurse is providing teaching to a client who is planning on becoming pregnant about the changes she should expect. Identify the sequence of maternal changes. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

-Amenorrhea -Goodell's sign -Quickening -Lightening Amenorrhea, a presumptive sign of pregnancy, is one of the first physiological indications of pregnancy that occurs by 4 weeks of gestation. Goodell's sign, a probable sign of pregnancy, is the next of physiological indications to occur. Goodell's sign is the softening of the cervix that typically occurs at 5 to 6 weeks of gestation. Quickening, the mother's perception of the first fetal movement, is a presumptive sign of pregnancy that typically occurs between 16 and 20 weeks of gestation. Lightening is the last of these physiological signs of pregnancy to occur. As the fetus descends into the pelvic cavity the fundal height decreases, which typically occurs between 38 and 40 weeks of gestation.

A nurse is assessing a client after administering a dose of losartan. The client has a hoarse voice, and swollen lips and tongue. In which order should the nurse take the following actions? Move the nursing actions into the box on the right, placing them in the selected order of performance. All steps must be used.)

-Assess the client's airway. -Call the emergency response team. -Initiate IV access. -Administer IV epinephrine. -Administer IV antihistamines. -Apply high-flow oxygen. The nurse should first assess the client's airway and oxygen saturation to determine the need for respiratory support. Intubation or tracheotomy is considered if adequate oxygenation is not maintained. The second step the nurse should take is to call the rapid response team to provide emergency treatment in case of cardiac or respiratory arrest. Next, the nurse should apply high-flow oxygen to increase oxygenation and then initiate an IV site, if one is not present, and administer isotonic IV fluids to prevent hypotension and provide access for IV medications. The nurse should then administer IV epinephrine to constrict blood vessels, dilate bronchioles, and increase cardiac function. And finally, the nurse should administer IV antihistamines and corticosteroids to block the effects of histamine and decrease edema.

A nurse is preparing to administer 10 units of regular insulin and 20 units of NPH insulin to a client. What is the sequence of events the nurse should follow? (Move the steps of mixing insulin on the left into the box on the right, placing them in the selected order of performance. All steps must be used.)

-Inspect vials for contaminants. -Roll NPH vial between palms of hands. -Inject air into NPH insulin vial. -Inject air into regular insulin vial. -Withdraw short-acting insulin into syringe. -Add intermediate insulin to syringe. • Inspect vials for contaminants: With the exception of NPH insulin, all insulin available today is supplied as a clear, colorless solution. Do not use insulin that is colored, cloudy, or has formed a precipitate. The first step is to observe the characteristics of the regular and NPH insulin to determine whether they are safe to use. • Roll NPH vial between palms of hands: Because NPH insulin is a suspension, the particles must be evenly dispersed by rolling the vial gently between the palms of the hands. This should be done gently because vigorous mixing may cause the solution to become frothy and cause inaccurate dosing. If granules or clumps are present after mixing, discard the solution. This should be done prior to withdrawing the solution into the syringe. • Inject air into NPH insulin vial: This creates a pressure in the vial for accuracy in measuring the amount prescribed. • Inject air into regular insulin vial: The amount of air injected into the vial of short-acting insulin is equal to the amount to be administered. • Withdraw short-acting insulin into syringe: When the prescription requires the administration of two types of insulin, it is preferable to mix the solutions into one syringe if they are compatible to prevent the client from receiving two injections. Of the longer-acting insulin available, only NPH insulin is mixed with short-acting insulin. When two insulins are to be mixed, withdraw the short-acting insulin first to avoid contaminating the stock vial with NPH insulin. • Add intermediate insulin to syringe: The mixture is stable for 28 days.

A nurse is assisting a provider with a sterile procedure and prepares to pour a solution onto a piece of gauze. Identify the sequence of steps the nurse should follow when pouring the solution. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

-Remove the bottle cap. -Place the bottle cap face up on a clean surface. -Pick up the bottle with the label facing his palm. -Pour 1 to 2 mL into a receptacle. -Pour the solution onto the gauze. The nurse should first remove the bottle cap in preparation for pouring the solution. He should not touch the inside of the cap because it is sterile. Next, he should place the bottle cap face up on clean surface. A bottle containing a sterile solution is sterile on the inside, but the outside is not. The outside of the bottle cap is also not sterile, but the inside of the cap is. Therefore, when he removes the cap, he should place it open end up on a clean surface, not on the sterile field. Next, he should pick up the bottle with the label facing his palm. This prevents the solution from running down the side of the bottle, which can wet and blur the printing on the label. Next, he should pour 1 to 2 mL of solution into a receptacle to discard later. This cleans the inside lip of the bottle in preparation for the next pouring of the solution, the final step, which is onto the sterile surface of the gauze.

A nurse is caring for a client who has hypernatremia and requires IV fluid therapy due to his NPO status. Which of the following solutions should the nurse prepare to infuse for this client? -Lactated Ringer's -Dextrose 5% in 0.9% sodium chloride -0.45% sodium chloride -Dextrose 10% in water

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

A charge nurse is planning a room assignment for a client who has a productive cough, a questionable chest x-ray, and a positive Mantoux test. Room 208 is a private, negative-pressure airflow room; room 212 is a semi-private, positive-pressure airflow room; 214 is a negative-pressure, semi-private room; and room 216 is a private, positive-pressure airflow room. To which of the following rooms should the nurse assign the client? -208 -212 -214 -216

208 A client who has or might have tuberculosis requires airborne precautions. That means a private room with negative-pressure airflow. Room 208 is the only one of these options that fits these requirements.

A nurse is caring for a client who has an NG tube. The nurse tests the pH of the secretions to determine if the tube is correctly placed. Which of the following readings should the nurse expect? -6.0 -4.0 -7.0 -8.0

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

A nurse is admitting a client who reports anorexia and is experiencing malnutrition. Which of the following laboratory findings should the nurse expect to be altered? -Creatine kinase -Troponin -Total bilirubin -Albumin

Albumin A low albumin is a measure of plasma proteins which reflects the nutritional condition of a client experiencing anorexia and malnutrition over an extended period of time.

A nurse is caring for a client who requires cold applications with an ice bag to reduce the swelling and pain of an ankle injury. Which of the following actions should the nurse take? -Apply the bag for 30 min at a time. -Reapply the bag 30 min after removing it. -Allow room for some air inside the bag. -Place the bag directly on the skin.

Apply the bag for 30 min at a time. The nurse should leave the bag in place for 30 min, but should check the client's skin after 15 min to make sure there are no adverse effects.

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

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

A nurse is implementing direct nursing care for a group of clients in an acute care facility. Which of the following actions by the nurse is considered an indirect nursing care activity? -Determining the client's length of stay -Assigning tasks to an assistive personnel (AP) -Providing anticipatory guidance to a client in crisis -Establishing the client's secondary medical diagnoses

Assigning tasks to an assistive personnel (AP) Delegation of nursing care to an AP is considered indirect care. To meet the clients' needs, activities of daily living such as ambulation, bathing and vital signs may be assigned to an AP, but the nurse is responsible for verifying that the tasks have been completed according to standards of care.

A nurse is ready to insert an indwelling urinary catheter for a female client. Which of the following instructions should the nurse give the client as the catheter is inserted? -Contract the pelvic muscles. -Take a sip of water. -Exhale slowly. -Bear down.

Bear down. Bearing down gently as if to void relaxes the external sphincter and eases urinary catheter insertion.

A nurse is helping an older adult client ambulate in the hallway for the first time since admission. The client has brought her standard walker from home. To ensure proper use of the walker and the safety of the client, which of the following actions should the nurse take? -Check that the client lifts the walker and then places it down in front of her. -Walk in front of the client to guide her in moving the walker. -Have the client move one leg forward with the walker. -Make sure that the upper bar of the walker is level with the client's waist.

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

A nurse is providing nail care for a client. Which of the following actions should the nurse take? -Clean under the nail with an orange stick -File the nails in a rounded shape. -Push the cuticles back with a metal nail file. -Trim the nails at the lateral corners.

Clean under the nail with an orange stick The nurse should use an orange stick to push back the cuticle and clean under the nail.

A nurse is receiving change-of-shift report for a group of assigned clients. The nurse anticipates which of the following activities first in delivering client care using the nursing process? -Critically analyze client data to determine priorities. -Collect and organize client data. -Set client-centered, measurable and realistic goals. -Determine effectiveness of interventions.

Collect and organize client data. The steps in the nursing process include assessment, analysis/diagnosis, planning, implementation and evaluation. The nurse should first collect client data, and then critically analyze the data to determine the clients' priorities. This is followed by the nurse planning client-centered, measurable and realistic goals. The nurse implements care, which involves putting the plan into action, followed by evaluation to determine the effectiveness of the interventions.

A nurse on a medical unit is caring for a client who suddenly becomes confused and drowsy. Additional data includes pulse 100/min, respiratory rate 24/min, BP 132/76 mm Hg, and temperature 36.8º C (98.2º F). Which of the following actions should the nurse perform? -Complete a neurological check. -Administer the prescribed PRN antihypertensive medication. -Increase the client's fluid intake. -Hold the client's evening dose of digoxin.

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

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

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

A nurse is teaching a client about the physical effects of chemotherapy. Following the teaching, the nurse asks the client to describe one physical effect. The nurse is focusing on which of the following elements of the communication process? -Feedback -Channel -Environment -Message

Feedback Feedback indicates whether the client understands the message, which was in the nurse's teaching.

A nurse is caring for a client who states, "I have got to get out of this hospital! They have found my address and are coming for my family!" The nurse responds, "Don't worry, no one will harm your family." Which of the following types of communication breakdown does this response represent? -Providing a passive response -Showing disapproval -Offering false reassurance -Offering sympathy

Offering false reassurance Offering false reassurance discourages further communication because there are no facts to support it. A better response would be to clarify the client's misperceptions.

A nurse is caring for a client in the emergency department who, 2 hr earlier, severed the tip of a finger in an accident. During the assessment, the nurse detects a strong smell of alcohol from the client's breath. For which of the following findings should the nurse assess first? -Client's history of previous accidents -Date of the client's last tetanus immunization -Client's blood alcohol level -Signs of wound infection

Date of the client's last tetanus immunization The greatest risk to this client is injury from infection with Clostridium tetani; therefore, the priority assessment the nurse should perform is to determine whether the client will require a tetanus immunization by identifying the date the client last received one. An adult should have a tetanus booster immunization every 10 years and after any severe or dirty wound.

A nurse in the emergency department is caring for a client who collapsed after playing football on a hot day. After reviewing the admission laboratory findings, the nurse recognizes that these findings are consistent with which of the following conditions? Sodium 152 mEq/L Glucose 102 mg/dL Potassium 3.6 mEq/L BUN 18 mg/dL Chloride 105 mEq/L Creatinine 0.7 mg/dL -Renal failure -Low-protein diet -Dehydration -Syndrome of inappropriate antidiuretic hormone (SIADH)

Dehydration Hypernatremic (hypertonic) dehydration occurs with excessive fluid losses due to perspiration, respiration, and inadequate fluid intake. The nurse should note that the client's sodium is above the accepted reference range, while glucose, potassium, BUN, chloride, and creatinine are within the accepted reference ranges. The client's history, collapsing after activity on a hot day, and the sodium findings are consistent with dehydration due to water deficit.

A nurse in a dialysis center is caring for a client who has a new diagnosis of end-stage kidney disease. When he arrives for his first dialysis treatment, he tells the nurse, "I decided to come today, but I am not sure if I will need to come back again this week. I am feeling much better since my discharge from the hospital and I think my kidneys are working again." The nurse should identify that this client is demonstrating which of the following Kübler-Ross stages of grieving? -Bargaining -Denial -Depression -Anger

Denial During the denial stage of Kübler-Ross's stages of grieving, the client acts as though nothing has happened and might refuse to believe or understand that a loss has occurred.

A nurse is preparing to administer three liquid medications to a client who has an NG feeding tube with continuous enteral feedings. Which of the following actions should the nurse take? -Mix the three medications together prior to administering. -Dilute each medication with 10 mL of tap water. -Maintain the head of the bed in a flat position for 30 min following medication administration. -Flush the NG feeding tube with 30 mL of water immediately following medication administration

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

A nurse is preparing to administer a cleansing enema to a client. Which of the following actions should the nurse take? -Keep the container of solution at a level to maintain client comfort. -Hold the container of solution 30 cm (12 in) above the anus. -Hold the container of solution level with the client's upper hip. -Hold the container of solution 15 cm (6 in) above the anus, then lower it 15 cm below the anus.

Hold the container of solution 30 cm (12 in) above the anus. The nurse should hold the container of solution 30 to 45 cm (12 to 18 in) above the anus when administering a cleansing enema to allow for a continuous, slow instillation of solution to promote evacuation of feces in the bowel.

A nurse in a long-term care facility is observing an assistant personnel (AP) changing the linen for a client who has fecal incontinence. Which of the following actions indicates that the AP understands the principles of infection control? -Shakes the soiled linen to remove any toilet paper remnants -Places the soiled linen on the floor before bagging it -Holds the soiled linen against her body while carrying it to the linen bag -Places clean linen that touched the floor in the soiled linen bag

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

A nurse is assessing a client's bowel sounds. At which of the following points in the assessment should the nurse auscultate the client's abdomen? -After palpating the abdomen -Prior to percussing the abdomen -After assessing for kidney tenderness -Prior to inspecting the abdomen

Prior to percussing the abdomen According to evidence-based practice, the nurse should auscultate the abdomen prior to percussing it to prevent altering the bowel sounds. Both percussion and palpation can stimulate the intestines, increase their motility, and intensify the bowel sounds.

A nurse finds an open vial of morphine lying on top of the cabinet in a client's room. Which of the following actions should the nurse take? -Return the medication to the unit's stock for future use. -Report the discrepancy immediately. -Administer the medication to other clients to avoid waste. -Independently dispose of the remaining medication.

Report the discrepancy immediately. Because this medication is a controlled substance, the nurse should remove the medication from the client's bedside and report the incident according to the facility's policy. After that, she may dispose of it with another nurse witnessing the discard.

A newly licensed nurse is applying prescribed wrist restraints on a client. Which of the following actions should the nurse take? -Secure the restraints using a quick-release tie. -Ensure four fingers fit under the restraints to prevent constriction. -Secure the restraints to the lowest bar of the side rail. -Anticipate removing the restraints every 4 hr.

Secure the restraints using a quick-release tie. The nurse should secure the restraints using a quick-release tie for easy removal in an emergency.

A nurse in a long-term care facility is caring for an older adult client who has dementia and begins to have frequent episodes of urinary incontinence. After the provider determines no medical cause for the client's incontinence, which of the following interventions should the nurse initiate to manage this behavior? -Remind the client to tell the nurse when he has to urinate. -Use adult diapers to prevent frequent clothing changes. -Take the client to the bathroom every 2 hr. -Request a prescription for an indwelling urinary catheter.

Take the client to the bathroom every 2 hr. By assisting the client to the bathroom every 2 hr, the staff establishes a regular pattern of toileting, and the client learns to trust that the staff places value on his bladder-training needs. He also learns a physical pattern that promotes bladder control.

A nurse is caring for a client who receives intermittent enteral feedings through an NG tube. Before administering a feeding, the nurse should measure the gastric residual for which of the following purposes? -To confirm the placement of the NG tube -To remove gastric acid that might cause dyspepsia -To determine the client's electrolyte balance -To identify delayed gastric emptying

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

A nurse is providing oral care for a client who is immobile. Which of the following actions should the nurse take? -Use a stiff toothbrush to clean the client's teeth. -Use the thumb and index finger to keep the client's mouth open. -Turn the client on his side before starting oral care. -Apply petroleum jelly to the client's lips after oral care.

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

A nurse is preparing to move a client who is only partially able to assist up in bed. Which of the following methods should the nurse plan to use? -One nurse lifting as the client pushes with his feet -Two nurses lifting the client under the shoulders -One nurse lifting the client's legs as the client uses a trapeze bar -Two nurses using a friction-reducing device

Two nurses using a friction-reducing device This method reduces the risk of injury to the nurses and to the client. The nurses can use a draw sheet as a friction-reducing device.

A nurse is admitting a client from a long-term care facility. The nurse should use closed-ended questions when assessing which of the following factors? -When determining if the client is eating a well-balanced diet -When asking the client about his receptiveness to the transfer -When asking the client how he completes his ADLs -When asking if the client took his medications this morning

When asking if the client took his medications this morning A "yes" or "no" response is sufficient when asking if a client took his morning medications. If he did not take them and should have, the nurse might want to explore the issue further.

A nurse is rehearsing assertive communication approaches to use when declining leadership of a nursing department committee. Which of the following statements should the nurse make? -"It's just not the right time for me to do this." -"Everyone knows there are others who can chair this committee better than me." -"Can you tell me why you chose me?" -"I decline the opportunity at this time."

"I decline the opportunity at this time." This is an assertive form of communication because it contains an "I" statement and it is clear and firm.

A nurse is creating a discharge plan. Which of the following nursing statements indicates the nurse understands when discharge planning should be implemented? -"I will begin 48 hr before the client's discharge." -"I will begin once the client's discharge order is written." -"I will begin upon the client's admission to the facility." -"I will begin once the client's insurance company approves discharge coverage."

"I will begin upon the client's admission to the facility." Effective discharge planning must begin upon admission of the client to the facility.

A nurse is caring for a client who frequently attempts to remove his IV catheter. A family member requests that the nurse apply restraints. Which of the following responses should the nurse make? -"I'll provide more stimulation in his environment." -"I will call the doctor and get the prescription." -"I will cover the catheter so he cannot see it." -"Let's wait until tonight to see if he continues this behavior."

"I will cover the catheter so he cannot see it." Using stockinette or clothing to cover the IV insertion site is an appropriate distraction technique and might steer the client's attention away from the catheter.

A nurse is teaching a client who has a history of falls about home safety. Which of the following statements should the nurse identify as an indication that the client understands the instructions? -"I will keep my walker at the end of my bed." -"I will keep the fluorescent ceiling light on in my room at night." -"I will place an area rug at the entry of my bathroom." -"I will place a bath seat in my shower to use when I bathe."

"I will place a bath seat in my shower to use when I bathe." A bath seat can help reducing slipping and falling in the bathtub or shower.

A nurse is providing teaching to an assistive personnel (AP) about caring for clients with restraints. Which of the following statements by the AP indicates an understanding of the teaching? -"I will tie restraints in double knots." -"I will tie a restraint to the portion of the bed that moves when the head of the bed is moved." -"I will ensure that restraints fit tightly against the client." -"I will put four side rails up if a client is confused."

"I will tie a restraint to the portion of the bed that moves when the head of the bed is moved." This statement by the AP indicates an understanding of the teaching. Restraints should be tied to the portion of the bed that moves when the head of the bed is raised or lowered.

A nurse is teaching an assistive personnel (AP) about using personal protective equipment while caring for clients. Which of the following statements should the nurse identify as an indication that the AP understands the instructions? -"I will wear gloves whenever I am in contact with clients." -"I will wear gloves and a gown when bathing a client who has open skin lesions." -"I will wear gloves to minimize the number of times I have to wash my hands." -"I will wear gloves when measuring a client's blood pressure."

"I will wear gloves and a gown when bathing a client who has open skin lesions." The AP should wear personal protective equipment when in direct contact with a client's bodily fluids, such as gloves and a gown when coming in contact with wound exudate is possible.

A nurse in a clinic is teaching a group of clients about preventing low back pain and injury. Which of the following statements should the nurse identify as an indication that the client requires further clarification? -"I'll sit with my knees lower than my hips." -"I'll do exercises that strengthen my abdominal muscles." -"I'll wear low-heeled shoes from now on." -"I'll carry heavy objects close to my body."

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

A nurse intercepts a messenger at the nurses' station who has a flower delivery for a client on the unit. As the nurse accepts the flowers, the messenger says, "I know Mrs. Welch from the neighborhood. What happened to her?" Which of the following responses should the nurse provide? -"You know it's not appropriate for you to ask me that." -"It's my responsibility to remind you that we have to respect our clients' privacy." -"It's a minor injury. I'm sure you'll see her back in the neighborhood soon." -"Oh, what lovely flowers. She will enjoy these."

"It's my responsibility to remind you that we have to respect our clients' privacy." This therapeutic response provides clarification to the messenger that the hospital staff cannot disclose information about clients.

A nurse is working with a licensed practical nurse (LPN) to care for a client who is receiving a continuous IV infusion. Which of the following findings reported by the LPN indicates to the nurse the client has phlebitis at the IV insertion site? -"The infusion rate has stopped but the tubing is not kinked." -"The area surrounding the insertion site feels warm to the touch." -"There is fluid leaking around the insertion site." -"There is no blood return when the tubing is aspirated."

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

A nurse is caring for a client who has fallen while getting out of bed and states, "I'm okay! I guess I should have called for help to the bathroom." After assessing the client, the nurse notifies the provider. Which of the following documentation should the nurse include in the client's medical record? -"There were no injuries sustained." -"An incident report was completed." -"An incident report was forwarded to risk management." -"The provider was notified."

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

A nurse enters an older adult client's room to insert a saline lock. The client asks the nurse, "Why do I need that? I am drinking plenty of fluids." Which of the following responses should the nurse provide? -"It is quicker to administer medications intravenously in the hospital." -"Clients over the age of 65 must have a saline lock according to facility policy." -"We administer all medications intravenously to clients in this unit." -"Your provider has prescribed antibiotic therapy to be administered intravenously every 6 hours."

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

A nurse is preparing to perform an abdominal assessment on a client. Identify the sequence of steps the nurse should take to conduct the assessment. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.) -Auscultate the abdomen for bowel sounds. -Inspect the abdomen for skin integrity. -Palpate the abdomen lightly for tenderness. -Ask the client about having a history of abdominal pain. -Percuss the abdomen in each of the four quadrants.

-Ask the client about having a history of abdominal pain. -Inspect the abdomen for skin integrity. -Auscultate the abdomen for bowel sounds. -Percuss the abdomen in each of the four quadrants. -Palpate the abdomen lightly for tenderness. Before initiating an abdominal assessment, the nurse should inquire if the client has a history of abdominal pain. The nurse should begin the assessment with an inspection of the client's abdomen, noting skin integrity, contour, and symmetry. Next, the nurse should auscultate for bowel sounds, vascular sounds, and peritoneal friction rubs. Auscultation precedes palpation and percussion because movement or stimulation of the bowel can increase bowel motility and create false results from heightened bowel sounds. After auscultation, the nurse should percuss the abdomen using a systematic pattern beginning in the lower right quadrant and proceeding to the upper right quadrant, the upper left quadrant, and then the lower left quadrant to determine the presence of tympany and dullness. The final step the nurse should take is to palpate the abdomen, beginning with light palpation, to detect any area of tenderness or muscle guarding.

A nurse is preparing to perform a capillary blood glucose test. Identify the sequence of steps the nurse should follow. (Move the steps of blood glucose monitoring into the box on the right, placing them in the selected order of performance. Use all the steps.)

-Check expiration date on test strips. -Perform a quality control test. -Perform hand hygiene. -Cleanse puncture site. -Apply blood sample onto test strip. -Document results. Check expiration date on test strips: When opening a new bottle of blood glucose monitoring test strips, the expiration date must be checked to ensure accurate test results. When using a bottle that has already been used, the expiration dates must also be checked. Expired test strips should not be used, as the sensitivity to the blood sample can be altered past the intended date of accuracy. Perform a quality control test: Many test strips have a code that must be entered into the glucose monitor, or the vial might contain a code key that must be inserted into the monitor when using a new bottle of test strips. For these types of devices, the test strip must match the code number or an inaccurate reading can result. A quality control test will verify the monitor is working accurately. The quality control test is performed the same way as a blood glucose test, except a special solution is used instead of blood. The monitor should be calibrated, and a quality control test should be performed when using a new bottle of test strips (or as indicated by the facility policy). Many facilities require a daily quality control test. Perform hand hygiene: Hand hygiene reduces the transfer of micro-organisms, which could lead to inaccurate readings. Hand hygiene reduces the number of transient micro-organisms that can enter the puncture site and cause an infection. The nurse should wash hands and don gloves prior to performing the glucose test. Cleanse puncture site: The site should be cleansed with warm water and soap and allowed to dry. Alcohol can interfere with the results and should be avoided. The nurse should puncture the lateral side of the finger, which has less nerve endings but is vascular, to provide an adequate blood supply for testing.Apply blood sample onto test strip: The first drop of blood might have less red blood cells and more serous fluid, which can lead to an inaccurate reading. The nurse should wipe off the first drop of blood and lightly squeeze the finger without touching the puncture site to ensure an adequate-size droplet for testing. After a blood sample is obtained, apply a cotton ball over the puncture site. Document results: The nurse should process the strip reading. Remove gloves and wash hands.

A nurse is conducting a primary survey of a client who has sustained life-threatening injuries due to a motor-vehicle crash. Identify the sequence of actions the nurse should take. (Move the actions into the box on the right, placing them in the selected order of performance. Use all the steps.)

-Open the airway using a jaw-thrust maneuver. -Determine effectiveness of ventilator efforts. -Establish IV access. -Perform a Glasgow Coma Scale assessment. -Remove clothing for a thorough assessment. A primary survey is an organized system to rapidly identify and manage immediate threats to life. The mnemonic "ABCDE" is a reminder of the steps of the primary survey. The first step is "airway," during which the nurse should establish a patent airway using the jaw-thrust maneuver. The second is "breathing," during which the nurse should assess the client's ventilator efforts to determine effectiveness of breaths. During the third step, "circulation," the nurse should establish IV access for fluids and blood administration as needed. The fourth step is "disability," during which the nurse should determine a baseline neurologic status by completing a GSC assessment. And the fifth step is "exposure," during which the nurse should remove the client's clothing to complete a thorough assessment of the client's injuries.

A nurse is teaching an older adult client who has herpes zoster about the order of occurrence of findings associated with this disorder. Identify the order in which the findings typically occur. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.) -Crusted lesions -Paresthesia -Postherpetic neuralgia -Redness and swelling -Vesicles -Weeping blisters

-Paresthesia -Redness and swelling -Vesicles -Weeping blisters -Crusted lesions -Postherpetic neuralgia The usual presentation of herpes zoster begins with paresthesias. Then, redness and swelling develops before the vesicles appear along the affected nerve. These vesicles usually open and begin to drain for a few days before they crust over and healing begins. Many older adult clients develop postherpetic neuralgia (pain along the nerve) for months after the lesions disappear.

A nurse is preparing to perform wound irrigation on a client who has a puncture wound to the left leg. Identify the sequence of steps the nurse should take to perform the irrigation. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

-Place a waterproof pad under the client's leg. -Don clean gloves and remove the client's dressing. -Clean the wound using a circular motion. -Open a sterile dressing set and supplies. -Irrigate the wound until the solution becomes clear. The nurse should first place a waterproof pad on the bed under the client's leg to prevent soiling the bed linen. The nurse should then apply clean gloves to remove and discard the old dressing. Next, the nurse should clean the puncture site using a circular motion, moving from the cleanest area in the center of the wound outward. After cleaning the wound, the nurse should prepare the equipment necessary for irrigation by opening a sterile dressing set and supplies. Finally, the nurse should irrigate the wound until the solution becomes clear to ensure that exudate is no longer present.

A nurse is providing anticipatory guidance to the parents of a newborn about feeding skills. Place the following feeding skills in the order the newborn should develop them. (Move the steps into the box on the right, placing them in the selected order of performance. All steps must be used.) -Eats pieces of soft, cooked food -Drinks from a cup held by another person -Begins experimenting with spoon -Pushes solid objects from mouth

-Pushes solid objects from mouth -Drinks from a cup help by another person -Begins experimenting with spoon -Eats pieces of soft, cooked food Starting at birth, the infant pushes solid objects from the mouth. Around the age of 4 months the infant is able to drink from a cup that is held by another person. At approximately 8 months of age the infant begins experimenting with a spoon, and finally, starting at 10 to 12 months of age the infant begins eating soft, cooked food.

A nurse is preparing an in-service for an annual skills fair at a community medical facility about fire safety. Place the steps in the order in which they should be performed in the case of a fire emergency. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.) -Pull the fire alarm. -Confine the fire. -Extinguish the fire. -Rescue the clients.

-Rescue the clients. -Pull the fire alarm. -Confine the fire. -Extinguish the fire. Following the RACE mnemonic the nurse should first rescue all clients by moving them to a safe area out of immediate danger. Next the nurse should pull the alarm fire and then, if possible, call the agencies emergency extension to report the location and details of the fire. The next step the nurse should take is to close all of the room doors and fire doors at the entrance to the unit to confine the fire. Lastly, the nurse should attempt to extinguish the fire with the appropriate fire extinguisher. If unable to do so, the nurse should evacuate the area.

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

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

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

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

A nurse is preparing to administer clindamycin 300 mg by intermittent IV bolus over 30 min to a client who has a staphylococci infection. Available is clindamycin premixed in 50 mL 0.90% sodium chloride (NaCl). The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

100 mL/hr

A nurse notices an assistive personnel (AP) preparing to deliver a food tray to a client who practices the Orthodox Jewish faith. On the tray is a roast beef dinner with nonfat milk. Which of the following actions should the nurse take? -Allow the AP to deliver the food tray to the client. -Call the dietary department and ask for a kosher tray. -Replace the nonfat milk with apple juice. -Explain to the client that he needs the protein in the milk and the beef.

Call the dietary department and ask for a kosher tray. This action shows cultural sensitivity and respect for the client's cultural and spiritual beliefs. Clients who practice the Orthodox Jewish faith do not eat meat and dairy together.

A nurse is caring for a client who requests prescription pain medication. Which of the following actions should the nurse perform first? -Reposition the client. -Administer the medication. -Determine the location of the pain. -Review the effects of the pain medication.

Determine the location of the pain. The first action the nurse should take using the nursing process is to assess the client. By determining the location of the pain, the nurse can take the necessary steps to alleviate the client's pain, such as administering pain medication, repositioning the client, and teaching the client about the effects of the medication.

A nurse is admitting a client who has pertussis. Which of the following types of transmission-based precautions should the nurse initiate? -Airborne -Contact -Droplet -Protective

Droplet The nurse should initiate droplet precautions for clients who have infections that spread by droplets larger than 5 microns, including mumps, streptococcal pharyngitis, and pertussis.

A nurse is caring for a client in the orientation phase of the nurse-client relationship. Which of the following communication techniques should the nurse use during this phase? -Elicit information from the client. -Encourage the client to use self-exploration. -Review the client's progress toward personal objectives. -Talk with others who have information about the client.

Elicit information from the client. Obtaining information from the client is a component of the orientation phase.

A nurse is caring for a client who expresses anxiety about his impending surgery. Which of the following actions should the nurse take? -Explore the client's feelings. -Discuss the competency of the surgeon. -Review another client's similar surgical experience. -Talk with the client's partner.

Explore the client's feelings. Asking the client to share his feelings encourages him to express the nature of his feelings of anxiety. The nurse can begin by offering general leads.

A nurse is caring for a client who has emphysema and has difficulty with mobility. The client receives home health care and spends most of his day in a reclining chair. Which of the following physiological responses to prolonged immobility should the nurse expect? -Increased insulin production -Decreased RBC production -Decreased sodium excretion -Increased calcium excretion

Increased calcium excretion Prolonged immobility leads to the breakdown of bone tissue. This results in increased calcium excretion.

A nurse receives a client care assignment from the charge nurse that he believes is unfair. The nurse voices his concern to the charge nurse. The nurse is using which level of communication at this time? -Transpersonal -Intrapersonal -Interpersonal -Public

Interpersonal Interpersonal communication is face-to-face interaction with another person. It results in an exchange of ideas, problem solving, expression of feelings, decision-making and personal growth.

A nurse is instructing clients in the community about relationship development. The nurse should explain that, according to Erikson, establishing relationships with commitment is a primary task of which of the following stages of psychosocial development? -Generativity vs. stagnation -Identity vs. role diffusion -Intimacy vs. isolation -Trust vs. mistrust

Intimacy vs. isolation During this stage, young adults (18 to 25 years) develop commitments to others and to their careers.

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

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

A client smoking in his bathroom has dropped a cigarette butt into a wastepaper basket, which begins to smolder. Which of the following actions is the nurse's priority? -Close the fire doors on the unit. -Activate the fire alarm. -Move any clients in the immediate vicinity. -Use a fire extinguisher to put out the fire.

Move any clients in the immediate vicinity. The greatest risk to clients is injury from smoke and fire; therefore, the nurse's first action is to move any clients near the smoke to a safe location. The acronym RACE is a reminder of the order in which to take steps in the event of a fire. The nurse should rescue the clients, activate the fire alarm, confine the fire, and extinguish the fire.

A nurse is caring for a client who has peripheral vascular disease and reports difficulty sleeping because of cold feet. Which of the following nursing actions should the nurse take to promote the client's comfort? -Obtain a pair of slipper-socks for the client. -Rub the client's feet briskly for several minutes. -Increase the client's oral fluid intake. -Place a moist heating pad under the client's feet.

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

A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA) in an abdominal wound. The nurse enters the room to check the client's pulse. Which of the following actions should the nurse take? -Wear an N95 respirator mask. -Wear sterile gloves. -Wear clean gloves. -Wear protective eyewear.

Wear clean gloves. The nurse should wear clean gloves to prevent the transmission of MRSA.

A nurse is assessing a client and discovers the infusion pump with the client's total parenteral nutrition (TPN) solution is not infusing. The nurse should monitor the client for which of the following conditions? -Excessive thirst and urination -Shakiness and diaphoresis -Fever and chills -Hypertension and crackles

Shakiness and diaphoresis When a sudden interruption in the infusion of TPN occurs, the client is at risk for hypoglycemia. Shakiness and diaphoresis are manifestations of hypoglycemia.

A nurse is administering a cold therapy application to a client. Which of the following manifestations should the nurse identify as an indication for discontinuing the application due to a systemic response? -Hypotension -Numbness -Shivering -Reduced blood viscosity

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

A nurse is caring for a client who is receiving heat applications using an aquathermia pad. Which of the following actions should the nurse take when applying the pad? -Set the pad's temperature to 42.2° C (108° F). -Stop the treatment if the client's skin becomes red. -Leave the pad in place for at least 40 min. -Use safety pins to keep the pad in place.

Stop the treatment if the client's skin becomes red. Reactions such as unusual pain or redness are indications for removing the pad and notifying the provider.

A nurse is reviewing the goals of the nurse-client therapeutic relationship with a client who is seeking counseling. Which of the following information should the nurse include in this discussion? -The client achieves optimal personal growth. -The client assumes responsibility for the interaction. -The client expects growth, not comfort, from the relationship. -The nurse's interventions take priority over the client's needs.

The client achieves optimal personal growth. The goal of a therapeutic nurse-client relationship is to help the client with achieving optimal personal growth, forming relationships, and reaching personal goals.

A nurse is assessing a client at a follow-up clinic visit for acute low back pain. A goal for this client is to use proper body mechanics at all times. Which of the following findings indicates that the client is meeting this goal? -The client faces the direction of movement when sliding an object across the floor. -When pushing an object, the client moves his front foot backward. -When moving an object to one side, the client puts his weight on his heels. -The client stands with his feet close together when lifting an object.

The client faces the direction of movement when sliding an object across the floor. Sliding an object across the floor rather than lifting it prevents strain on the lower back muscles. . Facing the direction of movement prevents twisting his back.

A nurse is caring for four clients who have drainage tubes. Which of the following clients should the nurse recognize as being at risk for hypokalemia? -The client who has a tracheostomy tube attached to humidified oxygen -The client who has an indwelling urinary catheter to gravity drainage -The client who has a chest tube to water seal -The client who has a nasogastric (NG) tube to suction

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

A nurse is caring for a client who is postoperative. The nurse should base her pain management interventions primarily on which of the following methods of determining the intensity of the client's pan? -Vital sign measurement -The client's self-report of pain severity. -Visual observation for nonverbal signs of pain. -The nature and invasiveness of the surgical procedure.

The client's self-report of pain severity Because nurses cannot measure pain objectively, it is standard practice to accept that pain is what the client says it is and to intervene accordingly.

A nurse is assessing a client's cardiovascular system. To palpate for unexpected pulsations in the pulmonic area, at which anatomical location should the nurse place her fingers? -The left second intercostal space -The right second intercostal space -The left fifth intercostal space -The left fifth intercostal space at the midclavicular line

The left second intercostal space The left second intercostal space is the location where the nurse can palpate pulsations at the pulmonic valve area. This is the site for palpating lifts and heaves in this area.

A nurse is assessing a client who had left femoral cardiac angiography. Identify where the nurse will palpate to assess the most distal pulse on the affected side. (Selectable areas, or "Hot Spots," are outlined in the artwork below. Select only the outlined area that corresponds to your answer.)

The most distal pulse refers to the pulse that is at the farthest point on the affected extremity. The dorsalis pedis pulse on the anterior foot is the most distal pulse below the femoral artery. Because the client had left-sided angiography, the correct answer will be the left pedal pulse.

A nurse is preparing an in-service presentation for a group of newly licensed nurses about the use of restraints. Which of the following should the nurse include as a criterion for applying restraints? -The provider must renew a restraint prescription every 8 hr. -The client must understand the need for the restraints. -The restraints should promote the client's safety and prevent injuries. -The nurse has already considered alternatives to restraints.

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

A nurse is performing a cardiac assessment. Identify where the nurse should place the stethoscope to auscultate the client's apical pulse. (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)

The nurse should auscultate the client's apical pulse over the apex of the heart, at the anatomical landmarks of the 5th intercostal space and below the left nipple line 7.6 cm (about 3 in) to the left of the sternum.

Complete the following sentence by using the list of options. The nurse should first (pad the client's wrist under the restraint/assess the area where the restraint is to be placed on the client/ensure two fingers can fit under the secured restraint) and then (attach the restraints to the moveable part of the bedframe/assess for readiness for discontinuation of restraints/remove the restraints one at a time).

The nurse should first (assess the area where the restraint is to be placed on the client) and then (attach the restraints to the moveable part of the bedframe). Drop down box 1: Pad the client's wrists under the restraint is incorrect. The nurse should first assess the area where the restraint is to be placed on the client before padding the skin and boney prominences that will be under the restraint. Assess the area where the restraint is to be placed on the client is correct. Prior to applying a restraint, the nurse should assess the condition of the client's skin, determine if there is appropriate circulation and sensation in the area, and inspect the range of motion of the extremity. Ensure two fingers can fit under the secured restraint is incorrect. The nurse should first assess the area where the restraint is to be placed on the client before applying the restraint. Drop down box 2: Attach the restraints to the movable part of the bedframe is correct. Attaching the restraints to the part of the bed that moves when the head of the bed is raised or lowered will prevent the restraint from restricting the client's circulation. Assess for readiness for discontinuation of restraints is incorrect. The client will need to be oriented and safe prior to having the restraints removed. Remove the restraints one at a time is incorrect. The client will need to be oriented and safe prior to having the restraints removed.

A nurse is preparing to perform postmortem care for a client who has died. Complete the following sentence by using the list of options. The nurse should first (remove all indwelling lines/apply clean gloves and a gown/conform the time of death was certified/cover the client's body with a shroud/validate the status of an autopsy) and then (identify the client using two identifiers/close the client's eyes/provide privacy for the client's family/complete the documentation on end-of-life care/clean the environment).

The nurse should first (conform the time of death was certified) and then (identify the client using two identifiers). Drop down box 1: Remove all indwelling lines is incorrect. Unless an autopsy or organ donation will occur, the nurse should remove all indwelling lines. However, there is another action the nurse should take first. Apply clean gloves and a gown is incorrect. The nurse should apply gloves and a gown prior to preparing the client's body. However, there is another action the nurse should take first. Confirm the time of death was certified is correct. Using the nursing process, the first step the nurse should take when providing postmortem care is to ensure the provider has certified and confirmed the time of the client's death. Cover the client's body with a shroud is incorrect. The nurse should cover the client's body with a shroud prior to transporting it to another location. However, there is another action the nurse should take first. Validate the status of an autopsy is incorrect. The nurse should validate the status of an autopsy. However, there is another action the nurse should take first. Drop down box 2: Identify the client using two identifiers is correct. Using the nursing process, the first step the nurse should take in providing postmortem care is to confirm the identity of the client is accurate. Close the client's eyes is incorrect. The nurse should close the client's eyes prior to completing the postmortem care. However, there is another action the nurse should take first. Provide privacy for the client's family is incorrect. The nurse should provide privacy for the client's family so they have an opportunity to visit and say goodbye. However, there is another action the nurse should take first. Complete the documentation on end-of-life care is incorrect. The nurse should complete the documentation on end-of-life care. However, there is another action the nurse should take first. Clean the environment is incorrect. The nurse should clean the environment prior to allowing the family to visit the client. However, there is another action the nurse should take first.

Complete the following sentence by using the lists of options. The nurse should first address the client's (abdominal pain/anxiety/nausea), followed by the client's (WBC count/decreased appetite/heart rate).

The nurse should first address the client's (abdominal pain), followed by the client's (WBC count). DROPDOWN 1 Abdominal pain is correct. Abdominal pain is the cardinal feature in appendicitis. The nurse needs to complete a thorough pain and abdominal assessment. Anxiety is incorrect. While the client is anxious and the nurse should address it at some point, it is not the priority. Nausea is incorrect. The child's nausea will need to be addressed but it is not a priority. The client did not report that they are currently nauseous, which gives the nurse time to address more pressing issues. DROPDOWN 2 WBC count is correct. An elevated WBC count can be indicative of infection and needs to be addressed immediately. The nurse should anticipate administering antibiotics. Decreased appetite is incorrect. Decreased appetite is not a priority to address for this client The decreased appetite is a recent manifestations, not a chronic condition. Heart rate is incorrect. The client's heart rate is slightly elevated, which is a common response to pain and anxiety.

Complete the following sentence by using the list of options. The nurse should first address the client's (fluid volume status/pain/bilirubin) followed by the client's (cardiac status/jaundice/neurological status).

The nurse should first address the client's (fluid volume status) followed by the client's (neurological status). Box 1 Fluid volume status is correct. The client has manifestations of fluid volume overload as evidenced by ascites, crackles, edema, and dyspnea. Using the urgent versus non-urgent priority setting framework, the nurse should address this first because the increased fluid volume is causing the client to have difficulty breathing. Pain and bilirubin are incorrect. The nurse should address the client's pain; however, using the urgent versus non-urgent priority setting framework, there is another finding that the nurse needs to address first. The client's bilirubin level is non-urgent because it is an expected finding in a client who has cirrhosis; therefore, there is another finding that is the nurse's priority. Box 2 Neurological status is correct. Using the urgent versus non-urgent priority setting framework, the nurse should next address the client's neurological status. The client is lethargic and only orientated to person and place. The client's ammonia level is also elevated, which can affect neurological status. If the client's neurological status is not addressed and becomes worse, the client may be at risk for respiratory complications, such as pneumonia and atelectasis. Cardiac status and jaundice are incorrect. The client's peripheral pulses are +2 upon palpation, which is an expected finding. Therefore, using the urgent versus non-urgent priority setting framework, there is another finding that is the nurse's priority. Jaundice is non-urgent because it is an expected finding in the client who has cirrhosis of the liver; therefore, there is another finding that is the nurse's priority.

The nurse is planning care for the client who is receiving treatment for amphetamine withdrawal. Complete the following sentence by using the lists of options. The nurse should plan to administer (donepezil/diazepam/varenicline) followed by (bupropion/disulfiram/Acamprosate calcium) once the client has been withdrawn from the amphetamine.

The nurse should plan to administer (diazepam) followed by (bupropion) once the client has been withdrawn from the amphetamine. Dropdown 1 Diazepam is correct. The nurse should recognize that diazepam is a benzodiazepine that is used to treat agitation in clients who are experiencing amphetamine withdrawal. The nurse should administer diazepam to the client. Donepezil and varenicline are incorrect. The nurse should recognize that donepezil is a cholinesterase inhibitor that is used to treat Alzheimer's disease. It is not used to treat amphetamine withdrawal. The nurse should also recognize that varenicline is a nicotine agonist that is used to treat the manifestations of nicotine withdrawal. Dropdown 2 Bupropion is correct. The nurse should recognize that antidepressants, such as bupropion, are effective in treating the manifestations of depression that can be experienced by clients who have been withdrawn from amphetamines. The nurse should administer bupropion to the client after administering diazepam. Disulfiram and acamprosate calcium are incorrect. The nurse should recognize that disulfiram is a diversion therapy that is used to treat alcohol use disorder. The nurse should also recognize that acamprosate calcium is a medication used to prevent relapse in clients who have alcohol use disorder.

A nurse caring for a client is using active listening skills. Which of the following actions should the nurse take? -Sit side-by-side with the client. -Have a pen and paper handy. -Use intermittent eye contact. -Lean back in the chair.

Use intermittent eye contact. The nurse should establish intermittent eye contact and maintain it during active listening. It demonstrates interest is what the client is saying.

A nurse is providing discharge teaching about clean intermittent self-catheterization for a client who has benign prostatic hyperplasia. Which of the following instructions should the nurse include? -Perform catheterization when you recognize the urge to void. -Hold the penis at a 30° to 45° angle when inserting the catheter. -Inflate the balloon when the urine flow stops. -Use soap and water to wash the catheter after each use.

Use soap and water to wash the catheter after each use. The client should wash the catheter using soap and water and store it in a clean container after each use.

A nurse administers an incorrect medication to a client. Following an assessment of the client, the nurse determines that the client has experienced no untoward effects as a result of the medication. The nurse does not complete an incident report because no harm came to the client. Which of the following ethical principles did the nurse violate? -Autonomy -Beneficence -Veracity -Confidentiality

Veracity Veracity is the duty to tell the truth. The nurse violated the ethical principle of veracity when choosing not to report the error instead of being truthful.

A nurse is reviewing the laboratory results of a client who has a pressure ulcer. The nurse should identify an elevation in which of the following laboratory values as an indication that the client has developed an infection? -BUN -Potassium -RBC count -WBC count

WBC count An elevation in the WBC count (leukocytosis) indicates that the client's immune system is defending him against the pathogens causing an infection.

A nurse accidentally sticks her hand with a syringe needle after administering an IM injection to a client. Which of the following actions should the nurse take first? -Report the incident to the charge nurse/ -Wash the are of the puncture thoroughly with soap and water. -Complete an incident report. -Go to employee health services.

Wash the area of the puncture thoroughly with soap and water. The greatest risk to this client is injury from any bloodborne pathogens on the needle; therefore, the first action the nurse should take is to provide immediate first aid by scrubbing the area thoroughly with soap and water.

A nurse is orienting a new assistive personnel (AP) to the unit. For which of the following actions should the nurse intervene? -Wears a gown when entering the room of a client who requires contact precautions -Dons gloves to empty a urinary drainage device -Washes and rinses her hands for 10 seconds -Wears a respirator mask when entering the room of a client who requires airborne precautions

Washes and rinses her hands for 10 seconds The nurse should intervene because the AP should wash her hands for at least 20 seconds.